Integrated Performance Report JULY 2017

Integrated Performance Report JULY 2017

Executive Summary July 2017 4 hour performance We have made a commitment to sustain a >90 for the delivery of the 4 hour transit time target. This has been challenging in July and we failed to achieve this for the month. Cancer Delivery against the 62 day standard remains a key priority. Increased scrutiny and management of the patient caseload continues and the team are working closely the NHSI Cancer Collaborative Coach and with colleagues in the other two sites to improve performance and patient care. RTT Performance against RTT also remains a focus. There is a growing backlog within Orthopaedics following cancellations in the winter period. Surgery has resumed with theatre and outpatient productivity work now being implemented with the support of Four Eyes Insight. Agency spend We remained below the agency spend target due to the increased level of grip and control. However, there is a concern about the overall pay cost, with further scrutiny of bank spend and WLI s.

QUALITY Dawn Patience Director of Nursing Tayyab Haider Medical Director JULY 2017

Harm MRSA Bacteraemia One hospital acquired MRSA Bacteraemia reported in July, secondary to a peripheral cannula. Learning The Peripheral Cannula policy guidelines were not followed. Visual Infusion Phlebitis (VIP) score not documented completely as per Trust protocol. C.Diff 1 new case in July with no lapses in care. VTE Screening Compliance with VTE screening remains challenging, but improving and is being addressed as part of the VTE quality improvement project. This programme of work will operationally be supported by the Thrombosis Committee. Mortality HSMR 12 month period = 96.87 HSMR trend Following a peak with the Feb 16 Jan 17 data set, the near-term trend for the rolling HSMR has been downwards for the last two sampling periods. HSMR The Trust is one of 7 Trusts (out of 17) below the HSMR target level Position vs. and currently sits within the as expected range. Peers Weekday vs weekend HSMR (emergency admissions) There is a difference between weekday and weekend HSMR but neither is significantly higher than expected. Weekday HSMR (Admissions) = 96.75 statistically as expected Weekend HSMR (Admissions) = 97.22 statistically as expected

Harm Preventable Pressure Ulcers There has been an increase in preventable pressure ulcers in July, 2 are Grade 3. The cases have been presented to the Harm Free Group and actions agreed. The common themes skin status not recorded as per policy, delay in SSKIN assessment, incorrect mattress selection. Currently there is a targeted education programme and competency assessments. Falls 2 injurious falls within the month, these are being investigated currently. Fallsafe care bundle was not completed Neuro observation not completed to policy for one of the patients Post falls not completed for one of the patients Medication Incidents with Harm These have been reviewed within the divisions and a theme for insulin administration has been identified SEPSIS bundle There has been an improvement within the sepsis KPI and concentration is now looking at oxygen and IV fluid administration. 100.00% 90.00% 80.00% 70.00% 60.00% 50.00% SEPSIS Bundle commenced within 1 hour

Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Clinical Effectiveness Caring for the deteriorating patient The cardiac arrest trajectory has been adjusted to 1:1000 admissions following noticeable sustained improvement. Serious Incidents 16 SIs were reported in July. There has been a noted increase in missed fractures in ED, a risk summit to examine this is more detail is being arranged. The data for the last 12 months has been refreshed 3.50 Cardiac arrests 3.00 Deteriorating patient group formed 2.50 2.00 New escalation policy MET introduced Cardiac arrest reviews in surgery, MET reviews in medicine E OBS roll out commenced trajactory readjusted 1.50 arrests per 1000 admissions median target 1.00 0.50 0.00

Clinical Effectiveness SI Approved Action Plan within 100 days Performance has continued to improve between May and July 2017 and work continues to meet the set target. Actions Working in partnership with the CCG to ensure reviews and comments are responded to in a timely manner. Outstanding action plans are reviewed at the Executive Review Group (ERG) to maintain momentum Patient safety managers meet weekly with the divisions RCAs within 60 days Although the 60 deadline has not been met in all cases, an extension has been agreed with the CCG due to the complexities of the cases. DNACPR This is the number of patients who opted for DNACPR, however the quality of completion of these decisions requires review. Clinic Letters Each division has a trajectory for recovery for clinic letters which are discussed at their PRM. Discharge Summaries The divisions have a trajectory to complete these timely and individuals are being chased to complete these timely, monitored at PRM Critical Care- Delayed Discharges The delay in discharges are related to timely ward discharges and speciality bed availability. Surgical Manager for the day will highlight at all Capacity meetings the number of patients and timeframe for discharge

