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, 26 February 2013 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) 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: Prof. Sir Robert Lechler (RL) Sally Lingard (SL) Tamara Cowan (TC) Apologies: Sue Slipman (SS) Trust Chair Non-Executive Director, Vice Chair 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 Executive Director (KHP) Associate Director of Communications Board Secretary (Minutes) Non-Executive Director 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 29/01/2013 Enc Matters Arising/Action Tracking Enc FOR REPORT/DISCUSSION 2.1. KHP Update Verbal R Lechler 14: Chair s and Non-Executive Directors Report Enc. 2.1 G Alberti 14: Update on Council of Governors Activities Verbal G Alberti 14: Chief Executive s Report Enc. 2.4 T Smart 15: Finance Report Month 10 Enc. 2.5 S Taylor 15: Performance Report Month 10 Enc. 2.6 R Sinker 15: Quality & Safety Focus: Quarterly Patient Experience Report Enc J Walters 15: Quarterly DIPC Report Enc G Walters 15: Quality Priorities & Report Enc G Walters 15:50 3. FOR INFORMATION 16: Confirmed Board Committee Minutes Equality & Diversity Committee 29/11/2013 Enc ANY OTHER BUSINESS 16:05 5. DATE OF NEXT MEETING Tuesday, 26 March 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 January 2013 in the Dulwich Committee Room, King s College Hospital. Members: Prof Sir George Alberti (GA) Graham Meek (GM) Chris Stooke (CS) Faith Boardman (FB) Sue Slipman (SS) Prof. Ghulam Mufti (GM1) Tim Smart (TS) Roland Sinker (RS) Simon Taylor (ST) Dr. Michael Marrinan (MM) Dr. Geraldine Walters (GW) Angela Huxham (AH) Jane Walters (JW) Non-voting Director Jacob West (JW1) - Non-voting Director In attendance: Anne Greenough (AG) Jill Locket (JL) Sally Lingard (SL) Rita Chakraborty (RC) James Eales Marion Mackay Fiona Clark Stuart Owen Apologies: Marc Meryon (MM1) Trust Chair Non-Executive Director, Vice Chair Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Chief Executive Chief Operating Officer Chief Financial Officer Medical Director Director of Nursing & Midwifery Director of Workforce Development Director of Corporate Affairs Director of Strategy Director of Education and Training, KHP Director of Performance and Delivery, KHP Associate Director of Communications Assistant Board Secretary (Minutes) NHS Graduate Management Trainee KCH Charity Governor Governor Non-Executive Director Item Subject Action 013/01 Apologies The Chair welcomed all public attendees. Apologies for absence were noted. 013/02 Declarations of Interest There were no declarations of interest. 1

4 Enc 1.4 Item Subject Action 013/03 Chair s Action There were no chair s actions 013/04 Minutes of previous meetings 18 December 2012 The minutes of the meeting held on 18 December 2012 were approved as a correct record. 013/05 Action Tracking/Matters Arising The Francis Enquiry was due to publish its report on 6 February and the recommendations could be far reaching. 013/06 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. Correction: GA did not chair Finance and Performance Committee on 18 Dec. 013/07 Update on Council of Governors Activities The Chair provided an update on Council of Governor activities: The recent Governor Development Day was very informative; The Membership and Community Engagement Committee had discussed the membership strategy and the Trust centenary plans; and Patient Experience and Safety Committee had received presentations on quality priorities, A&E survey results and improving the patient experience in the Acute Medical Assessment Units. 013/08 Chief Executive s Report The Board noted the Chief Executive s report for the period. TS highlighted the following key points: King s was the only London FT to be rated green for finance and governance at present; William McKee has been appointed Director of Transition and Transformation. There was some delay with the KHP full business case due to the awaited announcement by the Secretary of State for Health on the future of SLHT but this was expected imminently. Support was expected for the TSA s recommendation; 2

5 Enc 1.4 Item Subject Action The final decision on the Trust s acquisition of PRUH will be subject to concluding terms of agreement that the FT regulator and the Trust are content with. Throughout negotiations, the Trust has made it clear that it must maintain its existing financial risk rating from Monitor and that the outcome must be in the best interests of patients at King s and PRUH; and There was discussion about recent developments in the Integrated Care strategy. A 24/7 geriatrician hotline was operational. The programme was seeing a change in behaviours with referrals to assessment units, which are GP-led multi-disciplinary teams. A new programme director had been appointed. Fiona Clark commented that there was some anxiety amongst older members of the community that the message about integrated care has not been sufficiently publicised. JW1 responded that a website has been set up, there are more materials being distributed in the community and a public Board has been established including local users. SL offered to take the issues raised to the integrated care communications group. 013/09 Finance Report Month 9 ST presented the finance report for month 9. 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: Winter pressures were resourced by the local commissioners; The figures show a 2.4m deficit position after assets impairment but the Trust still remains in operating surplus with a financial risk rating of 3 and this is projected to continue to year end; 2013/14 initial tariffs suggest a 1.5% reduction in income. The Trust is likely to have to implement 2.3% savings. Education and training income will also be tight next year; CIP targets in tertiary specialties, emergency and diagnostics were the most challenging at present; In order to reduce the outstanding money from private patients, a more thorough check of each patient s entitlement should be undertaken before treatment commences. The downward trend in income from some countries was likely to continue; and Agency spending was high during winter as more temporary medical staff were hired to cope with the increase in patient activity. 3

6 Enc /10 Performance Report Month 9 RS presented the performance report for month 9. 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 9 performance against core Monitor targets was strong with all access, referral to treatment (with the exception of 62 day cancer wait) and infection control targets achieved; Performance challenges included A&E with some elective operations cancelled as the result of continuing high levels of emergency admissions. The referral to treatment target was unlikely to be met in Q4; Five other areas of concern are slips, trips and falls, complaints response times, Mixed Sex Accommodation (MSA) and Maternity and Day Surgery. Actions are in place to manage these; and Pressures on ED remains a major issue. Despite investment in A&E services and a 24/7 Acute Assessment Unit, the Trust was dealing with unprecedented levels of activity ; The Board made the following observations: The criteria for relocating patients involves identifying appropriate patients to move and network collaboration; The corporate dashboard is reviewed annually to ensure a balance of indicators that: i) provide an early alert, such as data on training and line audits for infection control; and ii) provide assurance on data accuracy, such as KPMG s scrutiny of 3 indicators and mock CQC inspections. A more explicit presentation of weak indicators was suggested. Despite the Trust s comparative good performance, a self-critical approach was welcomed; and It was noted that if the Trust acquires the PRUH and is able to improve standards there, this will have a positive effect on care and finances at King s also. 4

7 Enc 1.4 Item Subject Action 013/11 Quarterly Patient Outcome Report The Board noted and discussed the Quarterly Patient Outcome Report. The report summarised the work of the Public Health Committee and its Health Improvement Groups. There are high rates of lifestyle related illness and lower than average life expectancy in the local population; The Trust is encouraging patients to make healthier lifestyle choices; however it is acknowledged that acute hospitals have a limited impact in this area; Areas that the Committee and its feeder groups are focussing on are smoking, alcohol, obesity and healthy eating, physical activity, mental health, sexual health, oral health, occupational health, maternity and teenage pregnancy, sexual health and HIV, and older people s health; Some improvements have been identified in breastfeeding, teenage pregnancy rates and smoking in pregnancy; A national audit of King s health promotion showed the Trust was significantly better than the national average for assessing health risk factors but not for providing the appropriate interventions; and CQUIN targets were being achieved. The Board offered the following comments: Given the size of the combined KHP workforce, there were opportunities to change attitudes of staff and their families. The Global Corporate Challenge generated interest at all levels of the organisation; The proposed PRUH acquisition offered wider geographical reach across south east England; Hospital visits can be an effective trigger for behaviour change because of patient trust in hospital doctors; and Programmes run by local councils focus on targeting the population as a whole. 5

8 Enc 1.4 Item Subject Action 013/12 KHP Update Prof Anne Greenough presented a comprehensive update on the education and training workstream. Areas covered included: - Innovative technology and teaching KCL has adopted the quality mark; a learning hub provides all lectures on video via the website; - Inter-professional education and training patient safety is being developed as a vertical strand in the MBBS; - Increasing research capacity the quality of trainees is very good; - Careers management the model will be rolled out across all disciplines - Global health education and training a busy year including research on learning outcomes from electives in low and middle income countries; - State of the art simulation suite and learning centre; - CAG education and training leads and metrics KCL teaching database has now been extended to all NHS consultants; firm survey results mirror the National Student Survey questions and can be split by campus, CAGs, department and individual teachers; there are currently 30 MScs programmes available; - GMC review communication needs improvement; the KCH campus needs a state of the art education facility; - You said we did ; and - South London HIEC this project has brought together a large number of diverse organisations. An event on 15 March will explore SLHIEC solutions for the future. The Board offered the following comments: The NSS undergraduate survey results, GMC review and external review results all need to be taken on board. The expansion of the medical school made it much more challenging for staff to know each student. Prof Greenough responded that this was the case in phases 1 and 2 but that Firms should know their students in the later stage of the course as the numbers are the same as when we were KCH Medical School; and Real time feedback was available to identify non-attendance of teachers at large lectures. 6

9 Enc 1.4 Jill Locket, KHP Director of Performance and Delivery, updated the Board on the following: AHSN licencing will be announced shortly and KHP was hopeful of securing 10m over 5 years; Tariq Sethi has been appointed CAG Leader for Respiratory, Allergies and Critical Care; An event will be held on 16 April for the top 250 people to celebrate KHP s success; and The re-accreditation process will begin in October /13 Monitor Submission Quarter /13 The Board approved the Quarter 3 submission to Monitor. 013/14 Any Other Business There were no other items of any other business raised for discussion. 013/15 Date of Next Meeting Tuesday, 26 February 2013 at 14:30 in the Dulwich Committee Room. 7

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11 Board of Directors Public Meeting Action Tracker Enc 1.5 Meeting Date Item Action Who Due Date Notes 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. PE/LM 30/04/ /10/ /149 JW would undertake some research into the demographics of the cancer survey respondents and report back to the Board in due course. JW Early 2013 Board of Directors Meeting 26 March of 1

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13 Enc. 2.4 Report to: Board of Directors Date of meeting: 26 February 2013 By: Subject: Tim Smart, Chief Executive Chief Executive s Board Report 1. Executive Summary This has been a very difficult month on a number of fronts, both locally and nationally. We are very pressurised by the volume and acuity of emergency patients, and this is impacting on our ability to meet access targets. Unlike other organisations in the news, we have not yet had to make any really difficult decisions that compromise our ability to meet targets, and we have absolutely no intention of doing anything that compromises patient safety. New capacity is being brought into service, and this will make a difference to patient flows. We were all shocked by the distressing circumstances described by the Francis Report. The Board is digesting what it means for our assurance processes, and will report in due course. We are also starting a series of staff listening events, because one of our values is Inspiring Confidence in Our Care, and reassuring staff about our focus on patients, and listening to their concerns, is an important leadership process. We are also reviewing any Compromise Agreements which we have with ex staff, and are reviewing everything we do in this area to ensure that we encourage staff to identify concerns where they have them. And we continue to work with vigour and professionalism on the PRUH acquisition, and on the early stages of the KHP full business case. I would like to thank all staff, and the governors, for their engagement in these vital strategic matters. The Trust has been operating under significant financial strain this year, but we are in a position where we expect to breakeven at the close of the financial year. In Monitor s eyes, we are the highest performing Trust in London, which is a considerable achievement and I appreciate the hard work and commitment that has gone into attaining this. 2. Finance month 10 At the end of month 10 (January) the Trust has a deficit position of 3.071m, against a year to date planned deficit position of 624k. This is a variance from plan of 2.447m and a positive movement in month of 47k. The Trust s overall Monitor financial risk rating at month 10 remains at 3. This is in line with the overall risk rating in the annual plan. 1 of 4

14 Enc Performance month 10 As expected, January was a very challenging month for performance, with emergency admissions being even higher than expected. Despite this, the Trust achieved the required performance standard of 95% for treatment of all types of accident and emergency attendances within four hours. As planned, the Trust has not achieved the target of 90% for 18 week referral to treatment for admitted patients as the treatment of longer-waiting patients has been prioritised. At the end of the month the patients who remained on the waiting list were within the required targets. Cancer wait access targets have been under pressure in January and there has been a marginal underperformance. However, the Trust remains confident that this can be managed throughout the rest of the quarter in order to achieve the required levels for these indicators. The Trust has had another successful month with regard to hospital acquired infection rates. There have been no reported MRSA bacteraemia in month 10 and it is now over 300 days since our last reported post 48 hour bacteraemia. There have been two reportable C-difficile cases in month 10, resulting in a year to date performance of 47 compared with our quota of 63 cases. The start of month 11 has provided further challenge as emergency attendances remain higher than expected. 4. South London Healthcare Trust and King s Health Partners Following submission of the Trust Special Administrator s final report on the 08 January 2013, the Secretary of State announced his decision on the recommendations on the 31 January With the exception of the University Hospital Lewisham (UHL) service reconfigurations, all the recommendations were accepted in full. The UHL service reconfigurations will be subject to a review by the NHS Medical Director, Professor Sir Bruce Keogh. The King's team are continuing to prepare a full business case in relation to this transaction. There is now broad agreement that should the transaction proceed, although this is unlikely to happen before 01 July 2013 and, on this basis, the Board will review the business case in early April. If the Board decides to proceed, the business case will be submitted to Monitor for review in mid-april. Work continues within King s Health Partners on planning the next steps towards creation of a full business case for the potential merger of the three NHS Trusts and closer integration with King s College London. Following his appointment as Director of Transition and Transformation, William McKee is now beginning to assemble his team and progress development of the business case. However, due to the on-going focus on South London Healthcare Trust this work has of necessity slowed down. The team that has been developing plans for the south London Academic Health Sciences Network (AHSN) held a formal panel interview on 24 January, with the national lead, Sir Ian Carruthers, Sir John Bell, Russell Hamilton from the National Institute for Health Research, and senior industry representatives. We expect to hear by the end of February whether or not the AHSN will be licensed to operate from 01 April Good progress is being made, in particular with the first of the clinical themes: diabetes. On 01 February a large number of clinicians, academics, patients and other stakeholders from across the network area came together to discuss the needs across the 12 south London boroughs, and began to explore potential solutions. 2 of 4

15 Enc Integrated Care There are now 52 GP practices signed up to deliver integrated care across Lambeth and Southwark and 7 Community Multi-Disciplinary Teams (CMDTs) regularly meeting to discuss and action care for older people with complex needs. Work is on-going to simplify the hospital discharge process including looking at assessment and referrals from the acute sector, electronic information sharing, a single point of access for community services and a more responsive community service. The Programme Board has approved the proposals to use a small number of ICT products that support the sharing of patient information across the health and social care settings and work has begun to implement these. 6. Dignity Month This is Dignity Month, which involves all Board members and governors visiting wards in a programmed and organised way to promote patient dignity. Treating patients with dignity is a fundamental principle which runs through all of the King s Values. The Innovation in Dignity Care awards on 11 March will celebrate and promote innovation and will be the culmination of a programme of ward visits and masterclasses which champion the importance of dignified care. Ward visits represent an opportunity for interaction across the organisation and for patients, nurses, therapists, housekeeping staff, volunteers, governors and directors to share ideas about how to improve the experience of patients. 7. Capital, Estates & Facilities Critical Care Unit Enabling works are to commence in early March for this new purpose built critical care facility with capacity for 60 patients over two floors. Staff are invited to view architectural plans and to gain an understanding of the building process at drop-in events this month. Helideck Detailed design is underway and a works methodology has been developed in parallel with the Critical Care Unit scheme. Cheyne Wing Ground Floor Refurbishment of the corridors on the ground floor of Cheyne Wing will commence in early March and take 12 weeks to complete. The works will refurbish floors, walls ceiling, doors and lighting from Renal Outpatients to the central bear pit area. Solar Panel Installation During February the Estates team will install solar panels on two roof pitches of the Day Surgery Unit. By generating electricity to be used within the estate these solar panels will provide the Trust s first renewable source of energy. Golden Jubilee Wing Lifts Works have commenced to upgrade the lifts in the GJW. All lifts will be completed by the end of May of 4

