July (Month 4) Integrated Performance Report. Executive Directors. For Information For Discussion For Approval. Strategic Direction and Development

BOARD OF DIRECTORS AUGUST 2016 Subject/Title July (Month 4) Integrated Performance Report Executive Responsible Paper prepared by (if different from above) John Grinnell, Deputy Chief Executive and Chief Finance Officer Executive Directors Nature of Report Category of Item Context For Information For Discussion For Approval Strategic Direction and Development Performance and Governance Previous Board discussion Link to National Policy Link to Trust s Strategic Objectives Risk if no action taken Executive Summary The Trust s Month 4 Performance Report is detailed in the attached paper. Received or approved by Legal Implications None Recommendation Acronyms and Abbreviations It is recommended that the Board note: The performance during July 2016 (Month 4). VTE Venous Thromboembolism DVT Deep Vein Thrombosis PE Pulmonary Embolism CQUIN Commissioning for Quality and Innovation Payment Programme RTT Referral to Treatment UCL Upper Confidence Limit LCL Lower Confidence Limit BADS - British Association of Daycase Surgery I&E - Income and Expenditure C. difficile Clostridium difficile (bacterial infection) MRSA Methicillin-resistant Staphylococcus aureus (bacterial infection) STF Sustainability and Transformational Plan 1

BOARD OF DIRECTORS INTEGRATED PERFORMANCE REPORT JULY 2016 1. Introduction 1.1 The integrated performance report has been developed in order to assist the Board in monitoring the delivery of key performance metrics against local and national targets. 1.2 The report covers the five key domains of: -,, Resources, and External Perception. 1.3 Performance measurement targets within these domains are based on the following The core standards set nationally by Monitor, NHS England, Welsh Assembly Government and the Care Quality Commission Any locally agreed Commissioner driven targets including CQUIN quality improvement Internal performance targets in line with the Trust s Annual Operating Plan objectives. 1.4 The scorecard format provides an overview of the performance within each domain with further detail of specific metrics in graphical and tabular format. 1.5 The scorecard utilises two graphical presentation methods; line graphs and statistical process control (SPC) charts. SPC charts enable the analysis of the variability of a metric relative to average performance. Data points within the upper and lower limits are linked to natural variation in performance levels. 1.6 As agreed, a review of the scorecard is underway which will result in a revised format from Quarter 2 of 2016-17. 2. Overview 2.1 Month 4 saw the Trust maintain its excellent patient experience performance. Whilst overall the safety domain performed well, we report a spinal wrong level surgery never event in the report. 2.2 Our RTT performance met trajectory however a growth in referrals and the impact of lower activity than planned during the summer holiday period is putting increasing pressure in delivering our plan. Theatre activity levels in July were lower than anticipated and have had an adverse impact on our finances. With similar challenges forecast in August, an executive led group to oversee performance has been initiated. 3. Performance Overview 3.1 Domain 1 3.1.1 Overview Seven of the ten key metrics were rated as green in month. Although the number of incidents remains low overall, the Trust continually scopes areas for improvement and ensures learning is communicated throughout all appropriate areas. The following exceptions are noted for month 4. 2

3.1.2 Serious Incidents The scorecard reports one serious incident in July where a patient on the care of the elderly ward fell and sustained a fracture. The incident has been reported to the relevant external bodies. A further incident occurred in July that has also been reported as a Never Event with STEIS in August, therefore will show on the August scorecard. A patient underwent spinal surgery and during post-procedure checks a CT scan showed that wrong level spinal surgery had been performed. The Consultant spoke to the patient and their family to explain the outcome and the correct level surgery was consented and carried out the following day. 3.1.3 Mortality Rates There were no patient deaths in July. 3.1.4 Hospital Acquired VTE (DVT or PE) A patient was diagnosed with hospital acquired deep vein thrombosis six days following a total knee replacement. The patient had been risk assessed on admission and following diagnosis of the DVT, the patient s care plan was updated on the ward. One incident remains within the monthly tolerance levels. 3.1.5 Patients Falls (Harms) Seventeen patient falls occurred in July with eight patients capable of receiving medical advice not complying with the medical advice given at the time of the incident. For Inpatients, there were sixteen falls that when compared to activity levels correlates to 2.50% of activity. There was one further fall in Outpatients. Five patients experienced low level harm of skin abrasion (2), loss of consciousness (1) and pain (2). One further patient experienced moderate pain. Although six incidents with harm is above the limit of two, it remains within normal variation levels. 3.1.6 Hospital Acquired Pressure Ulcers Pressure Ulcers are graded on a scale from 1 to 4, with grade 1 relating to minimal harm and grade 4 being full skin loss and the highest level of harm. There were no incidents to report in July. 3.1.7 Medication Errors (Harms) The graph for this KPI within the scorecard displays the overall errors per month and those with harm. The performance rating is based on any harms. Twelve medication incidents relating to patient care at the hospital were recorded during July which were categorised as Prescribing (2), Administration (2), Dispensing (7) and the incorrect advice given to a patient (1). No patients experienced harm as a result of these errors. 3.1.8 28 day Readmission Rates to RJAH Seven patients were readmitted as an emergency within 28 days of initial discharge in June 2016 giving a readmission rate of 1.15% against the 1% limit. The reasons for readmission were wound issues (4), pain (1), query possible infection (1) and revision lumbar discectomy (1). 3.2 Domain 2-3.2.1 Overview July was a positive month for patient feedback with three hundred and fifty five compliments received, the highest so far this year. The comments received frequently refer to the friendly and professional manner that staff demonstrate throughout all areas of the patient s pathway of care. The following exceptions are noted for month 4. 3

