Annual Complaints Report 2014/15

Annual Complaints Report 2014/15

1.0 Introduction This report provides information in regard to complaints and concerns received by The Rotherham NHS Foundation Trust between 01/04/2014 and 31/03/2015. The report provides data in regard to the number of complaints received and identified trends in relation to issues raised with the Trust. The Trust deals with complaints and concerns from patients and users, their relatives/carers in accordance with its Complaints and Concerns Policy and the Care Quality Commission (CQC) Essential Standards of Quality and Safety. The priorities for the complaints service during 2014/15 were agreed as listed below Review capacity of the patient experience team with a view to establishing a Patient Advice and Liaison Service (PALS) team or front of house access. Strengthen systems for data capture. Provide greater analysis of themes of complaints. Strengthen systems for sharing learning from complaints Trust wide. Improve contact with complainant and reduce late responses. Review approach to management of cases referred to the ombudsman. Explore benchmarking opportunities with other Trusts. Progress against each of these priorities is covered throughout the report with detailed progress recorded in Appendix A. 2.0 Definitions The Trust procedure invites both formal complaints and concerns in line with national guidance and uses the following definitions: Formal complaints: This definition refers to complaints which are processed through a formal procedure which involves a written acknowledgement from the Chief Nurse within 3 working days and a written response from the head of the relevant service, together with a cover letter from the Chief Executive. We aim to respond to all formal complaints within 25 working days. If the complaint is very complex, is multifaceted or involves a number of organisations a timescale of 40 days is allocated. Concerns: This definition is used in response to issues that can be resolved to the complainant s satisfaction without having to make a formal complaint. Concerns are dealt with as proactively and as quickly as possible. This may include meetings or telephone calls with an appropriate senior manager. We aim to resolve a concern within 10 working days although the vast majority are resolved in a much shorter timescale. Concerns were not recorded separately prior to December 2013. Under the Trust s previous complaints policy all expressions of dissatisfaction were registered as complaints. The Trust has an integrated Patient Experience Team (PET) to manage and deal with complaints and concerns in accordance with its Complaints and Concerns Policy. 2

3.0 The Patient Experience Team (PET) The PET comprises 4.8 WTE Complaints manager (1WTE), Patient Advisor (2.8WTE) and an apprentice administrator (1WTE). The Complaints Manager is responsible for the day to day operational management of the team whilst the Deputy Chief Nurse has overall responsibility for leadership of the team and for the delivery of the standards outlined within the Trust Policy. The Chief Nurse has executive responsibility for the Trust wide management of complaints. 4.0 Data Collection and analysis Both complaints and concerns are entered into the Complaints module within Datix. The system allows for the analysis of data against a defined set of categories which enables more detailed analysis of themes and includes categories such as attitude and approach of staff and nursing and medical care. The data are also analysed to show the total number of contacts by ward, department and directorate. Work is underway and will complete in 2015/16 to standardise the way in which complaints are categorised against the themes identified in the revised K014 documentation (NHS Information for Health and Social Care Survey). This will allow electronic benchmarking. Where a concern and complaint are reported within the same contact, the issues are logged separately in order to ensure that all issues are captured and responded to. 5.0 Numbers of complaints and concerns In 2014/15 TRFT received 396 formal complaints and 634 concerns, this represents a total of 1,030. Figure 1: Numbers of Complaints and Concerns received 2014/15 Complaint type Concerns 2012/13 2013/14 2014/15 Not recorded 202 (not a full year of datacommenced December 2013) 634 Complaints 949 595 396 Total 949 797 1,030 1,030 complaints and concerns were received in 2014/2015 in comparison with 797 in 2013/14 representing a 30% increase in total contacts from the previous year; however, formal complaints have decreased by 33%. This reflects the emphasis on immediate resolution now adopted by the Trust through this time period. It is however of note that not all concerns raised with the Trust were formally recorded before December 2013 and therefore direct comparison is not possible. The number of complaints and concerns by quarter is shown in Figure 2 below. 3

Figure 2: Number of complaints and concerns by quarter 300 Number of Complaints by Quarter 250 200 150 100 50 183 113 180 92 139 122 144 144 104 103 170 77 Concern/informal complaint Formal complaint 0 Although there is a significant fluctuation in the number of contacts with PET there is a general increasing trend as can be demonstrated in Figure 3 below. Figure 3: Total Complaints and Concerns by Quarter 4