Patient Experience FFT results The divisional response rates continue to meet the targets, ED and OPD are focusing on their response rates. Complaint Response Times 73% of complaints received were responded within target response time in July. The complaints team have sickness related absence, together with vacancies within division which has contributed to some delay. However there has been an increase in the number of complex cases, whereby a more realistic timescale would have desirable.

OPERATIONAL PERFORMANCE Liz Wells Director of Operations JULY 2017

ED Performance Improving care for emergency patients continues to be a Trust priority, steadily improving but remains fragile. Performance in July was 88.2% of patients being seen and treated/admitted within 4 hours. Issues Staffing vacancies Remains a risk for Trust The high numbers of Medically Fit for Discharge patients continues to be high although DTOCs have decreased The conversion rate of attendance to admissions is high at approximately 30% Health and social care provision and capacity within the community

ED Performance Actions Streaming in place with senior decision maker and senior clinical support 24/7 in ED Ambulatory care model in medicine increased form 4 to 8 beds and continues to operate a PULL system. Plan to increase beds further and introduce frailty beds to support emergency pathways. Red2Green(R2G), SAFER bundle and Clinical Utilisation Reviews (CUR) are now live and being utilised by staff on 18 wards Daily board rounds in place 7 days a week, supporting morning and afternoon Board rounds in two wards with plan to increase to include medical and surgical wards. Consultants/therapies, social care/pharmacy in place at weekends to improve discharge process Daily Breach analysis and if performance below 90% completion of RCA which is discussed at Emergency Care Group. Revising bed management model including roles and responsibilities of all divisions to support performance Weekly LOS meetings for patients > 14 days including daily monitoring of all medically fit patients including DTOC. Plan to increase to include patients >7 days LoS. Dedicated manager of day in all specialities Robust weekend planning Resumed elective activity Change of culture and practice within escalation RAG rating which now changes as per current status of the hospital Planning with community and social care partners via A&E Board and Stepping Up Board.

62 Day Cancer Key issues across the group: Not now possible to deliver current trajectory for July compliance with 62 day standard (based upon patients already passed 62 days on the PTL and expected breach dates) Access to facilities for one-stop skin clinics in Southend Plastics capacity (OP and TCI) Capacity for diagnostics (Endoscopy, CT, MRI) Capacity for TCIs

62 Day Cancer Group actions: Group action plan including use of rapid recovery funding in place with actions underway including: Additional theatre lists in Plastics (MEHT) and Urology (SUHT). Outsourcing of SUHT benign urological cases Insourcing and outsourcing of endoscopy Insourcing and outsourcing of CT and MRI activity Standardisation of CWT oversight continuing across group. All Trusts undertaking weekly tumour site specific PTL review meetings with best practice being shared supported by Cancer Alliance colleagues. Daily check in started in BTUH and now SUHT and under discussion at MEHT. Data reporting across sites aligned to ensure equitable. The objective to enable future single Somerset PTL Additional one-stop Dermatology capacity on line from 14th July in Southend STP Cancer Board re-launched with focus on delivering national and regional priorities STP Tumour Site Specific Groups (TSSG) will be established in September to lead STP-wide co-design process in key priority pathways (Urology, Skin, Lung, Lower GI). PTL size for both 0-62 days and 63 +days is decreasing in size

Incomplete RTT Key Issues Incomplete 52 week breach at month end July - Biggest Risk areas - Neurology and Respiratory Sleep Backlog Position BTUH 4,047 - Neurology, Dexa/Osteoporosis, T&O, Gastroenterology