3.2.2 NHS Friends & Family Test The Friends and Family metrics within the scorecard is a combined measure representing the percentage of both inpatients and outpatients that would and would not recommend the Trust. In line with the national metrics, passive responses are not included within calculations. The results for July indicate that 99.13% of patients would recommend the Trust. 0.70% stated they would not recommend the Trust. Those who were unlikely to recommend were from a cross-section of areas and left no specific comments. The latest national averages published for May 2016 indicate that 96% of inpatients recommend Trusts with 1% not recommending so our performance continues to exceed those levels. 3.2.3 Complaints Two complaints were received in July, below the tolerance level. One of the complaints related to clinical care with reasons associated with the outcome of care. A further operational complaint related to appointment allocation following multiple DNAs. Each complaint is currently under review in line with the Trust s Complaints Policy. 3.2.4 Delayed Discharges The delayed discharges rate is reported as the total number of delayed days against the total available bed days for the month. In July there were 250 delayed bed days. When compared to the available beds this gives a rate of 5.04% which is higher (being worse) than the 2.50% target. As with previous months, the delays are predominately Spinal Injuries patients who were awaiting care packages. As a Trust we are unable to directly control this so we continue to raise the issue with the relevant Commissioners. 3.2.5 Access to Bone Tumour Services All cancer targets were achieved in July. Since last month s scorecard a shared breach has been uploaded to the national cancer waits database against the 62 day standard so performance has been updated to 66.67% for June. The patient commenced a pathway at this Trust and was then referred to SaTH on day 32 of their pathway, however, SaTH did not commence their definitive treatment within target. We are currently challenging the breach share allocation, as the patient was transferred to SaTH in a timely manner. 3.2.6 Access to Services - English Our July performance is 88.75% against the 92% open pathway performance for patients waiting 18 weeks or less to start their treatment. This is against a trajectory plan of 88.29%. The total number of breaches has increased by 63 from 687 to 750. It is important to note that overall list size has increased during the first quarter; we have seen an increase in the number of referrals received and have notified the Commissioners of the position. 3.2.7 Patients waiting over 52 weeks At the end of July there were no hospital initiated 52 week waits for English patients. There were 10 English patients (10 patient choice) and 10 Welsh patients waiting over 52 weeks (10 BCU). All patients waiting over 40 weeks are being monitored on a weekly basis, with Clinical Commissioning Groups. Welsh long wait patients are being managed in line with revised contract instructions and we are currently in discussions regarding the reduction profile for 2016/17. Our ability to meet our demand for spinal disorder patients remains a key area of focus operationally. 3.3 Domain 3 Overview July was a challenging month in terms of patient efficiency with a number of metrics rated as amber in month. Activity figures were lower than plan in July. 4

Internal theatre throughput levels fell below plan with 91.24% of theatre lists being utilised compared to a target of 96.60%. However, cases per session improved and exceeded target at 2.25. The following exceptions are noted for month 4: 3.3.1 Daycase Performance July saw an improvement in the performance against the composite target for BADS with performance reported at 85.96% against the 84% target and is rated green in month. The July casemix was a contributory factor in this although a daycase working group does meet on a monthly basis where performance against this standard is monitored. The Daycase rate for July deteriorated to 46.42% against the 51% target so is rated amber in month. The new development will support improvement in this area with extended opening hours for the unit supported by additional therapy service provision. 3.3.2 Admission on Day of Surgery The proportion of patients admitted on the day of surgery came back to the levels seen earlier in the year at 95.67%. The frequency of the forward look process is being reviewed to ensure there is continued focus on this measure. 3.3.3 Average Length of Stay Although the average length of stay was maintained at 3.85 days, the metric is rated as amber due to the target step change. Sustained focus is required to ensure this reduces over the remainder of the year. Despite a dip, the proportion of Primary Hip and Knee patients discharged in three days or less continues to exceed its target at 64.02% in July. 3.3.4 Outpatient Productivity The DNA rate decreased in July improving to 5.69% compared to 6.54% the previous month; however the target of 5.4% was not quite achieved. Areas of concern were added to the text reminder service and regular reviews will continue to make effective use of this system. 3.4 Domain 4 Resources 3.4.1 Overview We continue to adjust our Income and Expenditure performance to reflect the criteria attached to the control total target set by NHS Improvement. This excludes performance driven by donated assets (depreciation and income) and sustainability and transformation funding (STF). Achievement of our control total target at each quarterly milestone is a key deliverable in being eligible to receive the 0.5m of Sustainability and Transformation funding included in our plan. We have received 125k of this to date based on our quarter 1 performance. Our adjusted surplus for July was 41k against a plan of 191k leaving us 150k adrift of target. The shortfall was driven by lower than planned levels of inpatient activity and income as a result of higher than anticipated consultant annual leave. On a cumulative basis we have achieved a control total adjusted surplus of 341k ( 507k including STF) which is 135k behind plan. A further shortfall of activity and clinical income is expected for August. An executive led finance and RTT task and finish group has been set up to ensure appropriate booking of patients that optimises performance of both our key targets and to oversee a recovery of lost activity. Our FSRR for July has remained at a 4 (lowest level of risk). Our EBITDA margin year to date is 4.9% which is lower than plan by 0.6%. The key features of the financial performance for month 4 are detailed below: 5