6.0 Formal Complaints numbers measured against Trust activity The table in Figure 4 below relates to formal complaints only. Some complaints cross more than one area and therefore are counted more than once which accounts for discrepancy in the numbers recorded below and the total number of complaints recorded in Section 5 of this report. Figure 4: Complaints against Trust Activity 2014/15 Inpatient Attendances 2013/14 2014/15 Inpatient Complaints 409 196 Inpatient Episodes 68,183 70,034 Complaints per 1000 inpatient episodes 6 3 Outpatient Attendances Number of outpatient complaints 247 104 Outpatient episodes 211,000 212,533 Complaints per 1000 attendances 1 0.5 ED Patient Attendances Number of ED Complaints 75 61 ED Episodes 74.083 76,858 Complaints per 1000 attendances 1 0.8 Community Activity (across all Directorates) Number of complaints Not reported separately in 13/14 20 Number of contacts Complaints per 1000 contacts Not reported in 13/14 Not reported in 13/14 566,200 0.05 NB The numbers of complaints in the table above is higher than the total number of complaints per year as many complaints relate to more than one aspect of care. It can be seen that the number of complaints against activity is highest for in-patient areas. The total percentage of complaints against all Trust activity is 0.05%. 5

7.0 Number of complaints and concerns by Directorate Figure 5 below illustrates the number of formal complaints and concerns received by each directorate in 2014/15. Figure 5: Number of complaints and concerns received by each directorate for 2014/15 The Medical Directorate receives the majority of formal complaints and concerns. The Medical Directorate received 50% of formal complaints and 39% of concerns in 2014-15. This follows the on-going trend as the Medical Directorate received the most complaints registered in both 2012-13 and 2013-14. The Medical Directorate has the highest number of inpatient admissions (approximately 45%) and is the largest of the directorates. Figure 6: Formal complaints by Directorate 6

Figure 7: Complaints and Concerns by Speciality Figure 7 above shows the number of complaints and concerns by speciality in 2014/15. It can be observed that in general complaints and concerns follow a similar distribution across the specialities. The exception is estates and patient access where issues are raised as concerns. In these areas issues can be more immediately responded to and are therefore appropriate to be managed via the concerns process. The specialities of General Medicine and Accident and Emergency feature strongly as in all previous years. They represent the largest specialities in terms of patient episodes. In previous years, concerns have not been reported accurately so the full picture is unavailable. In 2014/15 the number of formal complaints has reduced and this is likely to be due to the successful resolution achieved via the concerns process. As a result of the reduction in formal complaints most areas have seen a reduction in formal complaints received however there are a small number of areas that have noted increases in comparison to 2013/14 data. These are within the Orthopaedics and Urology specialities. The rise in these areas has been driven by an increase in the number of complaints relating to the provision of medical care and is subject to further analysis within the Directorate of Surgery to identify learning that can be applied across all specialities. 7

8.0 Complaints by risk rating All complaints are rated as Red, Amber or Green (RAG) on receipt by the Patient Experience Team. This RAG rating is initially reviewed by the Chief Nurse and quality assured upon completion of the investigation by the directorate lead and therefore the initial RAG rating may change. The process of immediately reviewing all new complaints as they are received ensures that we can quickly identify and escalate any complaints which contain potentially serious issues that may require more urgent investigation or immediate action. Figure 8 below summarises the percentage breakdown of all complaints closed by risk grade for the period 2014/15 compared to previous years. Figure 8: Complaints by Risk rating over last three years Green Yellow Amber Red 2012/13 44% 48% 7% 1% 2013/14 24% 66% 7% 3% 2014/15 5% 70% 20% 5% Over the last three years the proportion of complaints graded high risk (red) has risen from 1 to 5%. This reflects increased overview of all complaints by the executive team and the revision of the criteria for assessing complaints against the risk matrix that took place in 2014/15. This lowered the threshold for assessing complaints as high risk and includes all complaints where there has been a breach of the fundamental standards of care. The number of complaints investigated in the moderate risk category (amber and yellow) has also increased over this time period driven by a marked reduction in the number of low risk (green) complaints investigated during 2014/15. This is due to the majority of lower risk complaints being successfully managed as concerns and resolved quickly. 9.0 Complaints by cause Many complaints are multi- faceted and may cover a range of issues and a number of areas and teams within the Trust. However, it is possible to highlight issues that occur most often. Figure 9 below highlights the issues that arise most often in A complaints and concerns, B concerns only, C complaints only 8