16 Enc Media & Events (17 January 15 February) Press and broadcast coverage 23 January - King s Consultant Hepatologist Dr Varuna Aluvihare provided expert comment for a BBC Online article about the UK s first altruistic liver donation. Dr Aluvihare discussed the risks involved in donating part of your liver. 29 January - Dr Varuna Aluvihare was also interviewed on BBC Radio 4 s Inside Health. Dr Aluvihare provided expert comment on the number of alcohol related deaths in February - Dr Emer Sutherland, A&E Head of Nursing Tricia Fitzgerald and social worker John Poynton were the focus of an in-depth article in The Sunday Times about how the work of our Emergency Department helps victims of gang violence. In the first scheme of its kind in the UK, youth workers are based in the Emergency Department at King s so they can talk to victims of gang violence when they are in a teachable moment. This work is sponsored not only by the Trust but also by the charities across KHP. 17 January-15 February - There has been extensive media coverage about the Trust Special Administrator s recommendations to break up South London Healthcare NHS Trust, and make changes to Lewisham s A&E and maternity services. There has been coverage albeit on a smaller scale - about the Secretary of State for Health s decision to recommend King s acquisition of the Princess Royal University Hospital. However, most of the media attention has been focused on changes to Lewisham, and the potential impact this could have on King s maternity and A&E services, as well as other hospitals in south east London. Events 31 January The Minister for Civil Society, Nick Hurd MP officially opened a new volunteers area at King s, located at the entrance of Hambleden Wing. During his visit, Mr Hurd MP was introduced to some volunteers and heard about what they do, why they do it, and their experience of King s. Mr Hurd was also given a tour of the Cardiac Catheter Lab, general surgery and our urology outpatient area. Upcoming 21 February King s staff and governors will be meeting with key stakeholders from Bromley to discuss the proposed acquisition of the Princess Royal University Hospital. 9. Consultant Appointments Following Advisory Appointment Committees in the past month, there have been three consultant appointments. Specialty New/Existing Appointee Start date Medical Microbiology New Surabhi Taori 01/03/2013 Anaesthetics (Major Surgery) Existing Derek Amoko 01/03/2013 Anaesthetics (Major Surgery) Existing Tim Hughes 01/04/ Chief Executive s Brief The CEO Brief for February is attached. 4 of 4

17 CHIEF EXECUTIVE S BRIEF February 2013 Issue 77 An update from the Chief Executive to all staff at King s College Hospital Mid Staffs will forever be synonymous with the lowest quality of care that the NHS is capable of delivering. Francis hopefully will be synonymous with a turning point for the culture of the NHS. Compassionate and kind care at the centre of everything we do. I think that is what our values mean, and in particular Inspiring Confidence in Our Care. I hope there won t be any knee-jerk reactions to the report, and we at King s will definitely want to look carefully at its findings and at the way the Board is connected to the ward. I will keep you informed of our plans, and I hope anyone in Team King s who is concerned about quality issues will let us know. As we come towards the end of another challenging year for the NHS, King s is in a relatively good place. Although our finances are as challenged as ever, we have had a very good year in terms of patient safety, and in terms of strategic development. We have a very strong team, and we are grateful to everyone for their commitment. At the beginning of last year I remember saying that our Values would help sustain us, and it seems that is the case, even though we still have financial and operational performance issues that need to be resolved. If we acquire the Princess Royal University Hospital in Bromley, it will be the most significant development at King s for many years. We will be able to improve healthcare for the populations in outer southeast London, and this will in turn improve our capacity constraints here on Denmark Hill. I know that all of us will want to embrace our colleagues in Bromley and welcome them to the culture that makes King s great. However, there are difficulties associated with last week s announcement by the Secretary of State. There is a lack of clarity about emergency care at Lewisham, and that will have knock-on effects for all of King s Health Partners, as will the downgrading of the maternity provisions at Lewisham. We will need to invest in more capacity on Denmark Hill, and we will have to work ever more closely with our colleagues at GSTT to ensure that we can accommodate the increased workload. The implications for the KHP journey, and the potential merger of the three FTs, are still being assessed. We are busy planning the events to commemorate the centenary on Denmark Hill, and I am quite excited about them. We have been making a contribution to the communities around this location for 100 years, and we are looking forward to the next 100 years. Who would care to imagine what healthcare will be like in 100 years. We certainly have to navigate some still very tricky waters in the next few years, but I am optimistic that we will do so. Last week we received a visit from Nick Hurd MP, the Minister for Civil Society in formal recognition that our volunteers programme is exemplary and could be used as a model to help improve the quality of care across the NHS. We have over 700 volunteers now, and they are very representative of the communities we serve. They undoubtedly improve the quality of care we provide, and I thank them all. I also thank staff across the hospital for helping them integrate into Team King s. Tim Smart Chief Executive

18 An update from the Chief Executive to all staff at King s College Hospital Find out more about new Critical Care Unit As many of you will know, the Trust is in the advanced planning stages for a new, cutting edge critical care facility here on the King s site. With capacity for 60 patients, accommodated over 2 floors, the new facility will enhance King s ability to care for our sickest patients. It will be equipped with state of the art assessment and monitoring equipment, and provide a more appropriate environment for staff to work in, and patients to be treated in. The Trust is holding two drop-in sessions during February so that staff within the hospital can view and comment upon the proposals, time line and work plan. They are as follows: Time/date pm; Monday, 18 February. 9am-2pm; Monday, 25 February. Location Dulwich Room Dulwich Room At these sessions there will be a chance to meet the architects, review the architectural designs and drawings, understand how the building process may impact upon the hospital, and how the new unit will change the environment we provide to care for critically ill patients. Staff Appraisals Appraisals are a key way for managers to monitor how their staff are progressing, and an opportunity for staff to identify ways for them to improve and progress in their careers. Everyone in the Trust needs to be appraised, and the details need to be completed on the Electronic Knowledge and Skills Framework (e-ksf) by 31 March. If you need a refresher course on how to use e-ksf, please contact the HR department on ext 1675 or ann.baker@nhs.net. 24 Hours in A&E Filming for series 4 and 5 of 24 Hours in A&E the documentary series about our Emergency Department begins on 12 February and finishes on 28 March. The production team have tried their best to meet as many teams as possible, particularly those that work closely with the Emergency Department on a regular basis. However, given the size of the Trust and the number of people that work here (over 7,000 people), it has of course not been possible for them to speak to everyone. If you or your team have not been contacted, or you simply want to find out more about the series, please contact Chris Rolfe in communications on x 3006 or chris.rolfe@nhs.net. Staff health & wellbeing drop-in event 14 February, 11am-2pm, Boardroom Staff spend their working day looking after the health of others. In doing so, it is easy for staff to overlook their own health needs. In order to keep our staff in tip-top condition, our occupational therapists will be holding a 'one-stop shop' event in February where staff can get advice on a variety of different aspects to help them lead a healthier life. There will be a number of both internal and external specialists on-hand to advise staff on physical and mental health, smoking cessation, losing weight and getting fit, and a great deal more. The event will be held in the Boardroom on 14 February between 11am and 2pm. There will also be a number of healthy snacks available for attendees. King s dignity awards - 11 March, 12pm 2pm, Boardroom (drop-in event) In March, we will be holding our annual awards ceremony for Innovation in Dignity Care. This year s finalists represent staff from many areas across the hospital, including nurses, therapists and housekeeping staff. It is crucial that we continue to champion the importance of treating people under our care as individuals with choice, control and a sense of purpose in their daily lives. We initiated these awards to help raise the profile of privacy and dignity and promote innovation in this area. The awards give us an opportunity to celebrate our work, to build on our culture of dignity and respect, and to improve the quality of care we provide. Staff, patients and stakeholders have been invited to attend the awards to hear all about the innovations in this area that is so fundamental to all the work we do. Date of last MRSA bacteraemia: 17 April 2012 Clinical area: Donne Ward (Ambulatory) Cause: Deep skeletal infection in a patient with previous MRSA bloodstream infection at another facility.

19 Enc. 2.5 Report to: Finance and Performance Committee Date of meeting: 16 th February 2013 Subject: Finance Committee Report Month 10 (January 2013) 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 1

20 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 2

21 Enc. 2.5 Finance Report Month 10 (January) 2012/13 Finance Committee 26 th February 2013

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

23 Month 10 Executive Financial Summary Enc. 2.5 Annual Budget YTD Budget YTD Actual Month 10 YTD Variance Month 9 YTD Variance Movement in Month '000 '000 '000 '000 '000 '000 Income (excluding off Tariff Drugs) 622, , ,351 12,604 8,127 4,477 Off Tariff drugs Income 24,950 20,792 24,116 3,324 2, Pay (368,492) (306,802) (308,222) (1,420) (259) (1,161) Non-Pay (excluding off tariff drugs) (304,198) (243,882) (257,150) (13,268) (9,988) (3,280) Off Tariff Drugs Expenditure (24,950) (20,792) (24,116) (3,324) (2,600) (724) Capital Charges, Interest and Dividends 44,172 34,273 34,108 (165) (145) (20) SLR/Internal Recharges (4) 40 (158) (198) (229) 31 Total (6,000) (624) (3,071) (2,447) (2,494) 47 Financial Summary The Trust is reporting a year to date deficit position of 3.071m, 2.447m adverse from plan, and an favourable movement of 47k from Month 9. An income accrual has been included in the month 10 position for Winter Pressure and SLHT Business Planning costs incurred to date ( 2.5m). Nursing costs have overspent by 1m in month across all Divisions except Ambulatory Care and these costs partly relate to Winter Pressure schemes. The current deficit of 3.071m includes a 6m asset valuation impairment accrual which means the Trust has achieved an operating surplus of 3.065m to date. The projected year end position is less straight forward due to the adverse financial movements in Liver, Neurosciences and Ambulatory Care in months 9 & 10. The projected financial scenarios for year end are shown on page 9 and the mid-case scenario is an operating deficit of 899k at a financial rating of 3. The CIP adverse variance is 5.9m to date and the year end CIP forecast is an adverse variance of 8m, a projected movement of 2.1m to year end (page 19). This is a projected 31m (79%) achievement against a plan of 39.1m. The key variances relate to income targets for RTT activity, Private Patient activity and productivity targets due to bed/theatre capacity issues and additional activity winter pressures. Non-pay savings have under-delivered in respect to procurement and managing diagnostic demand. The overall income position still remains positive with a favourable movement against plan on PCT income to the value of m; and off-tariff drug over-performance of 3.324m to date. The additional unplanned activity is not delivering a sufficient margin to compensate for the adverse CIP performance due to incremental non-pay cost pressures (e.g. agency staff costs and off-site working) and off-tariff drugs. The Monitor Rating for the year is 3 in line with the Annual Plan target to date. Page 5

24 Financial Risk Rating Ratios Enc. 2.5 Financial Criteria Weight (%) Metric to be scored Month 10 Month 10 Rating 12/13 Plan 12/13 Plan Rating Achievement of Plan 10 EBITDA achieved (% of plan) 91.0% % 4 Underlying Performance 25 EBITDA Margin (%) 5.5% 3 5.6% 3 Financial Efficiency 20 Net Return after Financing (%) 0.7% 3 0.8% 3 20 I&E surplus margin (%) 0.5% 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

25 Forecast Outturn Position 2012/13 Enc. 2.5 The historic variances at month 10 have been used as a basis for the year end financial projection as disclosed on pages 10 to 17. The following factors have also been built into the year end forecast: 1) The current bed pressure in respect to General Medicine bed outliers which is having a detrimental impact on the planned elective activity targets (notably Neuroscience services). 2) Winter pressure schemes to sustain patient safety and quality care (e.g. the mobile critical care service and quicker Mental Health patient pathways); and to deliver performance improvements (e.g. A&E access targets and LAS related KPIs by extending AAU). The Trust has submitted bids up to 6.5m but is expected to receive between 2m and 3m. The key schemes are shown on page 8. The Trust has already committed to a number of these schemes on the basis that this expected funding will be received. 3) The expenditure and funding to cover the SLHT business planning and due diligence process is also incorporated in the forecast. 4) The jointly agreed estimated LSL PCT contract outturn position is factored into the overall Trust income position. The Divisional Managers have been involved in and agree to the forecast outturn projections and will need to ensure these financial targets are achieved to maintain the Monitor Financial rating of 3. There have been exceptional adverse variances beyond the initial year-end projections for Liver, Neurosciences and Ambulatory Care (see page 9); and these variances will be reviewed at the Performance meetings on the 27 th of February. Although the Trust has received agreement of the following income flows, no payments have been received to date. 1) Project Diamond Funding (Tertiary tariff funding and MFF on R&D income) 2) SLHT Business Planning Funding 3) Winter Pressure Schemes Funding (Phases 1 3) The performance monitoring and support documentation is currently being agreed and supplied in respect to the appropriate income flows. Page 7

26 Examples of Winter Pressure Schemes Enc. 2.5 Phase Details of scheme to be funded Intended outcome of scheme e.g., what level of performance improvement will be achieved, and by when? 1 2 ED Nursing shifts to supporting opening of additional CDU beds RDL winter pressure beds (from mid Jan 13).These are necessary to support the move and refurbishment of the Acute Assessment unit. RD Lawrence ward will house 12 winter pressure beds during this period CC Consultant Saturday and Sunday working - ensure Consultant and medical cover at weekends is consistent with level of cover during the week, this will help 'pull-through' of patients into CC from ED/Major Trauma Provision of additional Beds to support Community Beds from December - March Mobile Critical Care Service to manage deteriorating and critically ill patients outside of CC. CC capacity is routinely operating at over 100%, additional beds approved within new build will not be operational until spring This is an interim measure to manage patients on the wards either as a substitute for ICU admission or in advance of ICU admission. This will facilitate the ability to flex more of the existing adult cc bed pool up to Level 3. This will also support increased ED/Trauma referrals. Out-treat service will facilitate early discharges and reductions in delayed admissions. Achievement of 95% target, immediate impact. (admission avoidance, ability to manage short stay patients more appropriately while maintaining assessment capacity within the department) Achievement of 95% target, immediate impact. (additional winter pressure capacity across medicine to deal with demand) Improved flow through of patients into critical care Additional Elective activity and appropriate cost effective care Supporting the rest of the Hospital and making it safe through increasing CC capacity to meet demand. To be implemented Jan 13 3 LAS performance - additional nursing & admin shifts Extending AAU - additional porter, nursing & medical shifts to support 24/7 opening Elective short stay admissions ward (9 beds) and admissions lounge Achievement of 95% target, immediate impact. (improved performance against 15 minutes handover target) Achievement of 95% target, immediate impact. (pull through of medical patients from ED, freeing capacity for timely assessment of ED patients 24/7. Supports admission avoidance) Improved RTT performance Page 8

27 Forecast Outturn Position 2012/13 Enc. 2.5 Division Year-end Forecast at M8 '000 Year-end Forecast at M9 '000 Year-end Forecast at M10 '000 Winter Pressure/ South London Business Planning Costs not already in Forecast Worst Case Scenario Mid-Case Scenario Best Case Scenario LRS -4,445-5,214-6, ,172-6,172-6,172 Networked Services -3,221-4,098-5, ,899-5,899-5,899 Guthrie -1,785-2,545-2, ,514-2,514-2,514 Facilities -1,101-1,333-1, ,603-1,603-1,603 TEAM ,275-1, ,112-1,112-1,112 Commercial services , ,048-1,048-1,048 Ambulatory PFI Operations Finance & Information ,753-3,175-3,175-3,175 Human Resources ENPDT W&C Corporate Strategic Development Dental Captial Charges CCTD CSDS 2,351 1,519 1, ,519 1,519 1,519 R&D 1,879 2,282 2, ,201 2,201 2,201 Income 3,000 5,040 5,464 6,074 11,638 12,388 13,138 Total Forecast Variance -5,388-5,692-9,070 3,321-5,649-4,899-4,149 Less planned operating surplus 4,000 4,000 4,000 4,000 4,000 4,000 Financial Gap to breakeven -1,388-1,692-5,070-1, Financial Rating Best case scenario includes full payment for RTT Activity / Winter Pressure Costs / SLHT Planning Costs / Project Diamond Funding Page 9