Incomplete RTT Actions and Mitigations RTT x-group being formed with initial focus on the development of cross-site PTLs (and PTL discussions) for long waiting patients to identify opportunities to transfer patients across site to aid earlier booking and prevent excessive waits for patients. Examine areas of capacity which could aid backlogs on other site. For example backlog of DC T&O at BHUT and SUHFT could potentially be supported by MEHT as although they have a T&O backlog this is predominately IP. SUHFT Exploring Theatre Costs and staff cost prior to potential commencement Network wide approach to neurology backlog to be discussed Theatre and Outpatient utilisation and productivity programme supported by Four Eyes Insight. Weekly PTL and Access Board meetings restructured, now supported by Four Eyes Insight. Planned move of cystoscopy from endoscopy unit to provide extra space for endoscopy. Cystoscopy outsourcing at BCH due to commence wc 4th September New RTT dashboard developed to support weekly monitoring of stops and sustainable backlog position. All site implementing robust PTL meetings and management and RTT leads from each site to ensure consistency of approach in relation to RTT Guidance application and Access Policies. Harm reviews routinely in place for all long waiting patients.

WORKFORCE & ORGANISATIONAL DEVELOPMENT Danny Hariram Director of HR & OD JULY 2017

6.00% 5.00% 4.00% 3.00% 2.00% 1.00% 0.00% 86.00% 84.00% 82.00% 80.00% 78.00% 76.00% 74.00% 72.00% Sickness Mandatory Training - Overall Compliance Turnover Higher this time of year due to most of the doctor changeover but there have been leavers across all staff groups. We continue to investigate reason for leaving and seek retention solutions such as developing new roles. Mandatory Training Reminders are shared at performance reviews however, in some areas the high vacancy levels are contributing to the ability to release staff. This is also not helped during high annual leave periods and will need to be addressed for compliance in the next few months. Vacancies An increase across all staff groups except additional clinical service, Estates and ancillary. Biggest area is nursing and we are exploring the areas and to see if there is any pattern and will check exit leaver information to seek causes Temporary staff reduction plan has been approved by our regulator (Appendix 1)

FINANCE & RESOURCES Stephanie Watson Director of Finance JULY 2017

I&E Financial Summary Page 1 In Month Year to Date Full Year Description Budget Budget Budget Budget Actual Budget Actual Budget Forecast Fav/(Adv) Fav/(Adv) Fav/(Adv) m m m m m m m m m Income 26.9 26.9 0.0 105.7 104.7 (1.0) 319.9 320.4 0.4 Pay (17.6) (18.8) (1.2) (71.9) (73.0) (1.1) (217.6) (217.7) (0.0) Non Pay (8.9) (9.5) (0.5) (35.6) (37.0) (1.5) (109.3) (111.5) (2.2) EBITDA 0.4 (1.3) (1.7) (1.8) (5.3) (3.5) (7.1) (8.9) (1.8) Financing (1.4) (1.2) 0.2 (5.4) (4.8) 0.6 (16.2) (14.4) 1.8 (Surplus) / Deficit (exc. STF) (1.0) (2.5) (1.5) (7.2) (10.1) (2.9) (23.3) (23.3) 0.0 S&T Funding 0.7 - (0.7) 2.3 0.0 (2.3) 10.7 10.7 0.0 (Surplus) / Deficit (Control Total) (0.3) (2.5) (2.3) (4.8) (10.1) (5.3) (12.6) (12.6) 0.0 Key Headlines - Commentary and Actions As at July 2017, the Trust is 5.3m behind its agreed control total of 4.8m planned deficit ( 12.6m planned deficit for the full year, which includes an STF allocation of 10.7m). Critical Care, direct access diagnostic, pass through drugs & devices and unbundle services underperformance against plan acc ounts for the adverse clinical income year-to-date variance. This adverse impact has been partly compensated for by a better than plan A&E, non-elective and outpatient clinical income delivery, in addition to medical research income. Premium on temporary staff employment to cover high levels of vacant establishment across medical and nursing budgets continu e to drive the adverse pay position to date. This is also in conjunction with the use of waiting list initiative payments to reduce the level of treatment backlog and cancer waits, as well as 0.7m of unidentified CIPs. The keys drivers for the adverse non-pay year-to-date position were: Unidentified CIPs ( 2.3m), diagnostics outsourced contractual services unplanned over-activity for pathology and imaging services, higher than plan estates soft FM costs (rates, utilities and laundry). The Trust's CIP programme is also forecast to deliver the full plan by year end, as a stronger CIP governance process has been put in place in the last couple of months. Due to the Trust being behind plan to date, the STF has not been achieved, but as the forecast is to delivery the control total for the year, this will be achieved in full at the end of the year. NHSI use of Resources scoreis current an overall rating of 4 with only Agency spend scoring a 2. METRIC Weighting Description Definition Score Actual SCORE Weighted 20% Capital service capacity (times) Degree to which the provider's generated income covers its financial >2.5x 1.75-2.5x 1.25-1.75x < 1.25x 0.1 4 0.8 Financial Sustainability Days of operating costs held in cash or 20% Liquidity Ratio (days) cash-equivalent forms, including wholly >0 (7)-0 (14)-(7) <(14) (23.8) 4 0.8 committed lines of credit available or Financial Efficiency 20% I&E margin I&E surplus or deficit / total revenue >1% 1-0% 0-(1)% <=(1)% (8.0%) 4 0.8 Year-to-date actual I&E surplus/deficit 20% Distance from financial plan Financial Controls in comparison to Year-to-date plan I&E >=0% (1)-0% (2)-(1)% <=(2)% 0.7% 4 0.8 20% Agency spend Distance from provider's cap <=0% 0%-25% 25-50% >50% 2.5% 2 0.4 KEY Scoring a '4' on any metric will mean that the overall rating is at least a 3 (i.e. either a 3 or a 4), triggering a concern. 1 (Best) to 4 (Worst) OVERALL SCORE for "Use of Resources" 4