Figure 9: Complaints by Cause A) Medical Care 169 (43%) formal 95 (16%) concerns Nursing Care 77 (20%) formal 69 (12%) concerns Attitude 29 (7%) formal 32 (5%) concerns B) Administration 34 (6%) concerns Appointme nt 51 (9%) concerns Waiting times 59 (10%) concerns C) Discharge 30 (8%) formal Figure 10 below shows the main issues arising in formal complaints and concerns and reflects the data presented above whilst the tables in Figure 11 and 12 compare the top 5 themes from 2013/14 to those identified in 2014/15. Figure 10: Main issues raised in formal Complaints and Concerns Figure 11: Medical care by Complaint Subject in 2014/15 in comparison with 2013/14 9

Medical care Complaint subject 2013/14 2014/15 Total 201 169 Delay in receiving treatment 15% 17% Incomplete/unclear information 11% 10% Complications of medical procedures 11% 9% Failure to diagnose 6% 9% Inappropriate treatment 8% Four of the top 5 themes occurred in both 2013/14 and 2014/15. Staff attitude did not feature in the top 5 in 2014/15 as it was replaced by inappropriate treatment. Staff attitude is recorded at 6% of total complaints in 2014/15. Delay in receiving treatment remains the top issue. Although information remains second in the table this was the top issue in 2012/13 recording 21% of complaints in this category which might suggest a sustained improvement in this area. However information features very strongly in the concerns analysis suggesting that information giving is still a cause for concern amongst service users but is more likely to be addressed via an informal route. Figure 12 below shows the top five themes identified against nursing care during 2014/15 and provide comparison with the previous year. Figure 12: Nursing care by Formal Complaint Subject Nursing care Complaint subject 2013/14 2014/15 Total 90 76 Overall care provided 16% 25% Failure to properly assess _ 11% Staff attitude 12% 8% Failure to comply with drug policy/delay in giving medication 13% 7% Incomplete/unclear information 9% 7% Privacy and dignity featured in the top 5 in 2013/14 but does not arise in 2014/15. Failure to assess properly has not been identified previously as an issue but is second most common cause of complaint in 2014/15. 10

It is noted that there is a significant rise in the percentage of complaints about the overall provision of nursing care which reflects some concern around the delivery of fundamental standards of nursing care. A number of actions have been taken in response to this issue and are detailed in section 13 of this report. 10.0 Performance against Key Performance Indicators (KPI) The Trust has 20 complaint KPIs which are all related to the delivery of timely complaint response. For the purposes of this report three KPIs will be reported which are directly related to the complainant experience of our service. These are: Acknowledgement within three days Response within 25 days or 40 days for more complex complaints Reopened complaints below 4% 10.1 Acknowledging Complaints The NHS Complaints procedure states an acknowledgement should be made within 3 working days of receipt by any method ( i.e. telephone, email, letter or in person). From December 2013, the Patient Experience Team has provided a written acknowledgement signed by the Chief Nurse in response to all formal complaints (In line with the Patients Association good practice standards). The complainant may receive acknowledgement of the complaint by phone or email in addition to the written acknowledgement. The Trust now continuously meets 100% of complaints acknowledged within 3 days in writing meeting the Trust KPI. 10.2 Responding to Complaints within the agreed Timescale The Concerns and Complaints Policy (2013) implemented a requirement to respond to complaints within 25 working days or 40 working days if the complaint was more complex. The PET has experienced severe difficulties in regard to performance over this time period with a history of extensive delays in response times and large backlogs of complaints. In December 2014 74% of complaints were in breach of timescales. Intensive work has been undertaken to resolve this issue and recently improvements have been achieved. In March 2015, 21% were in breach of the agreed timescale (this does not include complaints where meetings are being arranged as this is in negotiation with the complainant). The table below in Figure 13 provides data in regard to responsiveness to complaints for complaints closed within the time period. Figure 13: Complaint response times for complaints closed in the time period. Month < 25 days 26-39 days > 40 days Quarter 2 18% 37% 45% Quarter 3 23% 34% 42% January 2015 22% 34% 44% February 2015 48% 8% 44% March 2015 50% 29% 21% 11