28 I & E Summary Enc. 2.5 Income is over-performing by 15.9m YTD. However, 3.3m of this relates to off tariff drugs, without which the net over-performance drops to 12.6m. PCT patient activity 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 5.2m due to increased activity beyond plan in critical care, day case and outpatient services. Elective and tertiary activity continues to under-perform. 2.5m of winter pressure / SLHT Business Planning central funding has been accrued this month based on expected payments from South East London PCTs / NHS London. Pay is over-spent year to date by 1.4m an adverse movement in month of 1.2m. Nursing moved by 1.1m this month and is now 3m over-spent YTD. The unfavourable movement this month was mainly in LRS, NWS, TEAM (additional ED shifts), W&C (PICU/NICU) and CCTD (additional ICU beds and day surgery weekend lists). Non Pay is overspent by 17m, an adverse movement of 4m: The main drivers of this overspend are Drugs ( 8.4m) and Clinical supplies ( 5.5m). The adverse movement this month was mainly in clinical supplies and drugs some of which is recovered through off tariff income. Premises and fixed plant costs ( 1.7m):Energy 1m price inflation, additional insurance costs, maintenance costs as previously stated. External Contracts ( 2m) :Medihome, Consultancy this includes EY Business Planning costs, and various external contractors providing operational and legal support to various projects e.g. outpatient transformation, interpreting. Page 10

29 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. Page 11

30 Temporary Pay Analysis Trend Enc. 2.5 The graph to the left shows spend on bank and agency nursing over the previous periods and it is showing that the trend is on the increase. This month has seen an increase in CCTD B&A spend due to additional critical care capacity and weekend day surgery lists. The Emergency Department has also seen a significant increase this month due to additional shifts. Overall there has been an increase in the number of shifts being escalated to agencies this month and a need for more highly skilled nurses, particularly in ED. This has contributed towards the increased spend this month. The graph to the right highlights an increase in spend on agency medical staffing over the previous period, with a steady upward trajectory. This is in the main due to locum cover for recent consultant vacancies and holiday cover. Increasing activity demands has also put pressure on the usage of agency medical staff in order to achieve planned RTT targets, this must be monitored closely as access to beds and theatres will limit productivity. Page 12

31 Temporary Pay Analysis by Division Enc. 2.5 Agency spend (shown to the left) is 2% down on the same period year to date last year, with reductions in CSDS and Critical Care offset by increases in all other areas. Agency spend has started to increase and was particularly high in CCT and Team this month Bank spend (shown to the right) is 1% down on the same period year to date last year, with reductions in LRS, W&C and Critical Care, and increase in Networked services, and TEAM Page 13

32 Divisional Variance Analysis Enc. 2.5 Material off-track variances to plan are as follows: Ambulatory - 546k adverse, 881k adverse movement. There was a large adverse movement this month due to a significant increase in drugs expenditure in January. More information is needed from pharmacy to establish if this is recoverable through off tariff income. Cardiac - 1.3m adverse, 200k adverse movement. This is mainly due to income being less than anticipated in September but FCE s are now back up to expected levels. This months adverse movement is mainly due underperformance against elective income targets due to bed pressures. Neurosciences - 2.5m adverse, 742k adverse movement. Income is 1.1m adverse where Neurosurgery RTT and CIP targets are not being achieved. Drugs are 646k 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. This months adverse movement is mainly due underperformance against elective income targets due to bed pressures and the loss of recovery theatres for 2 weeks. Liver 2.2m adverse, 525k adverse movement. Income is over-performing by 803k but the majority of this is off tariff drugs income. Nursing is 636k overspent, particularly in theatres and LITU. Drugs are 1m overspent, although this is mostly recovered through income. (Removing the effect of drugs will make the income position adverse). The maid driver of this months variance is the use of agency staff in LITU and consumable cost relating to off site working. Surgery - 2.9m adverse, 314k adverse movement. Income is 2.8m 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. Page 14

33 Divisional Financial Performance Enc. 2.5 This Chart shows the Divisional adverse (red) and positive (green) variances against plan. Page 15

34 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 (122,487) (102,102) (101,543) (149) Nursing Staff (140,145) (116,561) (119,599) (3,038) (1,954) (1,084) A&C Staff/Senior Managers (54,477) (45,376) (44,628) PAMS (18,166) (15,133) (14,626) Directors (1,419) (1,182) (1,272) (90) (84) (6) Scientific/Professional (29,745) (24,737) (24,904) (167) (183) 16 Other (2,053) (1,711) (1,650) (19) Sub-total (368,492) (306,802) (308,222) (1,420) (259) (1,161) NON-PAY Clinical Supplies (59,416) (49,449) (54,957) (5,508) (4,452) (1,056) Drugs (58,090) (48,409) (56,802) (8,393) (6,515) (1,878) Non Clinical Supplies (32,191) (26,885) (28,863) (1,978) (1,402) (576) PFI (25,617) (21,348) (21,755) (407) (159) (248) Capital Charges (25,041) (18,395) (18,454) (59) (45) (14) Interest and Dividends (19,131) (15,878) (15,654) SLR Recharges (7) (5) (54) (49) (2) (47) Recharges 11 (35) Misc. Other Operating Exp (65,498) (49,957) (50,989) (1,032) (808) (224) Sub-total (284,980) (230,361) (247,316) (16,955) (12,962) (3,993) Total Expenditure (653,472) (537,163) (555,538) (18,375) (13,221) (5,154) All Income 647, , ,467 15,928 10,727 5,201 Income and Expenditure (6,000) (624) (3,071) (2,447) (2,494) 47 Page 16

35 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 103,972 85,788 88,673 2,885 2,889 (4) Pay (44,099) (36,741) (35,310) 1,431 1, Non-Pay (24,542) (20,489) (24,365) (3,876) (3,100) (776) Recharges (174) (145) (147) (2) (1) (1) AMBULATORY SERVICES Total 35,157 28,413 28, ,145 (707) Income 155, , , Pay (57,060) (47,549) (48,387) (838) (693) (145) Non-Pay (46,178) (38,416) (42,457) (4,041) (2,800) (1,241) Recharges NETWORKED SERVICES Total 52,478 43,184 38,908 (4,276) (2,933) (1,343) Income 40,754 33,824 36,324 2,500 2,597 (97) Pay (66,660) (55,523) (55,171) (181) Non-Pay (55,360) (46,017) (50,684) (4,667) (4,375) (292) Recharges CRITICAL CARE, THEATRES AND DIAGNOSTICS Total (81,266) (67,716) (68,975) (1,259) (823) (436) Income 136, , ,908 (1,353) (1,083) (270) Pay (56,574) (47,017) (48,277) (1,260) (1,142) (118) Non-Pay (25,887) (21,465) (22,105) (640) (244) (396) Recharges (47) (59) 12 LIVER, RENAL AND SURGERY Total 54,595 46,063 42,763 (3,300) (2,528) (772) Income 73,486 61,110 63,920 2,810 1,776 1,034 Pay (51,068) (42,487) (43,237) (750) (284) (466) Non-Pay (6,184) (5,151) (6,675) (1,524) (1,251) (273) Recharges TRAUMA, EMERGENCY & ACUTE MEDICINE Total 16,234 13,472 14, Income 94,257 77,935 79,995 2,060 1, Pay (53,149) (44,288) (45,223) (935) (758) (177) Non-Pay (7,819) (6,511) (7,492) (981) (1,033) 52 Recharges WOMENS AND CHILDRENS Total 33,289 27,136 27, Income 16,302 13,585 12,677 (908) (918) 10 Pay (2,774) (2,311) (2,377) (66) (35) (31) Non-Pay (4,036) (3,364) (3,295) (211) Recharges (1,005) (837) (1,171) (334) (264) (70) Private Patient Service Total 8,487 7,073 5,834 (1,239) (937) (302) Income 26,931 21,439 28,853 7,414 3,276 4,138 Pay (37,107) (30,884) (30,240) (117) Non-Pay (95,859) (73,032) (74,747) (1,715) (856) (859) Interest and Dividends (533) (674) (536) (138) SLR Recharges 11 (35) Recharges (19,131) (15,878) (15,654) Corporate Services Total (124,985) (98,249) (92,109) 6,140 3,066 3,074 Income 647, , ,467 15,928 10,727 5,201 Pay (368,491) (306,800) (308,222) (1,422) (261) (1,161) Non-Pay (265,854) (214,445) (231,820) (17,375) (13,379) (3,996) Interest and Dividends (533) (674) (536) (138) SLR Recharges 11 (35) Recharges (19,308) (16,024) (15,175) Trust total Total (6,000) (624) (3,071) (2,447) (2,494) 47 Page 17

36 Private Patient Income Enc. 2.5 Private Patient Projected Cap % 2012/ /2012 '000 '000 Private patient income * 15,212 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 18

37 2012/13 CIP YTD Summary Enc. 2.5 PERFORMANCE AGAINST PLAN CIP variance CIP YTD Target YTD Actuals Variance Forecast Identified ACLN 1,981 1,650 1, CCTD 3,565 2,813 2, TEAM 1, LRS 2,580 2,112 1, NWS 4,140 3,365 2, W&C 2,342 1,927 1, Facilities Corporate 1,243 1,038 1, Trustwide 21,913 18,113 14,639-3,474-4,699 TOTAL 39,119 32,109 26,180-5,929-8,064 Year to date under performance against CIPs amounts to 5,929k, 82% achievement. The forecast Year end CIP variance position is 8.064m, with the major variances as follows :- ACLN: 263k Pharmacy schemes ( 209k of which relates to drugs purchase schemes) CCTD: 310k MRSA, 300k OP Project, Divisional Income schemes 83k TEAM: 216k Reduction in outliers, Divisional Income schemes 108k LRS: 267k Reduction in diagnostics tests, 100k immunosuppressant savings, 73k Pharmacy drug purchase schemes, 51k Transplant Coordinator, 47k Hepatitis supplies re-tender, 30k FP10 reduction, 30k Ward shift overlap review NWS: 310k Spinal/Neuro consumables tenders (Procurement led), 225k additional EP/ NSTEAC list income, 130k Pharmacy drugs purchase schemes, 80k Cardiac theatre cross cover income, 70k Libyan BMT patients, 50k coding depth project, 50k Darbopoetin drugs W&C: 140k NICU/Maternity Bank & Agency reduction, 59k St Heliers patients, 27k Drug purchase schemes Facilities: 70k Reduction in Consultant / Legal fees, 7k wall washing contract reduction Corporate: Negligible Trustwide: 2.7m RTT, 1m Private patient / commercial income, 350k Noteless, 250k Nursing establishment reviews, 178k Service reviews, 117k Medical Productivity (due to inclusion in Divisional trackers), 100k HR Workforce CIP Recovery Action plans Finance / CIP meetings held on a monthly basis to discuss and agree recovery plans Key focus on RTT, diagnostic tests (MRSA & LRS), and resolution of Procurement tender savings with respect to Spinal Implementation of winter pressure capacity developments: AAU, CDU and elective short stay Surgery (transfer of Renal to Dulwich and other satelite units) to reduce medical outliers Page 19

38 2012/13 CIP YTD Performance by Key Themes Enc. 2.5 Cost saving Division specific 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 Original Plan 12,000 2,800 1,000 2, ,000 2,000 1,000 9,000 2,600 42,300 Revised Plan 10,180 1, ,218 3,913 1,070 9,000 3,713 39,119 YTD Plan 8,192 1, ,951 3, ,500 2,984 32,109 YTD Actual 6,285 1, ,864 3, ,500 2,460 26,180 YTD Variance -1, , ,929 Key Variance Notes 2,086k relates to RTT income under achievement, most notable in Bariatrics ( 1.2m), Neurosurgery ( 469k), Orthopaedics ( 218k), and Liver ( 120k). 3.2m of these schemes are RAG rated Red. 843k 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). 35k relates to Libyan BMT patients. 524k relates to an income shortfall based on productivity targets (e.g. reduced patient length of stay) across specific Divisional wards. 36k relates to coding optimisation income targets led by the Divisional management teams ( 61k), which has been partly offset by a small over-performance of centrally led Contracts/Coding team targets. 452k relates to diagnostics demand management targets not being achieved across specific Divisions. 275k relates to Procurement savings schemes the majority of which is due to the Neurosurgery Spinal implant tender ( 250k) 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 32.6m. Although a total CIP of 39.1m has been identified to date, 9.0m is red RAG rated. The data analysis for the and coding optimisation income CIP is based on 8 months activity and the savings achieved are potentially overstated. The Trust-wide income target above includes RTT activity, PCT activity QIPP and repatriation targets, central coding optimisation and Private Patient income targets. Page 20

39 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, ,041 W&C 1, Facilities Corporate 1, Trustwide 14,194 2,524 5,195 TOTAL 26,578 3,554 8, m CIPs identified against a stretch gross target of 42.3m. However 9.236m (23.6%) 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 If scheme has not yet started, RAG rating is based on delivery plan status. 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: TEAM: LRS: NWS: W&C: 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 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 132k Drug purchases savings substitution by Pharmacy 135k NICU Bank & Agency savings plan to recruit 36k Drug purchases savings substitution by Pharmacy Trust wide: 2.1m Bariatrics RTT income capacity issues & demand 1m Neurosurgery RTT income - capacity issues & demand Page 21

40 2012/13 CIP YTD Performance by Division Enc. 2.5 Notes ACLN: 220k adverse variance: 219k Pharmacy schemes under achievement (of which 174k relates to drugs purchase schemes) CCTD: 434k adverse variance: 258k Demand Management, 100k OP Dispensing Project, 67k activity increase (2 schemes) TEAM: 216k adverse variance: 121k reduction in outliers (high risk scheme,) 43k Divisional income opportunities, 25k Coding, 21k Drugs purchases schemes under achievement. LRS: 527k adverse variance: 178k Diagnostics reduction, 61k Drug purchases schemes, 25k FP10s, 34k Hepatitis supplies retender, 67k immunosuppressant savings, 40k Transplant co-ordinator vacancy, 24k Nursing workforce shift pattern overlap reduction NWS: 807k adverse variance: 250k Neuro Spinal implant tender, 125k Cardiology Saturday lists, 107k Drugs purchase schemes under achieved, 67k Cardiac Theatre utilisation, 56k additional EP sessions, 35k Libyan BMT patients, 30k coding depth project, 25k drug substitution scheme W&C: 178k adverse variance: 87k NICU bank and agency use reduction, 42k additional St Helier patients, 23k Pharmacy drugs purchase schemes under achievement, Facilities: Corporate: Trustwide: 62k adverse variance: 56k Reduction in Consultancy / Legal fees 12k adverse variance: 8.6k reduction in Consultancy costs, 0.8k Occupational Health Drugs purchase savings not achieving 3,474k adverse variance: 2,087k RTT income, 808k Private Patient / Commercial income, 233k Noteless, 167k Nursing establishment review, 78k Medical Productivity, 66k Shift pattern review, 59k Service reviews Page 22

41 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 ,650 CCTD 439 1, ,813 TEAM LRS ,112 NWS 1, , ,365 W&C 1, ,927 Facilities Corporate ,038 Trustwide 17, ,113 TOTAL 21,768 4,373 1,544 2,525 1, ,109 SPLIT OF CIP YTD ACTUALS BY MONITOR CATEGORY Non- Income Pay Drugs Clinical Supplies Clinical Supplies Other Misc Total ACLN ,430 CCTD 403 1, ,380 TEAM LRS ,585 NWS 1, ,558 W&C ,749 Facilities Corporate ,026 Trustwide 14, ,639 TOTAL 18,267 3, ,864 1, ,180 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, ,474 TOTAL -3, ,929 Page 23

42 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 ,143 2,342 Facilities Corporate 1, ,243 Trustwide ,218 2,700 1,000 9, ,913 TOTAL 10,180 1, ,218 3,913 1,070 9,000 3,713 39,119 Page 24

43 Month 10 Capital Summary Enc. 2.5 Capital Plan The annual capital budget is m as at month 10, an increase of 282k on month 9. The additional budget is covered by funding from the Foundation Trust Financing Facility for the Critical Care Unit of which 3m is expected to be utilised in 2012/13. Capital Expenditure YTD Capital expenditure to month 10 was m against a reforecast year-to-date budget of m, a YTD overspend of 770k. The overspend against YTD budget is primarily due to the overspends on the Endoscopy Unit and Units 4 & 6 (below). Capital Scheme Projected Variances The forecast overspend to year-end is 3.7m (19% of current capital budget) against the revised plan. Capital Scheme Overspend '000 Endoscopy 865 Comments 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. AAU move to old Endoscopy area 300 Additional costs due to design requirements and fees. 50k Accelerator fees included. Units 4 & Unit 6 change of use of 1st Floor to clinical area (Assisted Conception Unit) and Unit 4 additional cost to include transformer for power supply. Emergency Department 100 Additional external works required to install transformers. Transfer of Renal Services to Dulwich 200 No budget allocated as this is a new project required for Winter Bed Pressure Capacity Planning Brunel Ward 250 No budget allocated. Reconfiguration of Brunel Ward to accommodate additional Winter pressure capacity requirements. MRI Building Works 177 Delays due to equipment specifications leading to contract extensions and additional design fees. PET CT Scanner Design Fees & Enabling Works 100 No budget allocated as this was a new project required to accommodate the purchase of the PET CT Scanner. Other Major / Minor Work Schemes 369 Overspends due to unplanned essential capital maintenance works. Medical Equipment Purchases 905 Purchase of urgent medical equipment or equipment to support income generating schemes approved through BRSG in year. The Trust is exploring measures to reduce the forecast overspend at year end. These will include a review of IT schemes and Minor Works schemes to potentially defer projects which are not critical or have not been started. Page 25