3.4.2 Income - Clinical income fell short of plan by 263k driven by: Reduced theatre activity delivered internally 259k Reduced levels of outsourcing to the independent sector and pass through drugs 154k (benefiting cost base) Partly offset by: Increased non surgical activity and outpatients 150k Private patient income fell short of plan by 137k which was largely casemix driven. 3.4.3 Expenditure Overall pay costs were 107k under plan in month driven by lower than planned levels of out of job plan working. Agency spend remains a key area of focus for our regulator. In month our agency spend was 134k which was within our control limit. The number of agency agreements exceeding national price caps reduced by 2 to 13 and these continue to be reported to NHSI on a weekly basis. Non pay costs overall were 160k under plan linked to pass through items as reflected in the cost base. 3.4.4 Cost Improvements Our efficiency plan has been set at 3.5m for the year and full delivery of this is one of the core components of our ability to hit our control total. In month 201k was recognised against a plan of 266k whilst year to date we have achieved 698k against a plan of 759k leaving us 61k behind plan. The underperformance is largely linked to one of our key schemes (valued at 300k) associated with increased productivity in our theatres. As we have not met our planned internal activity levels this scheme has fallen behind plan. Delivery of remaining schemes is being closely monitored through our performance management framework and further mitigating schemes are currently being worked up and overseen by the task and finish group. 3.4.5 Capital Expenditure amounted to 0.83m in month and primarily related to the construction of the new Theatres and Tumour unit. Year to date we have spent 2.9m which is 360k ahead of plan largely driven by an earlier than anticipated commencement of the equipment replacement programme. We anticipate staying within our overall capital plan of 5m. 3.4.6 Cash Balances reduced by 0.3m in month to 4.6m which is 0.2m behind planned levels linked to the profile of the capital programme. 3.4.7 Sickness Absence Sickness absence for July decreased to 3.33%, following a reduction in short terms absences, stress and anxiety. The following exception report stating areas below the target is included for information. Medicine 4.11% Theatre 3.69% Surgery 3.35% - 3.4.8 Staff Stability Index The stability index for July improved to 91.05% which is just above (better than) the 91% target. The following exception report stating areas below the target is included for information. Corporate 88% - Theatre 90% Medicine 90% 6

3.4.9 Staff Appraisal Following further focus on this area, staff appraisals in July increased to 93.30% Trust wide of staffing having undertaken an appraisal within the past 12 months, above the 90% target. 3.4.10 Staffing Establishment The Trust monitor staffing levels twice daily and this is reported to NHS England monthly. As part of a review of our reporting of this indicator for this financial year we have changed the planned fill rate to be measured against a fixed establishment based on safer staffing levels and will provide a narrative on where we may vary from this in a planned way for example if we reduce bed numbers or for lower patient complexity. Previously the plan has been flexed to take account of these issues however it is felt to be clearer to fix the planned levels and narrate any variance. 3.4.11 All escalation processes have been followed to ensure patient safety is maintained with the shift fill rate of 97.8% above the target of 90%. The monthly Unify table is shown below. The average fill rates fell below target in some areas throughout the month but Wards remained safely staffed and supporting data monitors the patient numbers on the Wards at these times and includes the monitoring of patient acuity levels. 3.5 Domain 5 External Perception 3.5.1 As referenced in the resources section our financial performance and sustainability risk rating remained at a level 4 (lowest level of risk). 3.5.2 NHS Improvements governance rating shows the Trust being in breach of its licence and is therefore rated as red on the scorecard. 4. Recommendation 4.1 It is recommended that the Board: Note the performance for July (Month 4) John Grinnell Deputy Chief Executive and Chief Finance Officer 7