Careful consideration has been given to the reasons why there has not been the required improvement against the expected standard that 90% all complaints are responded to within the agreed timescale and the following factors have been identified. The Trust began the year with a significant backlog in complaints following the implementation of the revised concerns and complaints procedures in December 2013. Prior to December 2013 the Trust had been working to national guidance set out by the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. This guidance stated that complaints should be responded to within a maximum 6 month timeframe. This change in procedure was accompanied by a change in the Directorate structure which meant that new directorate teams and ways of working had to become embedded. As a consequence the backlog was not resolved and continued to build until October 2014. From October 2014 significant work has been undertaken to clear all overdue complaints which has resulted in a reduced number of open complaints overall. However as a result of complaints being overdue, performance against the target has yet shown the required improvement. A number of other contributory factors have been identified and include: Delays in receiving complaint response from staff have been a contributory factor to the backlog of complaints. Whilst the extent of this problem varies across directorate, delays are greatest in the Medical Directorate with some surgical specialities (urology, orthopaedics, ophthalmology) having a delayed rate of response. These areas also receive the highest number of complaints. Errors in the quality assurance process which has resulted in some complaints requiring multiple drafts and revision by the PET and the executive team. Until very recently the way in which we used the complaints management system in Datix required multiple data entry points and has made the system difficult to use effectively. This resulted in difficulty extracting data for reports which has increased the pressure on the PET. Recent feedback from complainants and from PHSO reports indicates that it may be preferable to receive a high quality thorough response and be kept informed throughout the investigation, even if this takes longer. This feedback will be considered as part of the review of the complaints process planned for next year and outlined in Section 15 of this report. 10.3 Managing reopened complaints During Quarter 4 significant progress was made against recording the number of re-opened complaints within the Trust. This was driven by improvement in the use of Datix by the PET and by a detailed review of all contacts that had been made with PET about closed complaints over the previous 9 month period. The Trust has set a KPI of less than 4% for reopened complaints. As can be seen in the table in Figure 14 below both quarter 3 and 4 of 2014/15 recorded rates of 13% which is significantly above the Trust KPI. This data is prone to inaccuracy as a complainant may return many months after the response has been received. This data therefore provides a snapshot rather than accurate annual data. 12

Figure 14: Number of re-opened complaints by Quarter (data recorded since Q3) Q3 2014 13% Q4 2014/15 13% Contact with other Trusts has identified that few Trusts have a KPI in regard to reopened complaints. However TRFT considers that the number of re-opened complaints is a proxy measure for complainant satisfaction and that it is reasonable to work towards reduction in the numbers of complaints that are re-opened across the Trust. 11.0 Satisfaction with the Complaints Service During 2014/15 a total of 37 satisfaction surveys were returned by complainants representing only 16% of all complainants. The questionnaire is seeking to understand a complainant s perception of how their complaint has been dealt with in line with recommendations from the Patients Association. The response rate is disappointingly low. Analysis of the patient satisfaction questionnaire gave an overall satisfaction rate of 43%. Improving satisfaction with the complaint process has been identified as a priority for 2015/16. A number of measureable outcomes have been identified in order to ensure delivery against this quality measure and are outlined in Section 14 of this report - Priorities for 2015/16. 12.0 Complaints Referred to Parliamentary Health Service Ombudsman (PHSO) We aim to resolve all complaints by undertaking a thorough investigation, providing comprehensive responses and offering complainants the opportunity to discuss further concerns with us. In addition the trend towards direct contact between the investigator and the complainant noted through 2014/15 provides additional opportunity to resolve concerns. However we are not always able to achieve a resolution which satisfies the complainant Under the NHS complaints system complainant who are dissatisfied with the response have the right to ask the PHSO for an independent review of their case. The right to go to the PHSO is explained to all complainants. 2013/14 cases In her annual report published November 2014, the PHSO reported that 22 enquiries had been raised with her about TRFT in 2013/14. Of these 8 were accepted for investigation and 1 upheld. 22 enquiries represent 3% of all complaints received by the Trust for 2013/14. 2014/15 The PHSO has reported on the number of complaints received by her office during the first two quarters of 2014/15. The second two quarters have not yet been reported. During the first six months of 2014/15 the PHSO office received 17 enquiries about TRFT, 1 of which was accepted for investigation and upheld. 17 enquiries at half year represent 4.2% of all complaints received. The trend towards an increase in enquiries to the PHSO is repeated across other NHS Trusts and is expected to continue in line with increased PHSO activity. The one case that was upheld during this time period related to a complaint within the Medical Directorate and an improvement plan has been developed to respond to the issues identified. 13