44 Projected 3 Year Capital Plan Enc. 2.5 Key Projects 2012 / / / / / / / / / / 16 Plan Additional Total Plan Additional Total Plan Additional Total Total '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 1 Maternity (MLU/MAU Expansion) 1,000 (650) 350-1,150 1,150 2 Emergency Centre (excludes MH/Suite 1) ,100 1,200 3 Endoscopy (Building costs - incl Decontamination and refurbishment of corridor/steam pipe removal) 2,500 1,000 3, Clinical Research Facility (Building) 1, , Unit 6 Development 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 1 14,000-12,468 1,532 30,483 (23,683) 6,800 15,000 15,130 30, 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) , 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 (183) MRI - Building Works (BRSG) _ Start 17 Sept (3 months) Ultrasound - Building Works (Single Sex / Diginity) 500 (500) Diabetic Foot Clinic - Environmental (H&S) - ON HOLD 250 (250) Outpatients Refurbishment / Dulwich Transfer (Suite 4) 114 (114) Minor work schemes 1,200 (9) 1,191 1,300 1,300 1,300 1, Information Technology - Tangible Assets 1,000 (50) 950 1,500 (500) 1,000 1,500 1, Information Technology - Intangible Assets 500 (337) Medical Equipment new and replacement (incl Donated) ,000 (500) 500 1,000 1,000 Total 31,558 (12,314) 19,244 40,683 (16,923) 23,760 29,300 18,230 47,530 18,700 Available Funding details Cash from operations Depreciation non-cash charge 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 (300) Cystic Fybrosis Foundation 430 (430) Consulting Rooms for ATOS (Funded by ATOS) Medical Equipment purchases PDC Received PDC Cash from External Loans FTFF (Critical Care Development) 16,000 (12,968) 3,032 30,783 (23,983) 6,800 15,000 15,130 30,130 18,700 Utilisation of Internal Cash Resources (760) 1, (6,741) 6,200 (541) (3,166) 3,100 (66) Total 31,558 (12,314) 19,244 40,683 (16,923) 23,760 29,300 18,230 47,530 18,700 Page 26

45 Capital Expenditure Summary Month 10 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 14,512 12,364 13,774 3,456 17,230 Minor works 1, ,241 Medical Equipment 1,452 1,817 1,252 1,105 2,357 IT and infrastructure Intangibles (IT) Donated - Major Works Donated - Medical Equipment (20) 521 Total Capital Position : Overspend (+) / Underspend (-) 19,244 16,513 17,283 5,634 22,917 Budget Period Budget Actual to date Anticipated Changes Y/E Forecast Gross capital expenditure b/f 19,244 16,513 17,283 5,634 22,917 Gross Cost 19,244 16,513 17,283 5,634 22,917 Less: Capital Donations held on Trust, NOF monies Total Capital Charge against Capital Resource Limit 18,268 15,781 16,307 5,634 21,941 Depreciation non-cash charge 14,996 12,349 12,364 2,632 14,996 PDC Received External Borrowings 3, ,032 3,032 Internal Cash Resources 240 3,432 3, FT Capital Plan 18,268 15,781 16,307 5,634 18,268 Variance : + over / (-) under ,673 Page 27

46 Month 10 Working Capital Summary Enc. 2.5 Working Capital Summary As at month 10 outstanding debtors totalled 29.8m including Private Patient and Overseas Visitors debts. Total gross outstanding debts relating to 2011/12 total 2.163m, a decrease on month 9 of 347k (there are a number of outstanding PCT Credits due to contract under-performance which will be offset against these debtors at year end). Outstanding Debt Relating to 2011/12 M9 '000 M10 '000 MOVEMENT '000 PCT SLA Over performance (6) PCT SLA Invoices NCA Invoices (16) Provider-to-provider Diagnostic Service (6) Staff recharges and other NHS organisations (56) Remaining NHS & Non NHS debt related balances (263) (Relating to: Clinical, Commercial & Non-commercial trial income, Course fees and other patient & non-patient related income) Total Outstanding Debt 2,510 2,163 (347) 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 2012 to January To date (February 2013), m has been received leaving a net outstanding balance of 4.756m. 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 Foundation Trust Financing Facility agreed in December 2012 to provide external funding to the Trust to finance the construction of the Critical Care Unit. 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

47 SLA Over-Performance Invoices 2012/13 Enc. 2.5 Quarter 1 Quarter 2 Quarter 3 Net Total Cash Received Outstanding Cash Croydon 464, , ,241 2,209,034 (970,507) 1,238,527 Bromley 103,544 (94,193) 941, ,402 (272,025) 678,377 West Kent 271, , ,364 1,049,022 (407,659) 641,363 Surrey 238, , ,636 1,139,058 (577,529) 561,529 E of E (All Contracts) 0 277, , , ,807 Croydon (for Renal) 143, , , ,054 (203,531) 259,523 Kingston 48, ,894 57, ,306 (48,290) 161,016 Bexley Care 690, , ,218 1,199,504 (1,044,385) 155,119 SACS (for EAST SUSSEX PCTs) 211, , , ,887 (367,036) 125,851 Medw ay (42,716) 116, , ,850 (171,659) 113,191 Brent Teaching 28,651 52,321 87, ,031 (64,781) 103,250 Ealing 15,732 (1,566) 88, , ,660 Wandsw orth (12,346) 121,466 86, ,782 (109,120) 86,662 Sutton and Merton 10,627 30,308 86, ,464 (40,934) 86,530 Enfield (29,596) 28,010 55,852 54,266 31,144 85,410 Havering 48,858 51,365 82, ,720 (108,346) 74,374 Haringey Teaching 12,784 37,243 23,240 73, ,267 Barking and Dagenham 24,936 28,794 38,537 92,268 (38,188) 54,080 SACS (for WEST SUSSEX PCT) 494, ,289 49, ,158 (716,392) 49,766 Tow er Hamlets (30,498) 55,528 39,477 64,507 (25,030) 39,477 Westminster 134,747 (9,479) 39, ,385 (125,268) 39,117 Barnet 93,476 43,888 6, ,482 (104,686) 38,796 Hammersmith and Fulham (26,926) (1,271) 29, ,197 29,130 Harrow 4,721 34,269 27,930 66,921 (38,991) 27,930 Islington (46,606) (18,922) 40,586 (24,942) 52,058 27,116 Hillingdon (5,374) 14,344 12,926 21, ,895 Richmond and Tw ickenham (2,397) 23,759 16,756 38,118 (21,361) 16,757 Kensington and Chelsea 87,962 4,199 28, ,206 (104,275) 15,931 Eastern and Coastal Kent (330,493) 147,868 (68,154) (250,780) 257,434 6,654 East Midlands SCG (Trent) 44,200 88,368 5, ,328 (132,568) 5,760 Lambeth 1,802,501 1,457,225 3,867,401 7,127,127 (7,125,266) 1,861 Lew isham 354, ,062 1,925,305 2,614,083 (2,613,823) 260 Southw ark 1,217,352 2,138,916 3,352,394 6,708,662 (6,708,661) 1 E of E (SOUTH ESSEX) 109,529 55, ,621 (164,621) 0 E of E (NORTH ESSEX) 152,275 8, ,526 (160,526) 0 E of E (NSC) (85,321) 344, ,455 (259,455) 0 E of E (Herts) 14,112 3, ,447 (17,447) 0 E of E (Bedfordshire) 24,482 66, ,367 (91,367) (0) Redbridge 6,341 (28,569) (2,823) (25,051) 22,228 (2,823) East Midlands SCG (Northants) 100,882 (17,302) (11,303) 72,277 (83,580) (11,303) Waltham Forest (88,472) (48,057) (13,627) (150,156) 136,528 (13,628) City and Hackney (29,569) 18,190 (14,357) (25,736) 11,379 (14,357) Yorkshire and Humber SCG 25, ,775 (16,521) 116,030 (132,916) (16,886) East Midlands SCG (Leics) (20,830) 24,773 (18,557) (14,614) (3,943) (18,557) South West SCG 131, ,031 (52,660) 453,158 (475,749) (22,591) New ham (71,960) (5,288) (26,151) (103,399) 77,249 (26,150) Camden (1,550) (28,042) (1,581) (31,174) 0 (31,174) South Central SCG (355,018) (256,871) (46,882) (658,771) 611,890 (46,881) Hounslow (59,500) 25,625 (68,600) (102,474) 0 (102,474) East Midlands SCG (Milton Keynes) (175,223) (154,793) (147,704) (477,721) 330,017 (147,704) Greenw ich Teaching (90,119) (334,369) 84,927 (339,561) 152,563 (186,998) 5,607,093 7,596,252 13,372,343 26,575,689 (21,819,228) 4,756,461 This table has been prepared as at 15 February 2013 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

48 Working Capital - Debtors Enc. 2.5 Total Outstanding 0-30 days days days Over 90 days NHS Bodies Primary Care Trusts 9,225,929 2,439,438 2,201, ,005 4,326,078 Department of Health / SHA 297, ,034 67,907 57,232 18,448 Provider Trusts 6,421,123 3,229,520 1,319, ,825 1,147,915 NHS Trade Debtors 15,944,673 5,822,992 3,589,179 1,040,061 5,492,441 Provision for Bad Debts (580,667) (580,667) NHS Bodies Total 15,364,006 5,822,992 3,589,179 1,040,061 4,911,774 Non NHS Bodies Scottish, Welsh & Irish Health Bodies 709,136 90,668 (7,614) 46, ,759 King's College London University 4,134, , ,619 2,427,408 1,388,627 King's Charitable Trust 49,818 5,169 6,892-37,757 Other Non NHS Bodies 2,602, , , ,485 1,148,996 Non NHS Trade Debtors 7,496,125 1,104, ,392 2,619,215 3,155,138 Provision for Bad Debts (588,492) (588,492) Non NHS Bodies Total 6,907,633 1,104, ,392 2,619,215 2,566,646 Total Accounts Receivable 23,440,798 6,927,372 4,206,571 3,659,277 8,647,579 % of Total Outstanding - Month % 30% 18% 16% 37% Month 9 100% 47% 16% 10% 27% Private Patients Accounts Receivable 3,238,318 1,254, , , ,548 Provision for Bad Debts (137,931) (137,931) Private Patients Accounts Receivable Total 3,100,387 1,254, , , ,617 Overseas Visitors Accounts Receivable 3,112, , , ,287 2,124,757 Provision for Bad Debts (617,887) (617,887) Overseas Visitors Accounts Receivable Total 2,494, , , ,287 1,506,870 Total PP & Overseas Visitors Accounts Receivable 6,350,969 1,472, ,620 1,214,366 3,051,305 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

49 Working Capital - Creditors Enc. 2.5 Overall Total 0-30 days days days Over 90 days NHS Bodies 6,331,853 1,159,145 2,249,623 1,794,303 1,128,783 Non NHS Bodies 26,841,777 7,356,218 10,188,380 4,878,547 4,418,633 Total 33,173,630 8,515,362 12,438,003 6,672,850 5,547,415 % of Total Outstanding - Month % 26% 37% 20% 17% - Month 9 100% 22% 41% 21% 17% Invoiced trade creditors excludes accruals and employer costs Page 31

50 Cash Summary Enc. 2.5 Cash Balances The Cash balance at the end of Month 10 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 10 was m against a forecast cash balance of m PCT contract over-performance payments of 4.756m remain outstanding (see page 29). To 31 January 2013, income of 352k 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 118k more than forecast to 31 January 201. This is partly due to an increase in NI, Pension and PAYE payments. Payments to NHS Professionals for bank and agency staff were 710kmore than forecast in January due to previous months delays in payment. Capital invoice payments were 1.801m 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. Revenue creditors were paid 810k less than forecast, February 2013 payments will be increased to cover this shortfall. Page 32

51 Cash Flow Enc. 2.5 TOTAL QTR 1 QTR 2 QTR 3 January February March ANNUAL PLAN 2012/ / / 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 21,871 31,699 24,731 Income NHS Clinical Income Southwark PCT SLA (Excl Merit Awards) 100,926 24,983 25,608 25,041 8,432 8,431 11,131 Lewisham PCT SLA 40,059 9,879 10,027 10,151 3,334 3,334 3,334 Lambeth PCT SLA 85,708 21,403 21,612 21,348 7,116 7,115 7,115 LSL PCT Other (Palliative Care) 4, ,361 1, SLAs : Other PCTs (incl PICU, NICU, BMT, HIV, Neuro Rehab) 183,469 45,541 45,347 47,425 15,718 15,052 15,052 LSCG ( Croydon) 61,715 11,069 20,859 14,730 5,087 5,019 5,019 Provider to Provider Income 16,452 4,210 3,843 4, ,416 1,416 PCT NCAs 2, DoH - patient activity (NSCAG) 23,957 6,066 5,949 5,991 1,268 1,977 1,977 RTA's 1, Patient SLA Overperformance 2012/ , ,879 10,505 9,317 2,293 2,952 Patient SLA Overperformance 2011/2012 3, ,247 2, Private Patients 15,230 3,658 4,145 4, ,000 1,005 Research and Development 2, Training & Educ: SIFT facilities, placement & HD 20,172 5,043 5,043 5,043 5, Training & Educ: MADEL & PGME 14,032 3,529 3,451 3,527 2, Training & Educ: Dental (SIFT) 7,392 1,848 1,848 1,848 1, Training & Educ: SELSHA WDC & Dental NMET 4, ,115 1,120 1, Merit Awards 3, , Pathology (Joint Venture) 18,586 5,301 5,178 4,657 1,508 1,150 1,150 Caregroup Operational Income 33,531 9,703 6,323 9,105 4,027 2,800 2,803 VAT reclaims 18,997 3,574 5,868 5,055 1,484 1,500 1,500 Consultant's Fees income (Private Patients) 3, sub-total 690, , , ,511 71,699 52,790 55,857 Expenditure Pay monthly (incl Pay Awards) 194,876 47,516 47,902 49,247 16,668 16,737 16,737 PAYE/NIC/SUPER (CHAPS) 146,227 36,225 36,514 36,789 12,420 12,233 12,233 Agency Spend (NHSP Bank) 30,308 6,541 7,842 6,661 4,974 2,946 2,500 Consultants' Fees 3, PFI project 30,216 8,422 7,779 7,865 2,677 2,050 2,050 AAH 4,367 1,126 1, Pathology (Joint Venture) 34,414 8,648 8,736 8,630 2,881 2,800 2,800 NHSLA Clinical Negligence 9,988 2,996 2,997 2, Non-pay Direct Debits (leases, rates) 11,387 3,462 2,370 2, ,350 Non-pay Revenue Trade Creditors (Incl. CIPs) 190,293 47,162 42,285 55,294 15,646 19,584 18,708 sub-total 655, , , ,540 57,726 57,915 57,093 Cash from operations 34,844 (2,208) 15,540 10,972 13,973 (5,125) (1,236) Capital & Financing Items Capital gross exp (Purchased) 20,206 4,867 5,832 5,052 3,286 1,590 1,484 Capital gross exp (Donated) Capital Income (Donated) (986) 0 (61) (11) 0 (608) (306) PDC Dividends (TDR) 8, , ,174 Loan Received (800) (4,200) Loan Repaid (Energy Centre) Loan Repaid (Business Park) Salix Loan Repaid Capital Element of Finance Lease repayment Interest on investments (74) (16) (20) (21) (7) (5) (6) 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, PFI Contingent Rental Payments 2, sub-total 39,615 8,430 12,820 8,789 4,145 1,843 2,092 Net Inflow / Outflow (4,771) (10,638) 2,720 2,183 9,828 (6,968) (3,328) Forecast Balance C/F 22,836 16,969 19,689 21,871 31,699 24,731 21,403 Page 33

52 '000 Analysis of Cash Balances (Monthly) Enc. 2.5 GRAPH A Monthly Net Cash Balances (incl. Overdraft) Monthly Cash Balances NatWest Cash Balance GBS- Citibank 35,000 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 Dec-12 Jan-13 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