Overall Performance Overall Performance Month Key Metric YTD Change Forecast Month Key Metric YTD Change Forecast Infection Control g g same g Friends & Family Test g g same g Serious Incidents a a same a of Complaints g g same g Never Events g g same g Theatre Cancellations g a same g Unexpected Deaths g g same g Delayed Discharges r r same a Clinical Quality a a worse g Access to Bone Tumour Services g g same g Safety Thermometer g a same g Access to Services - English r r worse g Medication Errors and those with Harm g g same g Patients Waiting Over 52 Weeks r r same g Pressure Ulcer Assessments g g same g 28 Day Emergency Readmission Rate a a worse g VTE Assessments Undertaken g g same g VISION To be the leading centre for high quality, sustainable Orthopaedic and related care, achieving excellence in both experience and outcomes for our patients Resources Overall Performance Overall Performance Month Key Metric YTD Change Forecast Month Key Metric YTD Change Forecast Sickness Absence a a same g Demand for Services a a same a Staff Stability Index g a better g Activity - Surgery a g worse g Staff Appraisal g a better g Activity - Medicine a g worse g Safe Staffing - % Shift Fill Rate g g same g Daycase Performance g a better g Net Surplus r r worse a Admission on Day of Surgery g g better g CIP Delivery a a worse a Theatre a a worse a Capital Expenditure a a worse g Average Length of Stay g g same g PSPP g g same g Bed Utilisation r a worse a Cash Balance g g same g Outpatient Productivity a a better a New to Follow Up Ratio (Consultant Led Activity) g g same g External Perception Overall Performance Month Key Metric YTD Change Forecast Monitor Risk Rating - Finance g g same a Monitor Risk Rating - Organisational Health r r same r 8

Infection Control Hospital Acquired MRSA Bacteraemia Infection Control Hospital Acquired C.Difficile Serious Incidents 5.00 4.00 3.00 Period Performance g g g g Period Performance g g g g Period Performance g g a a 9

Never Events Unexpected Deaths Clinical Quality Hospital Acquired VTE (DVT or PE) 6.00 5.00 4.00 3.00 Mean UCL LCL Period Performance g g g g Period Performance g g g g Period Performance 3.00 g 3.00 g 3.00 4.00 a 3.00 g 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 10

Clinical Quality Total Patient Falls and those with Harm Clinical Quality Hospital Acquired Pressure Ulcers - Grade 2 Clinical Quality Hospital Acquired Pressure Ulcers - Grades 3 or 4 2 2.50 19.00 18.00 17.00 16.00 15.00 14.00 13.00 1 1.50 1 1 9.00 8.00 7.00 6.00 5.00 0.50 4.00 3.00 6.00 5.00 4.00 3.00 Mean Harms UCL Total LCL Period Performance 5.00 a g g 6.00 r Period Performance g g g g Period Performance g r g g 11

% % Safety Thermometer Safety Thermometer - % with no new harms Safety Thermometer Safety Thermometer - % of patients with harm free care Medication Errors and those with Harm 10 10 10 99.00 99.00 98.00 98.00 97.00 97.00 96.00 96.00 95.00 95.00 94.00 94.00 93.00 9 10 98.00 98.00 96.00 96.00 94.00 94.00 9 9 9 9 88.00 88.00 86.00 86.00 84.00 19.00 2.50 18.00 17.00 16.00 15.00 14.00 13.00 1 1.50 1 1 9.00 8.00 7.00 6.00 5.00 0.50 4.00 3.00 Mean UCL UCL LCL LCL Period Performance 95.00 99.17 g 95.00 97.73 g 95.00 98.78 g 95.00 98.19 g 95.00 95.00 95.00 95.00 95.00 95.00 95.00 95.00 Mean UCL UCL LCL LCL Period Performance 95.00 92.56 r 95.00 92.42 r 95.00 95.73 g 95.00 96.99 g 95.00 95.00 95.00 95.00 95.00 95.00 95.00 95.00 Mean Harms UCL Total LCL Period Performance g 3.00 a g g 12

% % % Pressure Ulcer Assessments 28 Day Emergency Readmission Rate 28 Days Emergency Readmissions to RJAH Following an Overnight Stay VTE Assessments Undertaken 100.20 10 10 10 10 95.00 1.80 10 95.00 9 99.80 1.60 9 98.00 99.60 1.40 96.00 8 99.40 75.00 99.20 7 1.20 0.80 8 94.00 75.00 9 7 99.00 65.00 0.60 9 65.00 98.80 6 0.40 88.00 6 98.60 55.00 0.20 86.00 55.00 98.40 5 84.00 5 Mean UCL LCL Period Performance 99.00 10 g 99.00 99.90 g 99.00 10 g 99.00 10 g 99.00 99.00 99.00 99.00 99.00 99.00 99.00 99.00 Period Performance 1.36 r 0.97 g 1.15 a No Data g Period Performance 95.00 10 g 95.00 99.91 g 95.00 10 g 95.00 99.91 g 95.00 95.00 95.00 95.00 95.00 95.00 95.00 95.00 13