Although the full year report is not yet available from the PHSO we have kept a record of cases that we have been made aware of. In the second half of 2014 four cases have been accepted for investigation. Records have been copied to the Ombudsman in preparation of the investigation but no investigations have as yet been reported. 13.0 Listening and Learning from Complaints The Complaints process is closely monitored at senior level within TRFT in order to ensure that: Complaints are well managed with clear, accurate and helpful response Any serious issues area appropriately escalated Trends or patterns are identified and responded to rapidly The Patient Experience Group (PEG) is accountable to the Operational Quality Safety and Experience Group (OQSEG) which reports directly to Trust Management Committee. Monthly reports are received by both groups detailed complaints performance including response times and details of emerging trends. All investigations about high risk (red) complaints require that an action plan is submitted to PEG and monitored to completion by that group. A report detailing the outcome of high risk complaints, together with PHSO activity is provided on a monthly basis to the Quality Assurance Committee (QAC) a committee of the Board of Directors. As a result actions taken in response to service failures or serious concerns are afforded consideration at the most senior level within the organisation. From April 2015 Quarterly combined complaints and claims reports are received by QAC which enables triangulation of data and identification of themes. In order to drive improvement in learning from complaints across the organisation a number of actions have been introduced through 2014/15 to enable the capturing and sharing of lessons learnt from complaints. Summarised below: A requirement that all upheld complaints are not closed until an action plan has been provided with evidence of directorate level sign off which will become live from 01.05.2015 The complaint handling satisfaction questionnaire has been revised to encourage greater engagement of service users Complaint numbers and learning from complaints has been published on the Trust website since February 2015 A training programme to focus on complaint investigation and response has been developed by the Deputy Chief Nurse and is to be rolled out to all directorates starting in April 2015 Training on the Datix system is being undertaken with Governance Leads in May 2015 so that appropriate documentation can be easily accessed at directorate level Patient Stories are shared at BOD and Directorate Governance meetings as part of TRFT commitment to sharing and learning from feedback Quarterly review of 5 randomly selected complaints by Non-Executive Directors, the findings from which have been used to identify the complaints priorities for 2015/16 14

Figure 15 below identifies some of the issues raised by complainants and the learning and actions undertaken by the Trust in response to the issues. Some of the actions resulted from the learning from an individual complaint whereas others are in response to a number of complaints raising similar issues. Figure 15: Learning Identified From Complaints Issue Identified Action taken Lack of awareness of issues involved with dementia. Poor communication with relatives in regard to the needs of the patient. All staff in the Trust are being trained in Dementia awareness Forget-me-not scheme introduced Booklet in regard to patient needs, likes etc. to be kept by the bed for staff to familiarise themselves with the patient Board above the bed identifies special needs Planned changes to the environment to make them more appropriate for people with Dementia Patients with Dementia not to be moved to the discharge lounge Issues in regard to attitude of medical staff when giving difficult news Medical staff are being trained in advanced communication skills as part of the appraisal and revalidation process Issues in regard to discharge including Delays Provision of medication New discharge policy being developed and introduced Task and Finish group reporting to the patient experience Group has been established to drive delivery of the revised policy by July 2015 Planning Fundamentals of nursing care not always attended to Matrons are undertaking spot visits on Wards including weekends and nights including engaging with patients to see if they are happy with the care provided The trust is devising a Perfect Ward accreditation system Individual training for staff involved has been completed Changes have been made to the leadership and organisation of specific wards A revised programme of directorate led patient experience questionnaires has been introduced across the Trust in April 2015 15