53 '000 Analysis of Cash Balances (Daily) Enc. 2.5 GRAPH B Daily Movement of Cash Daily Balances Cash Balances (Net of Overdraft) Balance ( '000) 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10, Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan-13 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

54 Statement of Financial Position (Balance Sheet) Enc. 2.5 STATEMENT OF FINANCIAL POSITION AS AT 31 March 2012 Qtr 1 30 June Qtr 2 30 September Qtr 3 31 December 31 January Consolidated Annual Plan Forecast March 2013 '000 '000 '000 '000 '000 '000 NON-CURRENT ASSETS Intangible Assets 1,276 1, ,091 1, Property, Plant & Equipment 271, , , , , ,735 Investments in associates (and joined controlled operations) On-Balance Sheet PFI 75,679 75,155 74,630 74,096 73,920 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 10,593 10,530 11,500 Trade Receivables 23,535 21,692 27,107 36,174 31,169 26,900 Other Receivables 8,352 19,143 9,016 13,537 14,868 8,800 Impairment of Receivables (2,756) (3,033) (3,592) (3,443) (3,283) (4,000) Other Financial Assets 8,668 18,455 21,270 8,843 4,351 8,246 Prepayments 3,844 4,056 7,100 6,926 6,826 4,000 Cash & Cash Equivalents 27,607 16,970 19,689 21,871 31,699 22,835 Total Current Assets 80,213 88,353 91,741 94,501 96,160 78,281 CURRENT LIABILITIES Interest-Bearing Borrowings (1,135) (629) (567) (62) (62) (1,135) Deferred Income (6,181) (6,793) (6,353) (4,995) (4,469) (4,700) Provisions (983) (838) (649) (1,107) (1,386) (990) Current Taxes Payable (7,939) (7,901) (7,787) (8,014) (8,118) (8,200) Trade Payables (22,849) (16,770) (27,217) (24,555) (33,186) (23,900) Other Payables (9,742) (14,811) (12,090) (15,445) (13,066) (9,500) Other Financial Liabilities (26,159) (34,165) (33,716) (34,175) (32,111) (24,529) Total Current Liabilities (74,988) (81,907) (88,379) (88,353) (92,398) (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 85,872 85,841 87,667 Income & Expenditure Reserve 40,643 41,863 36,770 38,210 37,571 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

55 Public Sector Payments Policy Enc. 2.5 Paid to NHS Organisations Amount Paid on Time Public Sector Payments Policy 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 2,110 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% December 2,873 3,320 6, ,320 4,022 24% 100% 65% 73% January 1,443 5,873 7, ,873 6,606 51% 100% 90% 75% 23,536 35,293 58,829 8,149 35,293 43,442 35% 100% 74% 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% December 17,949 7,649 25,598 6,374 7,649 14,023 36% 100% 55% 67% January 17,421 7,424 24,845 9,142 7,424 16,566 52% 100% 67% 67% 156,658 77, ,171 78,562 77, ,075 50% 100% 67% Page 37

56 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

57 Enc. 2.6 Finance and Performance Committee Month 10 Performance Roland Sinker Chief Operating Officer 1

58 Enc. 2.6 Report to: Board of Directors Meeting Date of meeting: 26 February 2013 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 4 position based on performance reported for January It also contains an update on the Trust s contractual position at Q3 in relation to its CQUIN performance. 2. Action required Alongside the Monitor Quarter /13 report, the Board is asked to approve the performance reported against the governance indicators defined in the Monitor Compliance framework for Quarter 4 as detailed within this Month 10 Performance Report. 2

59 Enc Key implications Legal: Financial: Assurance: Clinical: Equality & Diversity: Performance: Strategy: Workforce: Estates: Reputation: Statutory reporting to Monitor and the DH. 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 Q4 position in 2012/13 based on January 2013 performance, with the exception of 2 cancer waiting time targets and the RTT Admitted target. The Trust can only achieve an Amber-Green governance rating for Q4 due to the RTT Admitted target not being achieved in January 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 Q4 position based on January 2013 performance as defined in the Monitor compliance framework, with the exception of 2 cancer waiting time targets and the RTT Admitted target. Performance against the Trust s annual plan forecasts and key objectives. None. There is no direct impact on Estates. Trust s quarterly and monthly results will be published by Monitor and the DH. Other:(please specify) None. 3

60 Contents Enc. 2.6 Executive Summary Trust Performance Summary Divisional Performance Summary Regulatory/Contractual Performance Monitor Q4 position CQUIN 2012/13 Q4 update Care Quality Commission (CQC) Quality Risk Profile Update Specific Performance Reports Emergency Care Action Plan Update RTT Q4 Performance Update Infection Control Update 4

61 Executive Summary (1/5) Enc Trust Wide Performance for Month 10: Good Performance The Trust achieved the 4-hour waiting time standard for January at 95.1% despite the sustained pressure experienced in the A&E department over the current winter period. RTT waiting time targets were achieved for Non-admitted and Incomplete pathways in January. However, the Trust did not achieve the RTT Admitted target of 90% as planned, with 88.8% of patients seen within 18 weeks. Cancer waiting time targets were achieved in January with the exception of the 2-week wait and 31 day subsequent treatment for surgery standards. No further MRSA cases were attributed to the Trust during January so the Trust has 1 case YTD which is lower than our quota of 4 cases for the YTD position. It is now over 300 days since the first case was reported this year. 2 further c-difficile cases were reported during January, so the Trust has declared 47 cases to date, lower than our quota of 63 cases for the same period. This compares favourably to the 85 cases that were reported at this point last year. Performance challenges ED - Delivery of the 4-hour A&E waiting time standard in Q4 remains a concern, given the continued high levels of bed occupancy experienced into February on general/acute wards and the critical care units. The Trust has reported two 12-hour trolley wait breaches for the first week in February predominantly due to patients waiting for side-rooms, but patient safety was not compromised. RTT The Trust continues to utilise off-site capacity from a range of providers to ensure that it can treat its long-wait and 52-week wait patients, as this is also one of the key areas of focus for the commissioners. Delivery of the RTT admitted target therefore remains a risk for remainder of Q4 which is in line with our plan submitted to Monitor. As this indicator has not been achieved in January, Monitor will assess the Trust as not meeting this standard for Q4 as the target must be achieved for each month in the quarter. Tertiary transfers Repatriation bedday delays increased to effectively 9 beds on average per day during January compared to 7 beds in December due to bed pressures and remains a strategic and clinical risk as reported last month. 5

62 Executive Summary (2/5) Enc. 2.6 Diagnostic Waits - There were 218 breaches of the 6-week diagnostic waiting time standard at the end of January compared to 147 breaches at the end of December. The increase was largely due to 49 breaches in non-obstetric ultrasound and 84 breaches in endoscopy. Over 4.4% of patients are waiting over 6 weeks for diagnostic assessment compared to the national 1% target. Current performance represents a significant risk to the Trust that the backlog will not be cleared by the end of March, as this indicator is included in the draft Monitor proposals for its Risk Assessment Framework. Actions Emergency Access Targets: Additional emergency medical beds have now come on-line as planned. The outcome of the Root Cause Analysis into the two 12 hour trolley breaches will be reported to the Finance & Performance and Quality & Governance Committees. To support the delivery of the agreed divisional actions which form part of the Trust s Winter Resilience Plan, daily meetings including all divisional managers continue, chaired by the Assistant Director of Performance & Contracts. Waiting List Access Targets: Additional on-site capacity for a short-stay elective ward became operational at the end of January to provide ring-fenced elective activity. Additional off-site capacity continues to be utilised, and additional lists have been secured at The Lister Hospital for General Surgery and T&O, and Harley Street for Neurosurgery. The internal audit that has been agreed with our commissioners to review our RTT monitoring processes has commenced which KPMG are leading on. EY are supporting the Trust on work around restricting access for out of area care and longer-term off-site moves. Tertiary transfers: The Trust plans to provide additional capacity with the proposed Infill 4 and 5 developments will mitigate concerns being raised by other hospitals in relation to the current delays experienced in transferring tertiary patients to the Trust. Diagnostic Access Targets: There is a further 2 week delay before the new MRI scanner becomes operational. Medinet will continue to run lists at the weekend, and will run additional lists during weekdays to fill unused capacity that cannot be run due to the difficulties in recruiting nursing staff for the new Endoscopy unit. An additional weekend list will be run by KCH staff from 18 February Additional weekend lists are being planned to help reduce the level of non-obstetric ultrasound breaches that were 6

63 Executive Summary (3/5) Enc. 2.6 reported at the end of January. The position deteriorated due to the loss of one scanner which could not be replaced by the manufacturer, and the department is attempting to source an additional scanner. Additional clinics have been run in February to reduce the echocardiography backlog and has more than halved the number of breaches. Additional room capacity is being sought in order to manage the demand and breach position from March onwards. Health Care Acquired Infection (HCAI): C-difficile remains a risk due to the low trajectory that has been set for this year. 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. Francis Report actions: The final report into the care provided by Mid Staffordshire NHS Foundation Trust was published on 6 February An internal working group has been convened with nonexecutive and Governor representation as well as senior leadership within the Trust. The group will provide an initial review of the recommendations within the Francis Report and assessment of key areas of reporting and Board Assurance that require improvement. An interim report will be taken to the Finance & Performance Committee in March. Other areas of concern: Day Surgery Unit (DSU): Detailed investigations are on-going and a full report on the DSU Action Plan following the mock CQC inspection will be taken to the Finance & Performance Committee in March. Mixed Sex Accommodation: There were 27 Single Sex accommodation breaches reported in January 2012, which represents a slight increase compared to the 23 cases reported in December. All breaches were delayed discharge patients from surgical and medical critical care units. Safety indicators: Red shifts, and slips, trips and falls remain high and above target. A never event due to a retained swab was reported in a Neurosurgery patient. Preliminary findings have been presented to the Serious Incident committee in February, with the aim of the formal findings being reported to the March committee meeting. 7

64 Executive Summary (4/5) Enc Regulatory Supplies of meat products: In light of recent events, Medirest have contacted the Trust to confirm that they have taken a decision to use only processed beef products where it has been sourced and processed in the UK and Ireland for the foreseeable future. Medirest has also commenced its own independent DNA testing programme across all of their processed meat products. Monitor Q4 position The Trust achieved all performance indicators in January with the exception of 2 cancer waiting time targets (31-day subsequent surgery and the 2 week wait for all cancers, and the RTT Admitted target. Although delivery of the cancer waiting time targets remains a risk, we expect to achieve the targets for Q4 overall. The Trust is therefore rating itself a provisional score of 2.5 in the Monitor Compliance Framework based on the January 2013 position, which would give the Trust a governance risk rating of Amber-Red. Due to the RTT Admitted target not being achieved in January, the best rating for Q4 would be Amber-Green. Care Quality Commission (CQC) Quality Risk Profile (QRP) 3. Contractual February 2012 QRP report showing 5 outcomes rated better than expected (previously 6) and 11 outcomes rated similar to expected (previously 10). The Trust is being proactive in working with our lead commissioners who have expressed concerns over our current RTT and diagnostic waiting performance and the recent 12 hour trolley breaches in A&E, as well as some issues in relation to incident reporting and A&E exception reporting. CQUIN 2012/13 The Trust has submitted Q3 CQUIN evidence and expects to achieve 100% of the CQUIN scheme standards, with an associated financial value of 2.7m. The Trust has achieved the National Inpatient CQUIN for this year based on the Inpatient survey and scored 6.85 compared to the 6.70 target, securing 241k income for Q4. Other CQUIN areas are on track for Q4 and work is on-going to finalise data collection and reporting functions for the dementia pathway. 8

65 Executive Summary (5/5) Enc. 2.6 CQUIN 2013/14 The Trust is awaiting feedback from the Clinical Commissioning Group on the first round of proposals for CQUIN schemes in In order to release CQUIN funding for , the Trust is required to report to commissioners on five DoH High Impact Innovations. Information is being collated on Trust plans to participate in telehealth/telecare, intraoperative fluid management, international and commercial activity, use of digital technology to reduce unnecessary face to face contacts and supporting carers for people with dementia. Details of the Specialised Commissioning CQUINs is outstanding but due imminently. 4. Specific Performance Reports Emergency Care Action Plan Update Medicine have continued to use the Cotton (surgical) ward until the middle of February and the additional 12 medical beds have now come on-line as planned. Despite the challenging performance issues that the A&E department is experiencing into February, the Trust has held off significant steps around restricting access. Further details on the priority actions can be found in the update later in this report. RTT Q4 Performance Update The Trust did not achieve the RTT Admitted target in January 2013 with 88.8% of patients seen within 18 weeks compared to the 90% target. Despite severe bed pressures impacting on elective activity and a 57% increase in the number of patients cancelled within 7 days of their admission during January compared to December, the Trust has managed to maintain its backlog position. The number of 52-week wait patients has reduced from 129 in December to 118 in January, and the plan is to have less than 50 patients waiting by the end of March. The Trust continues to utilise significant capacity from a wide range of providers to mitigate against the onsite bed pressures and improve its long-wait position. Additional list capacity has been secured in February and March at The Lister Hospital for General Surgery and Harley Street for Neurosurgery. Infection Control Further details on the enhanced actions for can be found in the HCAI Action Plan, provided later in this report. 9

66 Contents Enc. 2.6 Executive Summary Trust Performance Summary Divisional Performance Summary Regulatory/Contractual Performance Monitor Q4 position CQUIN 2012/13 Q4 update Care Quality Commission (CQC) Quality Risk Profile Update Specific Performance Reports Emergency Care Action Plan Update RTT Q4 Performance Update Infection Control Update 10

67 Trust Month 10 Performance Summary Enc. 2.6 Domain* Key Highlights Key Actions Clinical Effectiveness 10 5 Safety 8 Patient Experience 8 2 Finance & Operational Efficiency Patient access targets for Emergency care 4-hour performance, Referral to Treatment (RTT) Non-Admitted and Incomplete measures, and all Cancer Waiting Times except for 31 Day Wait for 2 nd Treatment (Surgery) have been achieved this month. Elective ALOS has increased to 5.9 days, 1.2 days above the 4.7 day stretch target. Repatriation bedday delays increased from 217 to effectively 9 beds per day on average for January compared to 7 beds per day last month. Key concerns are: RTT pathway targets whilst the 95% Non-Admitted target and 92% Incomplete target were both achieved in January, 88.8% of patients were admitted within 18 weeks in January, therefore not achieving the 90% RTT Admitted target. Emergency Care 95.1% of patients were seen in A&E within 4 hours, achieving the 95% target for January Leading indicators for efficiency: Recording of Expected date of discharge (EDD) has decreased to 51.3% across all divisions and the 90% internal target was only achieved by Haematology (95.0%) and Cardiovascular (92.2%) this month. No new MRSA cases were attributed to the Trust during January and it is now over 300 days since our last reported case. Key concerns are: HCAI 1 new VRE case reported this month in Haematology on Davidson Ward. 24 cases have been reported to date which is higher than the internal target of 14 cases, and higher than the 17 cases reported at this point last year. 2 CDT cases were reported during January 1 in TEAM on Twining and 1 in Surgery on Lister - which means 47 cases have been reported to date compared to the trajectory of 63 cases. Red AIs and red shifts 4 Red AIs were reported in January: 1 in Acute Medicine, 1 in Neuro-Imaging, 1 in Neurosurgery and 1 in AAU attributed to another Trust. 43 red shifts were reported in Jan: 17 in TEAM and 26 spread over 6 other Divisions. Leading indicators of safety: MRSA Screening % of elective patients and 97.2% of emergency patients were screened. Hand Hygiene audit compliance dropped to 85.3% overall in January (compliance was 89.3% for actual audits performed) Overall HRWD score has dropped by 1% to 85% in January, not achieving the 86% target. Although patient complaints increased slightly to 54, the response rate to complaints continues to improve with just under 50% replied to within 25 days. Key concerns are: 28 Day Cancellation Standard 4 breaches of this standard in January (2 breaches were due to over running lists, 1 to an emergency taking priority and 1 for an unknown reason). Single Sex Accommodation 27 ICU delayed discharge breaches were reported in January compared to 23 last month. Outpatient Cancellations 8392 hospital-initiated cancellations in January, an increase of nearly 2000 above target. At Month 10, the Trust has a net variance from plan of m. Further details can be found in the Finance part of this paper. Key concerns are: Theatre Utilisation Rate despite dropping by 1% to 80% in January, the overall rate is still achieving the 80% target. Main Theatre utilisation dropped by 3.4% to 81.4% in January, still achieving the target. Although DSU Utilisation rose by 5.1% to 78.1%, it is still not achieving the 80% target. Weekend discharges under 19% of patients were discharged over the weekend in January compared to 25% in December. DNA Rate increased by 0.5% from 12.3% in December to 12.8% in January, and is not achieving the 12.2% target. Latest actions and divisional plans can be found in the specific performance update reports in this paper for Emergency Care and RTT performance Daily meetings continue to be held with the COO to review breaches in A&E Weekly RTT meetings continue to take place to track longer-waiting patients Weekly Cancer waiting list meetings continue to take place to track individual patients. Continued focus on managing MRSA infection and screening. Critical Care has been red-rated for January. Weekly CDT meetings continue to review locally reported cases, and distinguish between true or colonised cases. Ongoing implementation of an action plan to ensure compliance with the DH document Start Smart, then Focus for antimicrobial stewardship. Continued focus on patient experience through Energising for Excellence, Safety Express and Ward 20/20 initiatives. Developing a Trust-wide plan for HRWD Adverse financial moves from the projected year-end position to be discussed at the Month 10 divisional performance review meetings. CCTD division are undertaking a 6-month theatre program which includes looking at improving the pre-assessment pathway to reduce cancellations and improve patient experience/care. Staffing measures 2 1 *Number of red/green indicators by domain from Trust scorecard Staff Vacancy rate is at 7.1% in January within the 5-8% target tolerance. Key concerns: Mandatory & Statutory Training overall training index score has increased by 2% in Jan to 65 but remains below target Appraisals 36.1% of staff have had their appraisal performed in-year compared to the 75% target. Focus on staff appraisals to be conducted for the end of March 11