% % Friends & Family Test Friends & Family - % Would Recommend (Inpatients and Outpatients) Friends & Family Test Friends & Family - % Would Not Recommend (Inpatients and Outpatients) of Complaints 10 10 10 95.00 9 98.00 96.00 8 94.00 75.00 9 7 9 65.00 88.00 6 86.00 55.00 84.00 5 1.20 3.00 2.50 0.80 0.60 1.50 0.40 0.20 0.50 16.00 14.00 1 1 8.00 6.00 4.00 Mean UCL LCL Period Performance 9 98.71 g 9 98.76 g 9 98.72 g 9 99.13 g 9 9 9 9 9 9 9 9 Period Performance 0.16 a 1.06 a 0.92 a 0.70 a Period Performance 9.00 1 a 9.00 9.00 g 9.00 7.00 g 9.00 g 9.00 9.00 9.00 9.00 9.00 9.00 9.00 9.00 14

% % Theatre Cancellations % Reportable Cancellations Theatre Cancellations Cancellations Not Rebooked within 28 Days Delayed Discharges % Delayed Discharges Rate 0.90 2.50 8.00 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 1.50 0.50 7.00 6.00 5.00 4.00 3.00 Mean UCL LCL Period Performance 0.70 0.26 g 0.70 0.27 g 0.70 0.51 g 0.70 0.66 g 0.70 0.70 0.70 0.70 0.70 0.70 0.70 0.70 Period Performance g r g g Period Performance 2.50 7.04 r 2.50 6.25 r 2.50 5.63 r 2.50 5.04 r 2.50 2.50 2.50 2.50 2.50 2.50 2.50 2.50 15

% % % Access to Bone Tumour Services Cancer Two Week Wait Access to Bone Tumour Services 31 Days First Treatment (Tumour) Access to Bone Tumour Services 31 Day Subsequent Treatment (Tumour) 10 10 10 10 10 10 95.00 10 9 95.00 10 9 10 95.00 99.00 9 98.00 99.00 98.00 8 96.00 8 98.00 97.00 8 75.00 75.00 96.00 75.00 94.00 7 97.00 7 95.00 7 9 65.00 96.00 65.00 94.00 65.00 6 9 55.00 6 95.00 55.00 93.00 6 9 55.00 88.00 5 94.00 5 9 5 Period Performance 93.00 10 g 93.00 95.24 g 93.00 10 g 93.00 93.94 g 93.00 93.00 93.00 93.00 93.00 93.00 93.00 93.00 Period Performance 96.00 10 g 96.00 10 g 96.00 10 g 96.00 10 g 96.00 96.00 96.00 96.00 96.00 96.00 96.00 96.00 Period Performance 94.00 10 g 94.00 10 g 94.00 10 g 94.00 10 g 94.00 94.00 94.00 94.00 94.00 94.00 94.00 94.00 16

% % % Access to Bone Tumour Services Cancer Plan 62 Days Standard (Tumour) Access to Bone Tumour Services Cancer 62 Day Consultant Upgrade Access to Services - English 18 Weeks RTT Open Pathways 12 10 105.00 10 10 94.00 95.00 10 9 95.00 10 9 95.00 9 9 8 95.00 9 8 8 8 88.00 6 75.00 9 75.00 75.00 7 7 86.00 7 4 65.00 65.00 84.00 65.00 6 2 55.00 6 8 55.00 6 8 55.00 5 75.00 5 8 5 Period Performance 10 g 10 g 66.67 r 10 g Period Performance 10 g 10 g 10 g 10 g Period Performance 9 88.57 r 9 88.90 r 9 89.21 r 9 88.75 r 9 9 9 9 9 9 9 9 17

% Access to Services - English 6 Week Wait for Diagnostics - English Patients Patients Waiting Over 52 Weeks Patients Waiting Over 52 Weeks - English Patients Waiting Over 52 Weeks Patients Waiting Over 52 Weeks - Welsh 100.20 10 10 95.00 9 99.80 99.60 8 99.40 75.00 99.20 7 99.00 65.00 98.80 6 98.60 55.00 98.40 5 3 25.00 2 15.00 1 5.00 4 35.00 3 25.00 2 15.00 1 5.00 Period Performance 99.00 99.94 g 99.00 99.77 g 99.00 99.73 g 99.00 99.89 g 99.00 99.00 99.00 99.00 99.00 99.00 99.00 99.00 Period Performance 4.00 r 4.00 r 9.00 r 1 r Period Performance 35.00 r 24.00 r 2 r 1 r 18