Lack of appropriate care and compassion in regard to end of life care Delay in responding to complaints A new End of life care programme based on the End Of Life Care Framework, led by Assistant Chief Nurse for vulnerabilities is to be rolled out across the Trust through 2015/16. Comprehensive improvement plan for complaints management has been introduced with an agreed improvement trajectory defined. Progress against the plan is being monitored by the Patient Experience Group. 14.0 Complaints Priorities for 2015/16 A review of the Complaints process will take place through 2015/16 which will aim to refine the existing policy to ensure a more efficient complaints process which is easy to access, improve the quality and timeliness of complaint responses and increase complainant satisfaction. The priorities for 2015/16 include: From 01.04.2015 we will simply the identification of complaints against the K104 categories so that benchmarking can be more easily undertaken across the Trust and to reduce the duplication of activity undertaken by the PET. To improve satisfaction with the complaints process by establishing a Trust wide baseline to include: 1. % of patients who feel their complaint has been resolved 2. % who feel their complaint was dealt with in a timely manner 3. % who were satisfied with the final response 4. % who feel that their complaint was well handled 5. % who feel they were listened to In line with PHSO recommendations we will simplify the coding of complaints from 01.04.3014 to ensure that only 2 categories are used, upheld and not upheld. The concept of partially upheld will be removed. The following definitions will apply: Upheld: Complaints in which the concerns were found to be valid on investigation Not Upheld: Complaints where the concerns were not substantiated on investigation. If a complaint is not upheld we will still recognise the validity of the complaint to the complainant and acknowledge that we have failed to meet their expectations. We will introduce a revised complaints management training programme from April 2015 which will focus on complaint handling from the patient perspective and include the importance of taking ownership of a complaint and acting to improve the patient experience. Undertake a review of the Trust webpage to clarify the process for making a complaint or raising a concern about the service. 16

Review the Trust Complaints and Concerns Policy against the requirements of the National Duty of Candour (2014) and complete any required amendments by the end of May 2015. Develop a stronger and more accurate process for capturing patient compliments. Map the feedback received via Patient Opinion and NHS Choices to the complaints themes identified within the Datix Complaints Module. Ensure we produce a child friendly complaint leaflet enabling the child/young person to raise concerns in their own right. 15.0 Conclusion At TRFT we remain committed to investigating, learning from and taking action as a result of individual complaints where it is confirmed that mistakes have been made or where services can be improved. We are committed to ensuring that Trust responsibilities in meeting statutory Duty of Candour requirements, ensuring and open, honest and transparent approach is the norm in the Trust s response when things go wrong and when dealing with the concerns of patients. We undertake a detailed monitoring and reporting of complaints which ensures that issues of concern are raised promptly and at a senior level within the organisation. We have outlined an ambitious plan to improve the quality of our complaints service over the next 12 months with specified objectives to achieve more timely complaints handling, increased complainant satisfaction and improved reporting processes. Anne Crompton Deputy Chief Nurse April 2015 17

Appendix A: Progress Report: Complaints Priorities 2014/15 2014/15 Priority Progress made Review capacity of the patient experience A full review of the capacity of PET has been team with a view to establishing a Patient completed. There has been significant increase in Advice and Liaison Service (PALS) team the number of issues dealt with as concerns during or front of house access 2014/15. An apprentice administrator has begun working with the team in order to support day to day administration within the team. An improvement plan has been developed in order to respond to some identified duplication of activity. Further work will be undertaken through Q1 2015 to identify additional action required to develop Trust wide PALS function further. Strengthen systems for data capture This action is complete. All complaints and concerns are now recorded on Datix together with action plans and investigation reports. Provide greater analysis of themes of complaints Strengthen systems for sharing learning from complaints Trust wide Improve contact with complainant and reduce late responses Review approach to management of cases referred to the ombudsman Explore benchmarking opportunities with other Trusts The move towards using K104 as the basis of complaint analysis will complete this action by end April 2015. All High risk complaints are reviewed at senior level within the organisation in order to ensure that learning is widely disseminated. All High risk action plans are monitored to completion through PEG. From 01.05.2015 all upheld complaints are required to have an action plan uploaded onto Datix which will be monitored through service level governance groups with escalation to directorate and from there to PEG if not completed. All complaints are contacted by PET or directorate lead if there is a delay in their complaint response. An improvement trajectory has been agreed by OQSEG such that 90% of complaints will be responded to within the agreed timescale by end July 2015. This action is complete. A record is maintained of all interactions with /requests from the PHSO. All PHSO investigations are reported to QAC with action plans monitored to completion by PEG. Benchmarking opportunities are limited as published data by Trust is variable and Trusts do not measure the same things. However the move towards using the K10.4 categories will enable greater comparison with nationally published data through 2015/16. 18