68 Enc

69 Contents Enc. 2.6 Executive Summary Trust Performance Summary Divisional Performance Summary Regulatory/Contractual Performance Monitor Q4 position CQUIN 2012/13 Q4 update Care Quality Commission (CQC) Quality Risk Profile Update Specific Performance Reports Emergency Care Action Plan Update RTT Q4 Performance Update Infection Control Update 13

70 M10 Division Performance Key Areas of Concern Enc. 2.6 Division Womens & Children Liver, Renal and Surgery Networked Services TEAM Critical Care, Theatres and Diagnostics Areas of Concern Finance position Ante-natal booking within 12+6 weeks (Obstetrics) Discharge Date Compliance (Child Health and Gynaecology) Hand Hygiene Audits HRWD (Obstetrics) Finance position RTT Admitted & Incomplete pathways (Liver & Surgery) MRSA Screening Elective and Non-Elective ALOS Red Shifts Finance position SHMI (Cardiac Services) Red shifts MRSA screening Hand hygiene audit (Neurosciences & Cardiovascular) Emergency Care Performance (4-hour target) Outliers HRWD CDT and Hand Hygiene Audit Red Shifts Bed occupancy throughput (Critical Care) Hand Hygiene Audits Delayed Discharge hours (Critical Care) Right on Time starts and Early Finishes (Theatres) Ambulatory Services & Local Networks Finance position Outpatient Cancellations by Hospital New to Follow Up ratio (Ambulatory) Hand Hygiene Audit (Ambulatory) 14

71 Divisional Summary (1/3) Enc. 2.6 Women s & Children Liver, Renal & Surgery Comment Finance Position: At the end of month 10, the division has an adverse variance of - 823k Child Health: Elective ALOS has increased significantly above its 3.9 day target to 8.4 days mainly due to the discharge of 3 patients with a LOS over 30 days, including a 186 day stay in Paediatrics. Non-elective ALOS has decreased to 4.1 days, remaining slightly above its 3.9 day target. Discharge Date Compliance decreased further to 58.2%, remaining below the 90% target. There were no new infections this month but Hand Hygiene Audit compliance has decreased to 85.7%, remaining below the target of 95% - audits were performed in all locations. Combined MRSA screening increased slightly to 98.5% but there were 2 un-screened emergency patients on Toni & Guy, 1 patient on Rays of Sunshine and 1 patient on Lion ward. 4 Red Shifts were reported on NICU. Gynaecology: Elective ALOS has increased above the 2.4 day target to 3.4 days; Non-Elective ALOS has decreased further below the 1.8 days target to 1.4 days. Discharge Date Compliance has dropped significantly to 64.3%, remaining below the 90% target. All Patient Access indicator targets have been achieved with the exception of the 2 week wait standard where 90.9% was achieved. Hand Hygiene audit compliance has improved significantly to 90.2% but remaining below the 95% target - audits were performed in all locations. Combined MRSA screening increased to 99.3%, remaining below the 100% target due to 1 un-screened emergency patient on Katherine Monk. VTE Assessments performed continues to achieve the 90% target at 94.8%. Obstetrics: Ante-natal booking within 12+6 weeks has decreased further below the 90% target and adjusted measures at 62% and 75% respectively. The total C-Section rate remains slightly above the 26% target at 26.4%, whilst the elective rate remains within the tolerance thresholds at 11.5%. All HRWD composite scores remain below target. Hand Hygiene audit compliance has improved significantly to 80.5%, remaining below the 95% target - audits were performed in all locations. Finance Position: At the end of month 10, the division has an adverse variance of m Liver: Endoscopy median waiting time remains within target at 28 days despite an increase of 9.6 days. Non- Elective ALOS has reduced by 3.7 days since last month to 12.4 days, but remains below the target of 14.4 days. Elective ALOS is above the target of 6.0 days at 6.7 days. Discharge Date compliance remains low at 4.2%. Under 85% of RTT incomplete pathways are waiting under 18 weeks compared to 92% target. No new Infection Control cases reported in December. Hand Hygiene audit compliance increased to 76.4% with only 1 of 6 locations not performing audits 91.7% compliance was achieved in audits performed. MRSA Screening is 98.4% due to 2 elective and 2 emergency patients not screened. 7 Red Shifts were reported 2 on Todd, 1 on LICU and 4 on Dawson ward. Renal: Elective ALOS is above the target of 2.2 days at 2.9 days and Non-Elective ALOS is also above the target of 9.0 days at 11.2 days. Discharge date compliance has decreased again this month to 38.0%, below the target of 90.0%. No new Infection Control cases reported. Hand Hygiene audit compliance has dropped below the target of 95% to 87.2% with 7 out of 8 locations performing an audit 99.7% compliance was achieved in audits performed. MRSA Screening is at 100%. 6 Red Shifts reported on Fisk & Cheere ward. Surgery: Elective ALOS remains above target of 3.6 days at 4.6 days and Non-Elective ALOS also remains above target of 4.8 days at 8.8 days. Discharge date compliance has improved to 65.1% in December but is still above the 90% target. 19 repatriation bed day delays in December - an improvement from 36 in November. Under 74% of RTT admitted patients treated within 18 weeks compared to the 90% target and 79% of RTT incomplete pathways waiting under 18 weeks compared to 92% target. No new Infection Control cases reported. Hand Hygiene audit compliance improved to 78.5% with all locations performing an audit. Key Action / Focus - Finance position - Discharge Date Compliance: Child Health & Gynaecology - Cancer Waiting Times: Gynaecology - Infection Control: Child Health - Hand Hygiene Audits - MRSA Screening: Child Health & Gynaecology - Red Shifts: Child Health - Ante-natal booking within 12+6 weeks (Standard and Adjusted): Obstetrics - C-Section Rate: Obstetrics - HRWD: Obstetrics - Finance position - RTT Admitted & Incomplete Pathways: Liver & Surgery - Elective & Non-Elective ALOS - Discharge date compliance - Hand Hygiene Audit: Liver & Surgery - Red Shifts - MRSA Screening: Surgery and Liver - Repatriation Bed Day Delays: Surgery 15

72 Divisional Summary (2/3) Enc. 2.6 Networked Services TEAM Comment Finance Position: At the end of month 10, the division has an adverse variance of m Cardiovascular: Summary In-hospital Mortality Index (SHMI) has been worse than expected based on the 12- months rolling position from November last year to January. Elective ALOS has increased from 5.7 days last month to 6.2 days this month and remains above the 5.2 day target. Non-elective ALOS has increased from 6.9 days last month to 7.1 days this month and is achieving the target of 7.1 days. Discharge date compliance has increased from 91.1% last month to 92.2% in this month, still achieving the 90% target. No new infections were reported in January. Hand Hygiene audit compliance has decreased from 92.9% last month to 91.9% and is just below the 95% target. Emergency readmissions within 30 days(ytd) has reduced from 2.8% last month to 2.6% this month and remains below the 11.7% target. The HRWD overall section score has decreased from 88% in December to 87% in January, still achieving the 86% target. Neurosciences: Non elective ALOS in Neurosurgery is 2 days above target at 15 days, due to 3 patients with average stay of 138 days each. Elective Neurology ALOS is 2.7 days above target, impacted by 4 patients with average stay of over 38 days each. Discharge date compliance improved slightly to 66.5%, but remains below the target of 90%. Repatriation bedday delays rose considerably to 200 days in January from 128 days in the previous month. Hand hygiene audit compliance improved to 93% from 89.1% but is still below the 95% target. There were 6 un-screened MRSA emergency patients - 1 on David Marsden, 3 on The Friends Stroke Unit (one of which was General medicine patient), 1 on Murray Falconer and 1 on Kinnear Wilson ward. There were 3 red shifts - 1 on David Marsden ward and 2 on The Friends Stroke Unit. Haematology: SHMI has improved further to 102 from 115, compared to the expected index of 100. Elective LOS is 19.4 days in January, above the 16.8 day target due to 19 patients with an average stay of over 32 days each. Discharge Date Compliance improved to 95%, and is above the 90% target. MRSA screening has dropped to 95% from 100% due to 3 un-screened emergency Medicine patients on Haematology wards. There was 1 red shift on RD Lawrence ward. HRWD survey results were below target in all sections with the exception of Patient Engagement.. Finance Position: At the end of month 10, the division has a positive variance of 0.267m TEAM: SHMI outcomes continue to perform well with an index of 54 compared to the expected index of 100. Non-Elective ALOS has decreased by 1.1 days, from 6.3 days in December to 7.4 days in January, and continues to achieve the target of 7.9 days - this is driven by the low ALOS for General Medicine patients. The number of Outlier bed occupancy has increased from December by an average of 17 beds with TEAM patients occupying on average 37.9 outlying beds per day in January (with 20.7 beds in Surgery with Medicine now using the surgical beds on Cotton ward, 4.5 beds in Neurosciences and 3.6 beds in Women s Health). The Type 1 Emergency care performance target of 95% was not achieved in January, with 94.4% of patients seen within 4 hours. Cancer Wait Times were not achieved in January with TEAM with 85% of patients seen within the 2 week referral standard. Hand hygiene compliance has increased by 4% to 85% in January, but remains below the 95% target with no data being supplied for 1 location 91.1% compliance was reported for actual audits performed. No MRSA or VRE cases were reported in January but 1 CDT case was reported on Twining ward. The overall HRWD score has achieved its 86% target which was driven by Care Perceptions and Environment meeting their respective targets. Patient Engagement section score was 84% and is below its target of 87. Red shifts have decreased by 12 from last month with 17 shifts now reported in January the main contributing wards were CDU with 8 Red Shifts and Mary Ray with 5 Red Shifts. Key Action / Focus - Finance position - SHMI: Cardiac Services - Red shifts - Repatriation bedday delays: Neurosciences - MRSA screening (Emergency patients): Neurosciences and Haematology - Hand hygiene - Neurosciences & Haematology LOS - HRWD: Haematology - Outlier patients - Emergency Care Performance (4-hour target) -Infection Control: CDT and Hand Hygiene audits - HRWD - Red Shifts

73 Divisional Summary (3/3) Enc. 2.6 Critical Care, Theatres and diagnostics Comment Finance Position: At the end of month 10, the division has a positive variance of 1.902m Critical Care (CC): Bed occupancy throughput has increased from 105% last month to 115% this month, and remains above the 85% target. No new bacteraemia cases reported this month, and Hand Hygiene compliance has decreased from 84.8% last month to 81.2% this month and remains below the 95% target. 3 Red or Amber adverse incidents were reported in January. Emergency MRSA screening remains at 100%. Delayed Discharge Hours has increased from 897 hours in December to 1268 hours in January - mainly due to Networked services (401 hours). Total Level 1 Bed Days Number has increased from 41 beddays in December to 46 beddays in January. Diagnostics: Same day CT wait (request pre 9:30am) has increased from 86% in December to 90% in January and is now achieving the 90% target. Hand Hygiene audit compliance has increased from 62.9% last month to 71.1% this month but remains below the 95% target. MRSA Screening is at 100%. 7 BBV incidents reported this month. No adverse incidents reported this month. Reporting Turnaround for Angio & Fluoro IP has decreased from 1.9 days last month to 0.7 days in January, and is now within the target of 1 day. Theatres: OTD cancellations (for no theatre team member or anaesthetist) have decreased from 2 last month to 1 in January. Hand Hygiene Audit compliance has decreased from 96.5% last month to 89.1% in January and is now below the target of 95%. No adverse incidents reported this month. 16 sessions were closed with 13 days notice or less in January. Main theatre utilisation has decreased from 84.8% last month to 81.8% in January, but still remains above the target of 80%. Right on time starts have increased from 17.4% to 20.5% this month, and remains below the 51% target. Early Finishes have increased from 30.3% to 34.3% and remain above the 9% target. Outpatient DNA rate has reduced from 17.4% to 12.7% this month and is below the17.1% target. Key Action / Focus - Bed occupancy throughput: Critical Care - Hand hygiene - Delayed Discharge Hours: Critical Care - Right on Time starts and Early Finishes (Theatres) Ambulatory Services and Local Networks Finance Position: At the end of month 10, the division has an adverse variance of k Ambulatory: The Summary Hospital Mortality Index (SHMI) has improved to 86 and continues to achieve the expected index of 100. Elective ALOS has increased to 5.7 days and is higher than the 3.6 day target, and whilst Non elective ALOS has reduced to 23.7 days it is above the 12.2 day target due to the discharge of two long stay Diabetic Medicine patients each with a stay of 84 and 72 days. Hand Hygiene Audit compliance is 80% and therefore below the 95% target. Audits were not performed in 1 area compliance was 91.4% for those audits actually performed. MRSA Screening is at 75% and has not achieved its 100% target due to 1 un-screened patient in Endocrinology. Outpatient Cancellations by Hospital have increased from 1812 to 2164 appointments and remain above the 1475 target. Camberwell Sexual Health Centre (CSHC) Waiting time < 2hours has failed to meet its 95% target achieving 93%. New to Follow up ratio remains at 2.8, above the target of 2.7. Dental: Elective ALOS has decreased from 1.9 to 1.4 days but remains above the 1.1 day target. Non Elective ALOS has decreased from 2.4 days to 1.9 days, therefore achieving its 2.1 day target. Hand Hygiene Audit compliance has dropped to 98.6% but remains above the 95% target - audits were completed in all locations. MRSA Screening remains on target at 100%. Outpatient Cancellations by Hospital have increased from 585 to 910 and remain above the 473 target. There was 1 breach of the Data Quality composite indicator, failing to achieve the New NHS No OP indicator. OP Coded Activity is 87% and not achieving its 95% target. - Finance position - Non Elective ALOS (Ambulatory) - Hand Hygiene Audit: (Ambulatory) - Outpatient Cancellations by Hospital - New to Follow Up ratio: Ambulatory 17

74 M10 Trust & Division Heatmap (1/2) Enc

75 M10 Trust & Division Heatmap (2/2) Enc

76 Contents Enc. 2.6 Executive Summary Trust Performance Summary Divisional Performance Summary Regulatory/Contractual Performance Monitor Q4 position CQUIN 2012/13 Q4 update Care Quality Commission (CQC) Quality Risk Profile Update Specific Performance Reports Emergency Care Action Plan Update RTT Q4 Performance Update Infection Control Update 20