R A G Action Owner I&E Financial summary trend forecast Page 2 Income & Expenditure (rolling 12 months) 1 2 3 4 5 6 7 8 9 10 11 12 Actual Actual Actual Actual Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Total '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 Income 25,178 26,015 26,568 26,926 27,135 26,295 27,135 26,714 25,876 27,135 25,030 26,716 316,723 Income (S&T Funds) 536 (536) 0 0 0 0 0 0 0 0 0 0 0 Pay (18,139) (18,535) (17,541) (18,778) (18,235) (18,235) (18,235) (18,235) (18,235) (18,235) (18,235) (18,235) (218,873) Non Pay (8,886) (9,308) (9,333) (9,482) (9,214) (9,234) (9,214) (9,214) (9,234) (9,214) (9,214) (9,234) (110,781) Non Operating (1,160) (1,238) (1,198) (1,201) (1,202) (1,202) (1,202) (1,202) (1,202) (1,202) (1,217) (1,217) (14,443) TOTAL DEFICIT (SURPLUS) (2,471) (3,602) (1,504) (2,535) (1,516) (2,376) (1,516) (1,937) (2,795) (1,516) (3,636) (1,970) (27,374) Developments & cost pressures yet to be incurred Winter Ward G LW 0 0 0 0 0 0 0 (120) (120) (120) (120) (120) (600) 0 0 0 0 0 0 0 0 0 0 0 0 0 Overseas recruitment G DH 0 0 0 0 (30) (87) (161) (140) (141) (101) (61) (21) (742) Four Eyes Fees G SW 0 0 0 0 (88) (89) (89) (89) (89) (89) (89) (89) (711) STF Funds G SW 0 0 0 0 0 0 0 0 0 0 0 10,724 10,724 Management actions including CIPs not yet realised Four Eyes - Theatre Productivity R G AH 0 0 0 0 0 32 55 76 82 96 87 91 519 Four Eyes - Outpatients Utilisation A AH 0 0 0 0 0 53 71 107 106 107 106 107 657 Four Eyes - Outpatients DNA's G AH 0 0 0 0 0 (3) 54 52 81 82 82 82 430 Foureyes - Endoscopy R LW 0 0 0 0 0 18 27 38 50 56 57 55 301 Foureyes - Cath Lab G LW 0 0 0 0 0 19 41 38 40 36 35 41 250 Foureyes Job Planning A DH 0 0 0 0 0 0 0 0 0 82 82 83 247 Close Escalation Beds A LW 0 0 0 0 0 125 125 125 125 125 125 125 875 Divisional CIPS G SW 0 0 0 0 0 65 65 106 130 131 131 133 761 Grip & Control A SW 0 0 0 0 61 61 120 131 145 146 145 350 1,159 Ramsey PP CIP A LW 0 0 0 0 0 0 3 53 103 103 103 103 468 Control Nursing Establishments A DP 0 0 0 0 0 60 60 60 60 60 60 60 420 Overseas Visitors A SW 0 0 0 0 0 0 0 5 10 10 10 10 45 Income 25,178 26,015 26,568 26,926 27,135 26,465 27,674 27,366 26,609 27,900 25,776 27,477 321,089 Income (S&T Funds) 536 (536) 0 0 0 0 0 0 0 0 0 10,724 10,724 Pay (18,139) (18,535) (17,541) (18,778) (18,164) (18,033) (18,100) (18,243) (18,238) (18,121) (18,078) (18,037) (218,007) Non Pay (8,886) (9,308) (9,333) (9,482) (9,342) (9,352) (9,517) (9,416) (9,382) (9,369) (9,364) (9,183) (111,934) Non Operating (1,160) (1,238) (1,198) (1,201) (1,202) (1,202) (1,202) (1,202) (1,202) (1,202) (1,217) (1,217) (14,443) FORECAST DEFICIT (SURPLUS) (2,471) (3,602) (1,504) (2,535) (1,573) (2,122) (1,145) (1,495) (2,213) (792) (2,883) 9,764 (12,571) PLANNED DEFICIT 2017-18 (2,815) (1,515) (248) (269) (752) (654) 308 (310) (2,752) (128) (2,423) (1,013) (12,571) Commentary The forecast and recovery trajectory detailed above will mean that the Trust will not be cumulatively back on track with it's operating plan until month 12. This means the Trust will not receive any of its STF funds until the last month of the financial year.