% % % Resources Resources Resources Sickness Absence Staff Stability Index Staff Appraisal 4.00 3.50 3.00 2.50 1.50 0.50 10 92.50 95.00 9 9 91.50 8 9 75.00 90.50 7 9 65.00 6 89.50 55.00 89.00 5 10 96.00 94.00 95.00 9 9 9 8 88.00 75.00 86.00 7 84.00 65.00 8 6 8 55.00 78.00 5 Mean UCL LCL Period Performance 3.00 3.47 a 3.00 3.39 a 3.00 3.53 a 3.00 3.30 a 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 Period Performance 9 91.31 g 9 90.89 a 9 90.39 a 9 91.05 g 9 9 9 9 9 9 9 9 Period Performance 9 83.48 a 9 83.60 a 9 89.63 a 9 93.30 g 9 9 9 9 9 9 9 9 19

Resources Safe Staffing - % Shift Fill Rate 10 10 10 98.00 96.00 8 94.00 6 9 9 4 88.00 2 86.00 84.00 Period Performance 9 94.20 g 9 95.70 g 9 95.50 g 9 97.80 g 9 9 9 9 9 9 9 9 20

Demand for Services Total Open Pathways Demand for Services Referrals Received for Consultant Led Services Activity - Surgery Surgical Division Activity - Inpatient Contract 1200 1000 800 600 400 350 350 300 300 250 250 200 200 150 150 100 140 120 120 100 100 80 80 60 60 40 40 200 50 20 Period Performance 850 1006 r 850 10354.00 r 850 1046 r 850 10805.00 r 850 850 850 850 850 850 850 850 Period Performance 2908.00 285 a 2908.00 2996.00 g 2908.00 3013.00 g 2908.00 No Data g 2618.00 2908.00 2908.00 2908.00 2327.00 2908.00 2908.00 2908.00 Period Performance 1039.00 1064.00 g 969.00 988.00 g 107 1057.00 a 1057.00 977.00 a 1005.00 1096.00 10 1093.00 956.00 10 103 1129.00 21

Activity - Surgery Surgical Division Activity - Outpatient Contract Activity - Medicine Medicine Division Activity - Inpatient Contract Activity - Medicine Medicine Division Activity - Outpatient Contract 900 800 800 700 700 600 600 500 500 400 300 200 100 30 25 20 15 10 5 200 200 180 160 140 150 120 100 100 80 60 50 40 20 Period Performance 6493.00 622 a 6055.00 6846.00 g 6689.00 7629.00 g 6604.00 6327.00 a 6279.00 6848.00 6776.00 6828.00 597 6776.00 6449.00 705 Period Performance 173.00 19 g 16 15 a 179.00 19 g 176.00 164.00 a 168.00 183.00 18 18 159.00 18 17 188.00 Period Performance 1577.00 1676.00 g 147 1567.00 g 1625.00 1819.00 g 1604.00 1495.00 a 1525.00 1663.00 1646.00 1659.00 145 1646.00 1566.00 1713.00 22

% % % Daycase Performance BADS Activity Daycase Performance Overall Daycase Rate Admission on Day of Surgery % of Elective NHS Inpatients Admitted on Day of Surgery 10 9 9 95.00 88.00 9 86.00 84.00 8 8 75.00 8 7 78.00 65.00 76.00 6 74.00 7 55.00 7 5 56.00 64.00 54.00 59.00 5 54.00 5 48.00 49.00 46.00 44.00 44.00 4 39.00 10 98.00 95.00 96.00 9 94.00 8 9 75.00 7 9 65.00 6 88.00 55.00 86.00 5 Period Performance 83.00 81.84 a 83.00 83.28 g 84.00 81.94 a 84.00 85.96 g 86.00 86.00 87.00 87.00 88.00 88.00 Period Performance 5 51.46 g 5 46.51 a 5 47.63 a 5 46.62 a 5 5 5 5 5 53.00 53.00 53.00 Period Performance 93.00 95.53 g 93.00 94.59 g 93.00 92.58 a 93.00 95.67 g 93.00 93.00 94.00 94.00 94.00 95.00 95.00 95.00 23

% Theatre % Staffed Theatre Lists Utilised Theatre Theatre Cases Per Session Average Length of Stay Average Length of Stay - Elective Excluding Daycase 10 95.00 98.00 9 96.00 8 94.00 75.00 9 7 9 65.00 6 88.00 55.00 86.00 5 2.35 4.00 2.30 3.50 2.25 3.00 2.20 2.50 2.15 2.10 1.50 2.05 0.50 1.95 5.00 4.50 4.00 3.50 3.00 2.50 1.50 0.50 Period Performance 96.00 94.44 a 95.90 96.11 g 95.50 96.57 g 96.60 91.24 r 9 96.70 96.90 97.90 90.40 96.80 95.80 90.10 Period Performance 2.20 2.23 g 2.20 2.18 a 2.20 2.10 a 2.20 2.25 g 2.20 2.20 2.20 2.20 2.20 2.25 2.25 2.30 Period Performance 4.00 3.65 g 3.90 3.76 g 3.90 3.85 g 3.80 3.85 a 3.80 3.70 3.60 3.50 3.50 3.50 3.50 3.50 24