77 Regulatory/Contractual Performance 2012/13 (1/3) Enc. 2.6 Regulatory Monitor Month 10 position: The Trust has achieved the majority of performance indicator targets in the Monitor Compliance framework for January with the exception of the 31-day subsequent surgery target, the 2 week-wait (2WW) for all cancers target and the RTT 18 Week Admitted target. However, the Trust is confident that the cancer waiting time indicators will be met for Q4 overall. Due to the RTT 18 Week admitted target not being achieved in January, the best position for Q4 will be an Amber-green governance rating. A&E attendances and sustained emergency access pressures continued during January, and the Trust achieved 95.12% performance against the 4-hour waiting time compared to the 95% target. Pressure continues during February and this target is now at risk for Q4. The Trust had no MRSA bacteraemia cases reported in January, and therefore maintained 1 attributed case YTD. This is consistent with the threshold but remains a risk as previously reported. 2 C-difficile cases was reported in January, bringing the number of attributed cases YTD to 47. This is also below the threshold of 63 cases for the YTD position, but remains a risk. Actions: Weekly Cancer waiting list review meetings continue to take place to track individual patients. This includes a review of patients on 31-day pathways, as well as those on 62-day wait pathways. Weekly RTT waiting list review meetings continue and further opportunities for weekend working and off-site options continue to be explored. Daily A&E breach review meetings are on-going and now extended to include all divisional managers. 21

78 Monitor Q4 interim position Enc

79 Regulatory/Contractual Performance 2012/13 (2/3) Enc. 2.6 Regulatory CQUIN 2012/13 update. Q3 evidence has been submitted. The Trust is expecting to achieve 100% of the CQUIN scheme standards, with an associated financial value of 2.7m. The Trust has achieved the National Inpatient CQUIN with a score of 6.85 compared to the target of This is an improvement of 0.4 on the 2011/12 national inpatient survey score resulting in 241k of secured income in Q4. All CQUIN areas are on track against Q4 targets however, work is on-going to finalise the data collection and reporting functions for the Dementia pathway. Actions: Continue to meet with Service and BIU leads to embed reporting along the Dementia pathway and to monitor Q4 progress with the relevant CQUIN leads. Receive confirmation of Q3 performance from Commissioners CQUIN 2013/14 The Trust is awaiting feedback from the Clinical Commissioning Group on the first round of proposals for CQUIN schemes in 2013/14. There are four National themes (Dementia, Safety Thermometer, Friends and Family Test and VTE screening). Local proposals are being worked up for the COPD bundle, Alcohol Screening, Patient Experience (acute admissions and outpatients), Hospital Acquired Pressure Ulcers, Cancer and improvements to Choose and Book. In order to release CQUIN funding for 13/14 the Trust is required to report to Commissioners on five DoH High Impact Innovations. Information is being collated on the Trust plans to participate in telehealth/telecare, intraoperative fluid management, international and commercial activity, as well as the use of digital technology to reduce unnecessary face to face contacts and supporting carers for people with dementia. Detail of local Specialised Commissioning CQUINs is outstanding but is due to be released shortly. Actions: Submit a CQUIN prequalification report to commissioners by end of February and finalise CQUINs in time for sign off by 1 April Further detail to be included in future reports to the Board. 23

80 Regulatory/Contractual Performance 2012/13 (3/3) Enc. 2.6 Care Quality Commission (CQC) Quality Risk Profile (QRP): The February 2013 QRP profile report was published in 6 February The report is currently showing better than expected across 5 outcomes (previously 6) and similar to expected across 11 outcomes (previously 10). The CQC has actioned a previous request and excluded Lewisham Hospital Endoscopy Global Rating Scale data from King s QRP. This led to adjustments to risk estimates for Outcomes 14: Supporting staff and Outcome 16: Assessing and monitoring quality of service provision. Marginal adverse movement from high green to low yellow for Outcome 21: Records due to much worse than expected results in refreshed National Bowel Cancer Audit Project data for patients receiving a CT or MRI scan. Assurance has been received that this is a resource issue relating to completion of data submission and that all CT and MRI scans are taken and reported in line with best practice. 24

81 QRP February 2013 position Enc. 2.6 Analysis of King s QRP February 2013 (published 6 February 2013): Overall Risk Estimates 25

82 Contents Enc. 2.6 Executive Summary Trust Performance Summary Divisional Performance Summary Regulatory/Contractual Performance Monitor Q4 position CQUIN 2012/13 Q4 update Care Quality Commission (CQC) Quality Risk Profile Update Specific Performance Reports Emergency Care Action Plan Update RTT Q4 Performance Update Infection Control Update 26

83 Emergency Care Performance Action Plan (1/13) Enc. 2.6 Continued Governance arrangements include: Winter Action plans for all divisions have now been signed-off and key actions being implemented The Emergency Care Board continues to meet monthly and the Emergency Care Board Operational Group continues to meet weekly. The Emergency Care Action Plan continues to be tracked and developed. Daily breach review meetings continue and all divisional managers now attend these meetings held at 10am. Outcome metrics reflecting the delivery of the action plan are being devised. Priority actions taken include: Focus on weekend discharges as part of TEAM winter plan workshop, a number of actions are now in place to improve weekend discharges. Increased staff at weekends (within the Emergency Department, Wards, Pharmacy and Therapy services). Maximise bed availability on a Monday morning by increasing discharge planning on a Thursday/Friday/Saturday and Sunday. Increase use of Medihome. 24/7 AAU model introduced. Increase nursing and medical staff within the Emergency Department and Acute Assessment Unit at times of peak demand to manage surges of patients. E-vision now reporting real time ED Performance and Phase 2 reporting requirements have been reviewed and are being developed. Additional capacity Plans to move the existing Acute Assessment Unit from a ward location to a new facility in the previous endoscopy unit have been escalated and the 12 additional medical beds have now come on-line. The latest Emergency Care Action Plan can be found in the following pages: 27

84 Emergency Care Performance Action Plan (2/13) Enc

85 Emergency Care Performance Action Plan (3/13) Enc

86 Emergency Care Performance Action Plan (4/13) Enc

87 Emergency Care Performance Action Plan (5/13) Enc

88 Emergency Care Performance Action Plan (6/13) Enc

89 Emergency Care Performance Action Plan (7/13) Enc

90 Emergency Care Performance Action Plan (8/13) Enc

91 Emergency Care Performance Action Plan (9/13) Enc

92 Emergency Care Performance Action Plan (10/13) Enc

93 Emergency Care Performance Action Plan (11/13) Enc

94 Emergency Care Performance Action Plan (12/13) Enc

95 Emergency Care Performance Action Plan (13/13) Enc

96 RTT Q4 Performance Update (1/3) Enc Referral To Treatment (RTT) January 2013 Update The table below summarises the Trust performance since April 2012 against the 3 RTT waiting time standards that Monitor assesses us against. In addition, the number of 52+ week waiters at the end of January relative to December are outlined here. Target Apr May Jun July Aug Sep Oct Nov Dec Jan Admitted Complete 90% 91.0 % Nonadmitted 95% 98.1 % Complete Incomplete 92% 90.1 % 91.2 % 98.2 % 90.6 % 85.7% 91.0% 90.1% 90.2% 91.4% 90.1% 90.1% 88.8% 98.3% 98.1% 98.2% 97.7% 97.1% 97.1% 97.0% 96.7% 92.2% 92.6% 92.3% 92.4% 92.8% 92.9% 92.7% 92.8% 52+ Week Waiters January December General Surgery Urology 1 1 T&O Neurosurgery 4 8 Cardiothoracic Surgery 1 1 HpB Cardiology 0 1 Other Specialities 0 2 Total

97 RTT Q4 Performance Update (2/3) Enc. 2.6 As planned with Commissioners, RTT Admitted Performance did not achieve the 90% target with 88.8% of patients seen within 18 weeks in January The Trust is planning not to achieve the admitted target in February and March, as part of a planned approach to treat long-wait patients. Specialties that failed to achieve the 90% target in January were: General Surgery (78.8%) Urology (74.6%) T&O (69.7%) Neurosurgery (72.0%) Cardiothoracic Surgery (69.0%) The number of 52+ Week waiters reduced from 129 in December to 118 in January. The Trust is planning to have less than fifty 52+ by the end of March. January was characterised by severe pressure on both general and critical care beds with a 57% increase in within-the-week hospital cancellations compared to December (the 409 admission cancellations in January was the highest monthly figure for the year to date). Despite this pressure on elective activity, the Trust has managed to maintain its admitted backlog position while reducing the overall waiting list and the numbers of 52+ week waiters. This has partly been achieved by continuing to utilise weekend onsite and offsite capacity from other providers, wherever possible. However, bed pressures are continuing into February which further increases the risk to achieving the target backlog trajectory. The Trust s priority focus remains on using whatever capacity it has available to clearing all 52+ week waiters. The Trust has continued to achieve its overall non-admitted performance target of 95% but two specialities did not achieve this threshold: Cardiology (90.1%) Neurology (81.4%) 41

98 RTT Q4 Performance Update (3/3) Enc Outsourcing Update The Trust continues to utilise significant off-site capacity from a wide range providers to help mitigate onsite bed pressures. There is a desire to do more off-site work and maximise utilisation still further, but the main constraint has been the inability of offsite providers to make further capacity available to the Trust. In addition, the Trust is finding it particularly challenging to secure appropriate capacity for patients whose care requires the presence of critical care facilities on-site, especially for HpB patients. Whilst off-site capacity is proving vital in maintaining the Trust s backlog and improving long-wait position alongside current bed pressures it is not proving effective in clearing historic backlogs. The Trust continues to rigorously explore possibilities for procuring more capacity from existing and alternative providers for February and March and increased capacity has been secured from Lister Hospital for General Surgery and T&O, and from Harley Street for Neurosurgery. It is not anticipated that funding from commissioners for the same level of off-site work will continue into 2013/14 hence future reductions in backlog will need to be achieved via increases in on-site capacity. In January the following KCH activity was managed offsite: Provider Speciality Activity Levels BMI Blackheath Neurosurgery 2 IP BMI Chelsfield General Surgery 5 IP BMI Fitzroy Place General Surgery Colorectal Lister Hospital T&O 4 DC London Bridge HpB 2 IP Sloane Hospital T&O 3 IP Weymouth General Surgery 5 DC Total 1 IP and 1 DC 6 DC 13 IP and 16 DC 42

99 Infection Control: Trust position Enc. 2.6 January MRSA (post 48 hour) bacteraemias good performance: One Trust attributable case reported in One in Ambulatory (Apr 2012) MRSA screening: 99.4% Elective (in January 2013) 97.2% Emergency (in January 2013) 2. VRE bacteraemias improved performance: 1 case of VRE bacteraemia in January with a total of 23 cases YTD (trajectory of 14 cases for the same period.) 3. C-difficile still under DH trajectory for number of cases and have seen a reduction in Q3 compared to Q2: 47 CDT cases reported to DH (as per National Guidance) in (trajectory of 63 cases YTD): Surgery - 10 cases compared to 13 in 2011/12 (YTD January) TEAM - 6 cases compared to 15 in 2011/12 (YTD January) Critical Care - 5 cases compared to 10 in 2011/12 (YTD January) Cardiac - 3 case compared to 5 in 2011/12 (YTD January) Trust attributable CDT Cases over the last 4 quarters: Q4 18 cases Q1 11 cases Q2 25 cases Q3 12 cases A further 94 cases have been reported locally as per the April DH testing guidance. All of these cases have been included in the Root Cause Analysis process and been managed as per Trust CDT guidance. This continues to place additional pressure on isolation provision. 43

100 C-difficile Action Plan Update (1/1) Enc. 2.6 Key focus areas: 1. Antimicrobial stewardship Monthly audits undertaken in all inpatient wards. Results are improving. Work completed to audit prophylaxis prescribing and administration in theatres. Results shared at appropriate meetings, highlighted a lack of prophylaxis guidelines in some surgical specialties. These are now being developed. The Antibiotic Usage Steering Group is leading on the implementation of the Start Smart then Focus action plan. Progress will be reported in the next quarterly report. 2. Hydrogen Peroxide Vapour (HPV) technology HPV has been used in a number of areas where CDT or multi-resistant gram negative infections occurred. Work is now underway to develop a proactive HPV programme to work in conjunction with the reactive programme already in place. 3. CDT root cause analysis The well established process for reviewing both DH and locally reportable CDT cases has been further developed so that divisions ensure completion of mitigating actions identified through this process. 4. Multidrug resistant organisms Child Health The trust has had cases of children colonised with a multi resistant family of organisms. A working group comprised of Capital, Estates and Facilities (CEF), Infection Control Prevention (IPC), Medirest and the division, have been formed to manage this situation. External reviews have taken place over the last few weeks and the Group is currently working towards completion of an action plan to address issues raised by the external review. 5. Water management group A group has been established with key stakeholders, including CEF, Infection Control and Medical Microbiology, to manage the Trust s response to new guidance on water quality. 44

101 Enc Report to: Board of Directors Date of meeting: 26 February 2013 By: Subject: Jane Walters, Director of Corporate Affairs Quarterly Patient Experience Report 1. Executive Summary Delivering a quality service to our patients is one of the Trust s core strategic priorities - safe, kind and effective care. The publication in February of the Francis Report underlines the importance of our strategy. The Trust has established a group to review the report s recommendations which will report to the Board in due course. Preparations are well underway to implement the new Friends and Family Test, results of which are published nationally from April Performance in the 2012 CQC National A&E Survey was improved since the 2008 survey. Performance against London peers and other national Major Trauma Centres was encouraging with King s leading the MTCs in London. The CQC National Inpatient Survey results 2012 are expected to be published nationally at the end of April/beginning May. All CQUIN targets for both the national and local patient experience CQUINS were achieved for Quarter 3. Positive HRWD results for inpatients continued in Quarter 3 and the numbers of patients responding to the outpatient survey is growing steadily. The number of complaints received was slightly higher last quarter, but in line with previous years. Performance in responding to complaints continues to be below target but improving. In December, a Quality Accounts Stakeholder Meeting gained valuable input from stakeholders about proposed quality priorities for next year. Volunteer numbers continue to be upwards of 700. Highlights for the last quarter include invitations to 10 Downing Street and the Cabinet Office to discuss King's approach to volunteering, followed up by a visit from Nick Hurd, Minister for Civil Society in January

102 Enc King s Quality Accounts /13 Quality Account The quality priorities for patient experience for 2012/13 are : 2.2. National Patient Experience CQUIN This CQUIN is worth 800K this year. A further three wards were identified in Q3: Kinnier Wilson (Neurosurgery) David Marsden (Neurology) Dawson (Liver) They will be putting actions in place to make improvements of 3% overall in 5 patient survey key question areas Local CQUIN: Improving outpatient experience This CQUIN is worth 1.4 million split evenly between development and roll-out of a trust How are we doing outpatient survey and targeted improvement in key aspects of outpatient experience. Q3 targets focussed on achieving responses to the How are doing survey. All targets were met. Suites 3 and 7 have been tasked with making improvements in five key question areas: If you had to wait for your appointment, were you told how long you would have to wait? How clean was the Outpatient Department you visited (including any toilets you may have used in the Outpatient Department)? Did a member of staff explain the results of your test(s) in a way you could understand? Were you involved as much as you wanted in decisions about your care and treatment? Overall, how would you rate the care you received in the outpatient department? This quarter text reminders and i-pads were introduced which have had a positive impact on the numbers of surveys completed by patients. All CQUIN targets to-date have been met Quality Priorities for In December we held a Quality Accounts Stakeholder meeting. Attendance was good with representation across our stakeholders including Governors, Overview and Scrutiny teams, Local Involvement Networks and commissioning colleagues. The Trust presented detailed updates on progress against current priorities and shared potential areas on which to focus for next year s priorities. For the patient experience metrics, stakeholders were positive about continuing work to embed the outpatient survey and to drive 2

103 Enc improvements across the Trust. There was also interest in both information and support for patients on discharge and improvement work in the Medical Assessment Unit. The Patient Experience Committee considered the comments received and has recommended that the two areas of focus for 2013/14 are improving outpatient experience and improving information for patients on discharge. The draft report will go out for consultation to stakeholders in April. 3. CQC National Patient Survey Programme A&E Survey results update The National A&E Survey results were published on the Care Quality Commission s website on December 6 th King s is rated amber for all sections of the survey in the expected range Results were positive with an increase of 3.7 points overall since 2008 and improvement in 4 out of 6 comparable sections, with significant improvement in care and treatment, environment and facilities and leaving the ED. King s was ranked 1st amongst the London Major Trauma Centres (MTCs) and 3rd for comparable MTCs nationally. A number of initiatives are being implemented both to drive and measure improvements. Friends and Family test is being introduced in the Emergency Department from March A How are we doing survey is in development to supplement the Major Trauma survey which is providing useful information from patients to inform service improvement The ED is continuing to work on improving younger people s experience of the ED, for example, continuing work with local voluntary groups including Red Thread and the Loughborough Junction Youth Club. A new collaboration with primary care partners has commenced which aims to improve the meet and greet function, improve communication with GPs, for example info on frequent attenders, addressing community health themes and an integrated IT system 4. External Radar The trust regularly monitors a range of external sources of patient experience data from the CQC Quality Risk Profile on websites such as NHS Choices, Patient Opinion and social networking sites including Facebook and Twitter. The rating system on the NHS Choices website has now changed to a star rating system and King s is currently rated as five star. Recent comments include: I had surgery and the team that looked after me was brilliant, they explained to me very fully what the procedure would involve and they were very professional, kind and caring. The surgery was successful and they have given me very thorough follow up care and monitoring. I made a good recovery and returned to work. What I liked: My daughter was treated on Lion Ward. The staff were all committed and very professional, but very caring and sympathetic. What could have been improved: The car parking was very expensive, maybe if you have a child in the hospital you should get some of this refunded? 3