'000 Cost Improvement Plans (CIPs) Performance Page 3 Delivered Profile by Month Actual Non Variance Budget Recurrent Delivery recurrent Fav/(Adv) 000's 000's 000's 000's 000's Apr 903 158 139 19 (745) May 903 158 139 19 (745) Jun 1,453 395 384 11 (1,058) Jul 1,453 1,628 1,564 64 175 Aug 1,453 564 555 8 (889) Sep 1,453 564 555 8 (889) Oct 1,453 688 680 8 (765) Nov 1,453 688 680 8 (765) Dec 1,453 688 680 8 (765) Jan 1,453 688 680 8 (765) Feb 1,453 688 680 8 (765) Mar 1,439 688 680 8 (751) Total 16,322 7,596 7,414 181 (8,726) 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 - CIPs Rating - 135 310 7,067 2,163 302 2,709 1,234-420 320 484 214 1,023 L0 L1 L2 L3 L4 Green Amber Red Work stream by work stream Budget Delivered In Month YTD Plans for 18/19 000's 000's 000's 000's 000's Income generation 0 465 0 0 1,354 Workforce 5,050 928 85 300 96 Procurement 2,707 2,184 209 696 9 Efficiency & Productivity 2,090 0 0 0 900 ESR 1,000 30 4 15 103 Additional 5.5M 5,475 3,990 1,330 1,330 63 Unfound/(Slippage Contingency) 0 0 0 0 0 Total 16,322 7,596 1,628 2,340 2,525 Work Stream L0 - Idea L1 - Scoping L2 - QIA L3 - Implementa tion L4 - Complete TOTAL Income generation 200 1,322 50 1,201-2,773 Workforce 383 1,796 116 410 899 3,605 Procurement 595 165 467 1,034 2,149 4,410 Efficiency & Productivity 677 20 - - - 697 ESR - 25 - - 30 54 Additional 5.5M - - - 852 3,990 4,841 Unfound/(Slippage Contingency) - 58 - - - - - 58 1,797 3,328 633 3,497 7,067 16,322 Commentary The Trust is current 2.3M behind its CIP plan of 4.7M. This is predominantly due to slippages within clinical divisions. A total of 7.6M of schemes have been delivered, 7.1m of which relates to schemes that are complete, with a further 9.2M of identified schemes at different stages of the Trust's maturity matrix framework. Only 5% of schemes in the pipeline have been rated red. This gives a level of assurance to the delivery of this year's programme. Four eyes consulting are work with the Trust to support the delivery of a number of efficiency and productivity projects, which have been risk rated and captured in the over CIP pipeline. Of the 5.5M additional CIP challenge that was required to deliver this year's control total, 4.0M has been delivered and closed, with a an additional 0.9M inthe implementation phase. In addition to weekly CIP meetings to review progress of the entire programme, the CIP programme is part of the SMART working stepping up programme portfolio, where performance against milestones and mitigating actions are reviewed.