% % Average Length of Stay % of Primary Hip and Knee Patients Discharged in 3 days or less Bed Utilisation Bed Occupancy - Adult Orthopaedic Wards Outpatient Productivity Outpatient DNA Rate 8 8 7 77.00 6 7 5 67.00 4 6 3 57.00 2 5 1 47.00 4 9 100.0 8 90.0 80.0 7 70.0 6 60.0 5 50.0 4 40.0 3 30.0 2 20.0 1 7.00 6.00 5.00 4.00 3.00 Period Performance 55.00 73.00 g 55.00 63.73 g 55.00 70.69 g 6 64.02 g 6 6 65.00 65.00 65.00 7 7 7 Period Performance 78.00 63.51 r 8 69.42 r 8 75.34 g 8 71.98 r 8 83.00 84.00 86.00 87.00 87.00 87.00 Period Performance 5.50 5.84 r 5.50 5.67 a 5.50 6.54 r 5.40 5.69 a 5.40 5.40 5.40 5.30 5.30 5.20 5.10 5.00 25

New to Follow Up Ratio (Consultant Led Activity) 3.50 3.00 2.50 1.50 0.50 Period Performance 2.90 2.34 g 2.90 2.23 g 2.80 2.37 g 2.80 2.22 g 2.70 2.70 2.60 2.60 2.60 2.50 2.50 2.50 26

( ) Category Income and Expenditure '000s Annual Plan Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust Finance Dashboard 31st July 2016 Year To Date Position Plan Variance Clinical Income from activity 88,800 29,114 28,975 (139) (263) Private Patient income 4,870 1,580 1,149 (431) (137) Other income 6,130 2,059 2,135 76 (37) Pay (55,452) (18,274) (18,068) 206 107 Non-pay (38,585) (12,668) (12,600) 68 160 EBITDA 5,764 1,811 1,590 (220) (171) Finance Costs (4,348) (1,342) (1,243) 99 24 Capital Donations 1,000 500 700 200 0 Operational Surplus 2,416 969 1,048 79 (146) Remove Capital Donations (1,000) (500) (700) (200) 0 Add Back Donated Dep'n 571 174 160 (14) (4) Remove STF Funding (500) (167) (167) 0 0 Control Total 1,487 476 341 (135) (150) STF Earnt 500 167 167 0 0 Planned Surplus 1,987 643 507 (135) (150) EBITDA margin 5.8% 5.5% 4.9% -0.6% Debt Service Cover 4 I&E Margin 4 Liquidity (days) 3 Variance in I&E Margin 4 Overall FSRR 4 Movement In Variance From Prior Month YTD Debtor Days 26 24 Creditor Days 42 41 Statement of Financial Position '000s Category Movement Drivers Capital investment above depreciation and impairment of Theatre 7 Fixed Assets 66,416 66,804 389 and HDU. Non current receivables 653 642 (11) Total Non Current Assets 67,069 67,447 378 Inventories (Stocks) 1,142 1,097 (45) Receivables (Debtors) 5,966 5,911 (55) Reduction in contract over performance Cash at Bank and in hand 4,895 4,601 (294) Total Current Assets 12,003 11,608 (395) Payables (Creditors) (9,983) (10,295) (312) PDC 0.1m and an increase in deferred income 0.2m. Borrowings (1,030) (1,226) (196) Reclassification of loan repayment to current liability. Current Provisions (526) (419) 107 Total Current Liabilities (< 1 year) (11,538) (11,940) (401) Total Assets less Current Liabilities 67,533 67,115 (418) Non Current Borrowings (9,045) (8,849) 196 Reclassification of loan repayment to current liability. Non Current Provisions (143) (134) 10 Non Current Liabilities (> 1 year) (9,188) (8,983) 206 Total Assets Employed 58,344 58,133 (212) Public Dividend Capital (33,260) (33,260) 0 Revenue Position (1,007) (795) 212 Small in month surplus 41k offset by impairment ( 253k) Retained Earnings (6,766) (7,019) (253) Impairment of Theatre 7 & HDU Revaluation Reserve (17,312) (17,059) 253 Impairment of Theatre 7 & HDU Total Taxpayers Equity (58,344) (58,133) 212 8.0 7.0 Cash Flow 1,600 1,400 1,200 S u 1,000 D r e p 800 f l i i 600 c u i s 400 t / 200 Monthly Surplus/Deficit Plan C a s h M 6.0 5.0 4.0 3.0 2.0 1.0 0 ( 200) Period Cumulative Variances '000s 0 0.0 Monitor Plan M 5.4 4.7 4.9 4.8 4.7 4.6 4.9 5.1 5.2 5.4 4.8 4.2 M 4.8 4.7 4.9 4.6 Forecast M 4.8 4.7 4.9 4.8 4.4 3.6 4.4 4.8 5.1 5.2 4.8 4.2 ( 100) V ( 200) a r i ( 300) a n c ( 400) e Risks Income Risk Expenditure Risk High Low Commentary Income - Requires agreement of recovery plan to address YTD shortfall and further shortfalls are expected for August. Expenditure - Cost pressures in excess of reserves. ( 500) CIP Risk ( 600) Clinical Income from Private Patient income Other income Pay Non-pay U:\Trust activity Board & Committees\Public Trust Board\2016-17\August 2016\Month 04 Integrated Performance Report 27 Medium CIP - Further mitigating schemes are being scoped and will in all likelihood be required to fully deliver plan.