104 Enc The Friends and Family Test update The Friends and Family Test has been included in the government s mandate to the NHS Commissioning Board. Making sure that people have a positive experience of care is a key requirement in the Mandate, published on 13 November It means every patient will be able to give feedback on the quality of their care, even in hospitals which currently have no established patient survey programme. The rollout plan is: acute hospital inpatients and accident and emergency patients from April 2013 for women who use maternity services from October 2013 as soon as possible after October, for all those using NHS services. The Friends and Family test is being widely trailed as one of the government s responses to the Francis Report. Results will be publically available and will play a role in where patients choose to receive their care. It has been announced that the Friends and Family Test will be the only national Patient Experience CQUIN for 2013/14. The CQUIN will be structured with three separate elements: 30 per cent of the funding for phased expansion: NHS providers will need to deliver the nationally agreed roll-out plan to the national timetable. Missing any element of this will result in non-payment of the CQUIN. 40 per cent of the funding for increasing the response rate in the acute inpatient and A&E areas. Initial minimum response rates required are 15-20%. This presents a particular challenge in A&E due to the high throughput. Going forward, achieving a response rate in the top 50 per cent which also improves on the Q1 response rate will be required. 30 per cent of the funding for increasing the score of the Friends and Family Test question within the 2013/14 staff survey compared with 2012/13 survey results. 6. Summary of patient experience feedback King s Patient Experience Report King s monthly Patient Experience Report presents integrated patient feedback from patient complaints, Patient Advice and Liaison Service (PALS), How Are We Doing and patient comments. It also monitors performance against CQUIN targets and Eliminating Single Sex Accommodation How are we doing? Performance over the quarter has been very positive. The overall HRWD score met the benchmark throughout Q2 and for 2 out of the 3 months in Q3. Scores for both patient engagement and care and treatment reached the benchmark of 87 for two months in Q3. Environment scores reached the benchmark in November, but dropped back one point for October and December. The food rating has remained green for the last 12 months. Patients rated their experience in Day Surgery green with a score of 92. Maternity scores fell back slightly from 83 to 82. 4

105 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Enc Response rates for HRWD were disappointing for the quarter at 37%. Rates will need to improve. Within the Divisions, Cardiac and Children s met the overall benchmark for all three months of the quarter and Haematology for two out of three months The trust also continues to do well in meeting patient expectations for receiving their care in single sex accommodation. The average satisfaction score for this quarter was rated green at 91. In January a revised version of the HRWD inpatient survey was launched which includes the new Friends and Family question, as well as a question on whether a patient was admitted through a planned route or as an emergency. It also includes a question about volunteers to assess their impact on patient experience and a question on whether a patient has diabetes to support staff in improving the experience and care of patients with diabetes Complaints and Patient Advice and Liaison Service (PALS) 90 Complaints No. of Compl ai nts Compl ai nts T r end There were 176 complaints this quarter. YTD there have been 500 complaints, against a target of 405. We will exceed our end of year stretch target (540), and expect an increase compared with 2011/12 (590). The trend in complaint numbers has remained similar since Q3 11/12, against a pattern of increasing activity. 47% of complaints for YTD were responded to within the target of 25 working days against a target of 70. The profile of complaints has remained the same for the last two quarters. There was a notable reduction in concerns about inpatient cancellations in Q3, although conversely PALS report an increase in this area, which suggests that issues remain, and are being picked up through different routes. Neurosciences received the highest number of complaints during the quarter. The highest proportion of PALS issues continue to be related to outpatients. 5

106 Enc Volunteering King s volunteers are continuing to play a key role in helping staff and patients. Numbers continue to be high with upwards of 700 volunteers from the local community actively involved in King s. Highlights for last quarter include invitations to No 10 Downing Street and the Cabinet Office to discuss King's approach to volunteering, and a visit in January from Nick Hurd, Minister for Civil Society, and the Department of Health, to see King's volunteers in action, and as a possible model for wider rollout within the NHS. 8. King s Patient Experience Transformation Programme We are continuing to drive improvement in patient experience through our Patient Experience Transformation Programme. To summarise progress: 8.1. Video Stories Good progress has been made in developing video patient stories as a method for gathering and using patient experience feedback to drive service improvement. This quarter saw the first four areas trained in the methodology and carrying out their first video stories. Both MAU wards, Mary Ray and Oliver have filmed patients as well as videos in Renal and in the Derek Mitchell Unit as part of the trust s cancer improvement work. A second tranche of wards and outpatient areas will carry out their first video stories in the New Year and begin to use these to focus in on local areas for improvement. They are Cotton Ward, Elderly Medicine, Radiology and Suite 1 outpatients. Some Governors are involved in the project and receiving training so that they can both produce patient video stories and support staff to introduce video stories across the trust Improving Patient Experience in the Medical Admissions Unit (MAU) Work has begun on Mary Ray and Oliver to get a better understanding of how patients experience these two very busy wards. The diagnostic phase has looked closely at existing data on patient experience and is also gathering new information from patients. Two focus groups are planned as well as observations on the wards. Based on this, a set of actions will be put in place to improve the experience of patients admitted to the MAU which will then be monitored and measured through the How are we doing survey. 9. Recommendation The Board is asked to note this report, and offer any comments. 6

107 Enc Report to: Board of Directors Meeting Date of Meeting: 26 February 2013 Subject: Infection Control Quarterly Report Quarter 3; 2012/13 Author(s): Presented by: Sponsor: History: Status: Erika Grobler; Deputy Director of Infection Prevention and Control Dr Geraldine Walters, Director of Infection Prevention and Control Dr Geraldine Walters Quarterly DIPC report For report. 1. Background/Purpose A summary of the Infection Prevention and Control activity from October till December Action required To note the content of the report. 3. Key Implications Legal: Financial: Assurance: Clinical: Equality & Diversity: Performance: Strategy: Workforce: Estates: Reputation: Other: (please specify) The Trust has a statutory responsibility to ensure compliance under the Hygiene code. The submission of a quarterly report is part of the Code. Poor infection control practices and increase in infection rates has a direct financial impact as a result of additional drug costs and increase in Length of Stay The infection Prevention and Control report provides an overview of Infection Control activity and identifying significant trends and developments. This report incorporates the risk register relating to infection control also. Good Infection Prevention and Control practices are key to providing high quality care to King s patients The content of this report has no implications for equality and diversity Infection rates have a direct impact on length of stay, our Monitor performance rating and our CQC registration status. None None None Poor compliance in infection prevention and control standards could adversely affect the reputation of the organisation.

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109 Enc Quarterly DIPC report Quarter 3 Geraldine Walters Director of Nursing and Midwifery; Director of Infection Prevention and Control 1

110 Contents Enc Executive summary Trust Performance Summary Divisional Performance Summary Key focus areas Antimicrobial stewardship CDT Root Cause Analysis process Other areas of note ICE pod installation Consumables standardisation IV line insertion role of the IV team 2

111 Executive Summary (1/3) Enc MRSA (post 48 hour) bacteraemias good performance: One Trust attributable case reported in One in Ambulatory (Apr 2012) MRSA screening: 100% Elective (in December 2012) 96.6% Emergency (in December 2012) 2. VRE bacteraemias improved performance: 1 case of VRE bacteraemia in December for a total of 22 cases YTD (trajectory of 13 cases for the same period.) This does indicate an improvement on Q2 (13 cases in Q2; 6 cases in Q3) 3. C-difficile still under DH trajectory but number of cases and have seen a reduction in Q3 compared to Q2: 45 CDT cases reported to DH (as per National Guidance) in (trajectory of 56 cases YTD): Surgery - 9 cases compared to 12 in 2011/12 (YTD December) TEAM - 5 cases compared to 13 in 2011/12 (YTD December) Critical Care - 2 cases compared to 8 in 2011/12 (YTD December) Cardiac - 3 case compared to 5 in 2011/12 (YTD December) Trust attributable CDT Cases over the last 4 quarters: Q3 22 cases Q4 18 cases Q1 11 cases Q2 25 cases Q3 12 cases A further 88 cases have been reported locally as per the April DH testing guidance. All of these cases have been included in the Root Cause Analysis process and been managed as per Trust CDT guidance. This continues to place additional pressure on isolation provision. 3

112 Executive summary (2/3) Enc E.coli bacteraemia The Trust has reported 82 cases YTD for 2012/ Meticillin Resistant Staphylococcus aureus (MSSA) bacteraemia The Trust has reported 20 post 48 hour cases of MSSA bacteraemia YTD for 2012/13 Key focus areas: 1. Antimicrobial stewardship Monthly audits undertaken in all inpatient wards. Results are improving. Work underway to audit prophylaxis prescribing and administration in theatres. Results to be available shortly. The Antibiotic Usage Steering Group is leading on the implementation of the Start Smart then Focus action plan. Progress will be reported in the next quarterly report. 2. Hydrogen Peroxide Vapour technology HPV has been used in a number of areas where CDT or multi-resistant gram negative infections occurred. Areas that have been treated, i.e. surgical and renal wards have shown a marked reduction in CDT cases. 3. CDT root cause analysis The well established process for reviewing both DH and locally reportable CDT cases has been further developed so that divisions ensure completion of mitigating actions identified through this process. 4. Multidrug resistant organisms Child Health The trust has had cases of children colonised with a multi resistant family of organisms. A working group comprised of CEF, IPC, medirest and the division, have been formed to manage this situation. 5. Water management group A group has been established with key stakeholders, including CEF, Infection Control and Medical Microbiology, to manage the Trust s response to new guidance on water quality. 4

113 Executive Summary (3/3) Enc Other areas of note: 1. ICE pod installation: Two pods will be installed on Annie Zunz during the first week in December. A further 5 pods to be installed once bed pressures allow. 2. Healthassure and the Infection Control Gap Analysis The IPC team is working with others in the Trust to implement the Healthassure system. The Hygiene Code model will provide a more accurate view of Trust compliance than the systems currently being used. Progress will be reported as part of this report in the future. 3. Consumables standardisation: The Infection Prevention and Control team will take an active role in the newly established Product Selection Group by co-opting the appropriate clinical leaders onto the group, i.e. the Continence Nursing team when decisions on continence products are made. 4. European Directive provision of safety engineered devices The Lead IV practitioner is leading on the implementation of safety engineered devices. These are sharp devices that pose a risk to staff of needlestick injuries. The Trust has implemented safety engineered peripheral cannulaes and venepuncture equipment. Trials will take place over the next few months on other devices, i.e. hypodermic syringes and needles and needles for intramuscular and subcutaneous injections. 5

114 Contents Enc Executive summary Trust Performance Summary Divisional Performance Summary Key focus areas Antimicrobial stewardship CDT Root Cause Analysis process Other areas of note ICE pod installation Consumables standardisation IV line insertion role of the IV team 6

115 MRSA bacteraemia Enc

116 VRE bacteraemia Enc

117 C.difficile DH reportable Enc

118 C.difficile locally reportable Enc

119 MSSA bacteraemia Enc

120 E.Coli bacteraemia Enc

121 IC scorecard Dec 2012 Enc

122 IC scorecard Dec 2012 Enc

123 IC scorecard Sept 2012 Enc

124 Contents Enc Executive summary Trust Performance Summary Divisional Performance Summary Key focus areas Antimicrobial stewardship CDT Root Cause Analysis process Other areas of note ICE pod installation Consumables standardisation IV line insertion role of the IV team 16

125 Divisional performance Enc Two divisions continue to be identified each month as requiring additional scrutiny and input from the Infection Prevention and Control (IPC) team The criteria on which this decision is based has been widened to include the number of non-compliance assurance audits on the Infection Control Scorecard, but also other potential areas of concern, i.e. any clusters or outbreaks that have occurred. There is also an aim to ensure that all divisions meet with the IPC team in this way at least once in the financial year. Turnaround meetings during Q3: October: Cardiac and Child Health November: Emergency Department and Liver 17

126 2012/13 December Infection Control heatmap (1/2) Enc

127 2012/13 December Infection Control heatmap (2/2) Enc

128 Contents Enc Executive summary Trust Performance Summary Divisional Performance Summary Key focus areas CRE Antimicrobial stewardship CDT Root Cause Analysis process Other areas of note ICE pod installation Consumables standardisation IV line insertion role of the IV team 20

129 CRE Carbapenemase Resistant Enterobacteraceae A group of organisms that normally live in the gut Organisms are very resistant to antibiotics, making the treatment of infections due to these organisms very difficult. Prevention is important as treatment options are limited. Carbapenemase can be transferred between organisms. Infections caused by CRE is associated with high mortality Enc CRE at KCH August 2012 KCH notified by a hospital in Dublin that three paediatric liver patients transferred were found to be positive September 2012 Weekly screening of all patients on Rays of Sunshine and Thomas Cook introduced. Sixteen patients in Child Health have been have been identified in Child Health, predominantly in Rays of Sunshine. 21

130 Antimicrobial stewardship (1/3) Enc The Trust continues to be the only Teaching hospital in London that undertakes a monthly audit of antimicrobial stewardship; a process coordinated and managed by the Medical Microbiology team. Results for November 2012: KPI1 compliance (is an indication recorded) = 96% KPI 2 compliance (stop / review date recorded)=79% KPI 3 compliance (IV / PO switch not overdue) = 96% KPI4 compliance (indication as per guideline) = 91% 22

131 Antimicrobial stewardship Nov data (2/3) Enc

132 Antimicrobial Stewardship Nov data (3/3) Enc

133 CDT root cause analysis process Enc Root cause analysis process: The weekly CDT review meetings is fully established and has become more important in reviewing locally reported cases to distinguish true or colonised cases. These review meetings have now been changed to strengthen local Divisional and Speciality ownership and review. 25

134 Contents Enc Executive summary Trust Performance Summary Divisional Performance Summary Key focus areas Antimicrobial stewardship CDT Root Cause Analysis process Other areas of note ICE pod installation Consumables standardisation PICC line insertion role of the IV team 26

135 ICE pod installation Enc ICE (infection control enclosure)-pod isolation facilities A product recently brought to the market by Bioquell. It is a semipermanent structure that is constructed bespoke for each bed space. The Trust has ordered 7 (installation w/c 5 th Dec) of these pods to: Provide more flexibility in isolation room provision Increase the uptake of HPV usage by reducing the time required to implement this technology. The first two pods have been installed on Annie Zunz. The further 5 pods will be installed once bed pressures allow. It is important to note that this technology is not a direct replacement for increasing isolation room provision but does provide more flexibility. 27

136 Consumables standardisation Enc A group; the Product Selection Group, has been established under the chairmanship of the Director of Procurement for KHP to work towards standardisation of clinical consumables to: ensure that the quality of consumables used is of a sufficiently high standard to increase patient safety to explore economies of scale through joint procurement across KHP. The first product range to be worked on will be urinary catheterisation products. 28

137 PICC line insertion role of the IV team Enc Peripherally inserted Central catheters (PICC) are used for patients who require longer term intravenous therapy; i.e. IV antibiotic therapy or TPN nutrition. The IV team are taking on more of a role in inserting PICC lines (currently undertaken by interventional radiologists) in order to relieve the pressure on PICC insertion waiting times. The team have also commenced pre-assessment of these patients to: Improve the consenting process Improve the information given to patients Improve the utilisation of PICC insertion lists in Radiology The team have been given authorisation by the Novel Procedures Group to trial a new device for keeping PICC lines in place. Currently around 25% of slots on the insertion lists are used for resiting lines that have either accidentally been removed or have migrated. This trial will commence in January

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139 Enc Quality Priorities & Accounts Geraldine Walters 13 February 2013 Making King s First Choice for patients and staff