'000 Income Page 4 Contracted Clinical Income In Month Year to Date Commentary Budget Actual Fav/(Adv) Budget Actual Fav/(Adv) '000 '000 '000 '000 '000 '000 Elective 4,058 4,000 (58) 15,652 15,469 (183) Non Elective 8,349 8,905 556 32,587 33,076 489 Outpatients 4,538 4,387 (150) 17,519 17,692 173 Critical Care 1,731 1,258 (473) 6,757 6,062 (695) Accident & Emergency 1,413 1,446 33 5,514 5,623 109 Maternity Pathway 801 1,023 222 3,091 3,461 371 High Cost Drugs & Devices 1,837 1,425 (412) 7,186 6,221 (965) CQUIN 518 550 32 2,071 2,145 75 Fines 0 0-0 0 - Other 974 861 (113) 3,776 3,372 (404) Direct Access 717 643 (75) 2,767 2,443 (325) S&T Funding 715 0 (715) 2,324 0 (2,324) Total 25,651 24,498 (1,152) 99,244 95,564 (3,679) Other Income Budget In Month Actual Variance Fav/(Adv) Budget Year to Date Actual Variance Fav/(Adv) Private Patients 51 70 20 199 188 (11) Injury Cost recovery 154 115 (39) 624 534 (90) Training & Education 515 537 22 2,081 2,133 52 Research & Development 92 137 45 368 466 98 Other Income 1,135 1,568 433 5,535 5,804 268 Total 1,947 2,428 480 8,806 9,123 317 30,000 25,000 Income Budget v. Actual Elective includes Day Cases, Elective Inpatients & Elective Excess bed days. The majority of the under performance is derived from Elective IPs only. This is due to Cardiothoracic Surgery ( 246k) and T&O ( 153k). Bothe these specialties relate to being under on planned activity as opposed to a movement in the case mix. Non Elective favourable variance is due to an increase in non elective activity Cardiothoracic Surgery from plan. Given this is underperforming in Elective review is being undertaken to ensure that there is not a data capture change. The other speciality which is currently over plan is Neurology. General Surgery and Obstetrics are the two main specialties under plan. Obstetrics appears to relate to an overly ambitious plan and is likely to remain under for the remainder of the year. Outpatient favourable variance of 173k is due an over performance in OP First attendances in General Surgery and COE, This is offset by under performance on Follow-ups across the board. Critical care underperformance variance of 695k due to lower activity than planned. Maternity pathway showing an over performance of 371k due to more complex antenatal cases than planned. High Cost Drugs & Devices showing an adverse variance of 965k (Drugs 725k & Devices 240k). A review of the Drugs Income & Expenditure is currently being looked into further. The majority of the Devices adverse variance is due to a reduction of ICD's & ICD CRT's. The Other adverse variance is made up of Best Practice Tariff top ups, Palliative Care & an Income Provision. Direct Access adverse variance 325k - the majority of this variance relates to Direct Access Pathology 228k. This is due to the difference in the counting methodology used in the plan and the data currently being received from First Pathology. We are working closely with IPP to rectify this. 20,000 15,000 10,000 5,000 S & T funding showing an adverse variance of 2.3 million. 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Last Year CLINICAL INCOME OTHER INCOME BUDGET