Cost Improvement Programme Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust Finance Dashboard 31st July 2016 In Month CIP Achievement 000's Year To Date CIP Achievement 000's Trust YTD Achievement Against YTD Plan 000's Miscellaneous Income Workforce Redesign Miscellaneous Income Workforce Redesign 800 700 600 CIP by Theme Transformation Procurement Productivity Capacity Alignment Bring Forward FYE Transformation Procurement Productivity Capacity Alignment Bring Forward FYE 500 400 300 200 100 (10) 0 10 20 30 40 50 60 70 80 Jul Plan Jul 0 50 100 150 200 250 YTD Plan YTD 0 YTD Plan Total YTD In Month CIP Achievement 000's Year To Date CIP Achievement 000's Theatres RAG of Total Schemes Being Tracked CIP by Division Theatres Corporate Estates & Facilities Diagnostics Medicine Corporate Estates & Facilities Diagnostics Medicine 2,387 68.2% g 857 24.5% a 256 7.3% r 3,500 100.0% Surgery Surgery 0 20 40 60 80 100 0 50 100 150 200 250 300 350 Jun Plan Jul YTD Plan YTD Capital Project Year to date capital programme 000's Annual Plan Year to date Plan Year to date Completed Year to date Variance In Month Forecast Outturn Outturn Variance Backlog Maintenance 430 108 103 5 79 800-370 Medical equipment 400 0 332-332 137 400 0 Plated Meal Trollies 200 200 195 5 0 200 0 IT 300 40 60-20 29 300 0 Project Management 170 80 59 21 13 170 0 Contingency 300 33 0 33 0 224 76 Theatre and Tumour Development 2,440 2,099 2,162-63 417 2,516-76 Outpatients Department Upgrade 300 0 9-9 0 300 0 Increased Theatre Capacity 500 0 0 0 0 130 370 NHS Capital Expenditure 5,040 2,560 2,920-360 675 5,040 0 Commissioner Performance Year To Date Commissioner Income against Plan m Shropshire BCU Specialist Other English Contracted Powys Telford Other Uncontracted - 4.00 6.00 8.00 1 1 Theatre and Tumour Equipment 0 0 150-150 150 150-150 Donated Capital Funding 0 0 150-150 150 150-150 YTD actual YTD plan 28

Appendix 1 Declaration of risks against healthcare targets and indicators for 2016/17 or Indicator (per Risk Assessment Framework) Month 4 Achieved / Not Met Referral to treatment time, 18 weeks in aggregate, incomplete pathways 92% 1.0 Yes Not met Cancer 62 Day Waits for first treatment (from urgent GP referral) 85% 1.0 No Achieved Cancer 62 Day Waits for first treatment (from NHS Cancer Screening Service referral) Threshold or target YTD Scoring Risk declared at Annual Plan 90% 1.0 No Not relevant Cancer 31 day wait for second or subsequent treatment - surgery 94% 1.0 No Not relevant Cancer 31 day wait for second or subsequent treatment - drug treatments 98% 1.0 No Not relevant Cancer 31 day wait for second or subsequent treatment - radiotherapy 94% 1.0 No Not relevant Cancer 31 day wait from diagnosis to first treatment 96% 0.5 No Achieved Cancer 2 week (all cancers) 93% 0.5 No Achieved Clostridium Difficile -meeting the C.Diff objective 2 1.0 No Achieved Risk of, or actual, failure to deliver Commissioner Requested Services N/A No No CQC enforcement action within last 12 months (as at 31 Mar 2015) N/A No No CQC enforcement action (including notices) currently in effect (as at 31 Mar 2015) N/A No No CQC enforcement action (including notices) currently in effect N/A No No Moderate CQC concerns or impacts regarding the safety of healthcare provision N/A Report by No No Exception Major CQC concerns or impacts regarding the safety of healthcare provision N/A No No Unable to maintain, or certify, a minimum published CNST level of 1.0 or have in place appropriate alternative arrangements Score of 7 or less in standard 1 assessment at last NHSLA CNST inspection (maternity or all services) Trust unable to declare ongoing compliance with minimum standards of CQC registration N/A No No N/A No No N/A No No Overall Score 0 Indicative Risk Rating RED 29