Units of Activity Units of Activity Units of Activity Units of Activity Units of Activity Units of Activity Activity Page 5 SLA clinical activity by Point of Delivery (POD) Budget Actual Fav/(Adv) Budget Actual Fav/(Adv) Currency Units Units Units Units Units Units Elective spell 655 592 (63) 2,416 2,599 183 Day Case spell 2,547 2,386 (161) 9,388 9,346 (42) Regular Day Patients spell 0 0-0 0 - Non Elective spell 4,559 4,777 218 18,380 18,806 426 Outpatients attendance 29,925 29,756 (169) 110,293 112,578 2,285 Critical Care day 1,856 1,468 (388) 7,486 6,556 (930) Accident & Emergency attendance 10,334 10,451 117 41,681 41,748 67 Maternity Pathway epidsode 899 813 (86) 3,311 3,115 (196) Note: Neonatal are in Critical Care and Renal in Regular Day Attender Activity in Elective & Non Elective excludes Excess Bed Days and Non Chargeable In Month Year to Date Commentary and Actions Elective - This is due to an increase in excess bed days compared to the plan. Non elective - high level of activity since month 2 onwards. Outpatients - increase in First attendances, Unbundled Radiology, Outpatient Procedures however a reduction in Outpatient follow up attendances. Critical care - lower activity than planned. Maternity pathway - activity slightly under plan, however income has increased due to more more complex antenatal cases than planned. 3500 3000 2500 2000 1500 1000 500 0 Elective: Budget v. Actual Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar ACTUAL - DC ACTUAL - RDA 6000 5000 4000 3000 2000 1000 0 Non Elective: Budget v. Actual Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 35000 30000 25000 20000 15000 10000 5000 0 Outpatients: Budget v. Actual Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar ACTUAL - Elective BUDGET ACTUAL BUDGET ACTUAL BUDGET 2500 Critical Care: Budget v. Actual 12000 A&E: Budget v. Actual 1000 Maternity: Budget v. Actual 2000 10000 800 1500 1000 8000 6000 4000 600 400 500 2000 200 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar ACTUAL BUDGET ACTUAL BUDGET ACTUAL BUDGET

'000 Pay Expenditure Page 6 Pay Expenditure In Month Year to Date Commentary and Actions Budget Actual Fav/(Adv) Budget Actual Fav/(Adv) '000 '000 '000 '000 '000 '000 Medical and Dental 5,082 5,643 (561) 20,502 21,687 (1,185) Nurses and Midwives (inc. HCAs') 7,248 7,825 (577) 29,173 30,230 (1,056) Scientific, Therapeutic & Tech 1,837 1,733 0 7,350 6,893 0 Other Pay 3,342 3,565 (223) 14,472 14,161 0 Reserves 28 12 0 1,129 22 1 Unidentified CIPs 37-0 (684) - (684) Total 17,574 18,778 (1,205) 71,941 72,993 (1,052) 20,000 19,000 18,000 17,000 16,000 15,000 14,000 13,000 12,000 11,000 10,000 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 Pay: Budget v. Actual Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Medical and Dental adverse pay position has been driven by the premium on agency and locum staff employment to cover vacant establishment, as well as the use of Waiting List Initiative payments to recover adverse RTT position. The use of agency nursing, with associated premium cost, to plug the high levels of current nursing vacancy. The spike in the month was as a result of increase bank usage from the 3rd week of June, paid in July. was also anincrease in bank uptake from the 3rd week of June. Weekly nursing assurance group meetings have been set to review and sign-off temporary staffing requirements in advance of use, in addition to challenging the heads of nursing on agency reliance. There are a number of key wards with persistent use of temporary staffing exceeding their over all establishment. This is being investigated. STT staffing is underspent to date due to difficulties, nationally, in recruiting Radiographers and Therapists. The adverse effect of unidentified CIPs would reduce over time as schemes are delivered. Reserves mainly includes the central agency premium reserve which has yet to be delegated to divisions. A proportion of this reserve is also a unreported CIP due to the reduction in the overall usage of agency in 17/18. Recovery plans are being worked to bring the position back to budgets, most of which is centred around tighter control on agency employment and waiting listinitiativepayments. LAST YEAR ACTUAL OTHER ACTUAL STT ACTUAL NURSING ACTUAL M&D BUDGET

'000 Pay Analysis Page 7 TOTAL PAY Spend Additional Month Pay Bill Overtime Bank Agency Total on BANK Medical Nursing STT Other Total Sessions Month Spend '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 Apr 15,425 458 77 1,152 1,026 18,139 Apr 144 863 41 103 1,152 May 15,894 446 73 1,242 880 18,535 2% May 179 897 57 109 1,242 8% Jun 15,024 412 72 1,031 1,003 17,541-5% Jun 122 771 42 95 1,031-17% Jul 15,592 394 73 1,716 1,004 18,778 7% Jul 235 1,256 75 150 1,716 67% Aug - - - - - - Aug - - - - - Sep - - - - - - Sep - - - - - Oct - - - - - - Oct - - - - - Nov - - - - - - Nov - - - - - Dec - - - - - - Dec - - - - - Jan - - - - - - Jan - - - - - Feb - - - - - - Feb - - - - - Mar - - - - - - Mar - - - - - Total 61,935 1,710 295 5,141 3,912 72,993 Total 681 3,787 215 457 5,141 84.9% 2.3% 0.4% 7.0% 5.4% 13% 74% 4% 9% Aver Week on Week 1,200 1,000 800 600 400 200 - Agency Cap Target (annual) 11,990 '000 Medical Agency Reduction Target (annual) 6,072 '000 YTD Actual 3,912 YTD Actual - Medical agency 1,719 YTD Agency Plan 3,867 45k ADV YTD Medical Agency Target (pro rata)* 2,024 305k FAV Agency by staff group Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Medical Nursing STT Other Agency Ceiling Medical agency cap NHSI target is to reduce medical agency spend by 469k over previous year AGENCY Spend Medical Nursing STT Other Total '000 '000 '000 '000 '000 Apr 510 299 115 102 1,026 May 332 296 117 136 880-14% Jun 422 270 159 153 1,003 14% Jul 456 320 151 76 1,004 0% Aug - - - - - Sep - - - - - Oct - - - - - Nov - - - - - Dec - - - - - Jan - - - - - Feb - - - - - Mar - - - - - Total 1,719 1,184 542 466 3,912 44% 30% 14% 12% Month on Month

'000 Non Pay Expenditure Page 8 Non Pay In Month Year to Date Commentary & Actions Budget Actual Fav/(Adv) Budget Actual Fav/(Adv) '000 '000 '000 '000 '000 '000 Drugs 669 571 98 2,728 2,646 82 High Cost Drugs 1,203 1,566 (363) 4,811 4,302 509 Supplies & Services Clinical 3,805 2,584 1,221 15,252 15,899 (647) Supplies & Services General 365 395 (30) 1,475 1,331 144 Establishment 249 347 (98) 1,013 1,119 (106) Premises 791 888 (98) 3,339 3,505 (167) Outsourcing - - - - - - CNST 1,005 992 13 4,021 3,968 52 Other 967 2,139 (1,171) 4,063 4,237 (174) Reserves 210-210 1,235-1,235 Unidentified CIPs (319) - (319) (2,386) - (2,386) TOTAL 8,943 9,481 (538) 35,551 37,007 (1,456) Overspend on Clinical Supplies is as a result of outsourced contractual services in the areas of pathology and imaging services. This is currently being reviewed by the CSS division. High cost drugs remains under plan as mentioned in the income section. Also, CTC over-performance on high cost device income meant anadverse variancefor ICDs. Premises adverse variance is due to an Increases in rates and utilities in the Trust's estates budgets, as well as laundry service contract. Non Pay: Budget v. Actual Overseas and home recruitment drive for nurses and recruitment fee charge for agency staff conversion to substantive, explains the overspend on Establishment. There is a budget for this spend but is currently still showing in reserves and will be moved to offset inmonth 5. 11,000 As CIPs schemes go live, the level of unidentified CIPs would reduce, improving the non-pay position. 10,000 The need to recovery the year to date position will require the Trust to implement a more stringent control over discretionary non pay requiring Director of Financesign off. 9,000 8,000 7,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar LAST YEAR ACTUAL BUDGET