agenda - king's college hospital - 491.1 - bod agenda and papers se… · 1.4. minutes of...

Key: FE: For Endorsement; FA: For Approval; FR: For Report; FI: For Information

AGENDA

Meeting Public Board of Directors

Time of meeting 09:30-12:15

Date of meeting Wednesday, 09 September 2016

Meeting Room Dulwich Room, Hambleden Wing

Site Denmark Hill Site

Encl. Lead Time

1. . STANDING ITEMS Chair 09:30

1.1. Apologies

1.2. Declarations of Interest

1.3. Chair’s Action

1.4. Minutes of Previous Meeting – 06 July 2016 FA Enc. 1.4

1.5. Action Tracker & Matters Arising FE Enc. 1.5

2. . BEST QUALITY OF CARE

2.1. Patient Story FR Presentation C&N Stott/ C Greensitt

09:35

2.2. Quarterly Patient Outcomes Report FR Enc. 2.2 J Wendon 10:05

2.3. Quality & Governance Committee Chair Update FI Enc. 2.3 G Mufti 10:20

3. . Chief Executive’s Report FR Enc. 3 N Moberly 10:30

4. TOP PRODUCTIVITY

4.1. Performance Report (Month 04) FA Enc. 4.1 P Fry 10:45

5. . SKILLED, CAN DO TEAMS

5.1. Monthly Nurse Staffing Levels Report FE Enc. 5.1 P Townsend 11:05

6. . FIRM FOUNDATIONS

Sound Finances

6.1. Finance Report (Month 04) FE Enc. 6.1 C Gentile 11:15

6.2. Finance & Performance Committee Chair Update FI Enc. 6.2 S Slipman 11:40

Rigorous Governance

6.3. Council of Governors Report FR Verbal C North 11:50

6.4. Board Committee Minutes FI Chair 12:00

6.4.1. Finance & Performance Committee – 26/06/2016 Enc. 6.4.1

6.5. Chair & NEDs Activity FI Enc. 6.5 Chair 12:05

7. . ANY OTHER BUSINESS Chair 12:10

8. DATE OF NEXT MEETING

Wednesday, 05 October 2016, 11:00, Bromley Library

Members:

Lord Kerslake (BK) Trust Chair

Sue Slipman (SS) Non-Executive Director, Vice Chair

Faith Boardman (FB) Non-Executive Director

Prof. Ghulam Mufti (GM) Non-Executive Director

Prof. Jonathan Cohen (JC) Non-Executive Director

Dr Alix Pryde (AP) Non-Executive Director

Erik Nordkamp (EN) Non-Executive Director

Nick Moberly (NM) Chief Executive Officer

Dawn Brodrick (DB) Director of Workforce Development

Colin Gentile (CG) Chief Financial Officer

Toby Lambert (TB) – Non-voting Director Interim Director of Strategy

Paula Townsend (PT) Acting Director of Nursing

Prof. Julia Wendon (JW) Medical Director

Attendees:

Tamara Cowan (TC) Board Secretary (Minutes)

Peter Fry (PF) Director of Performance

Chris North (CN) Lead Governor

Norah Stott (NS) Patient

Charles Stott (CS1) Patient

Chris Greensitt (CG) IV Practitioner

Apologies:

Jane Farrell (JF) Chief Operating Officer

Ahmad Toumadj (AT) – Non-voting Director Interim Director of Capital, Estates and Facilities

Christopher Stooke (CS) Non-Executive Director

Trudi Kemp (TK) – Non-voting Director Director of Strategy

Circulation List:

Board of Directors & Attendees

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King’s College Hospital NHS Foundation Trust Board of Directors - PUBLIC

Minutes of the Meeting of the Board of Directors held at 09:30 on 06 July 2016 in the Dulwich Committee Meeting Room, Hambleden Wing, Denmark Hill site

Members: Lord Kerslake (BK) Trust Chair Sue Slipman (SS) Non-Executive Director, Vice Chair Faith Boardman (FB) Non-Executive Director Chris Stooke (CS) Non-Executive Director Prof. Ghulam Mufti (GM1) Non-Executive Director Prof. Jonathon Cohen Non-Executive Director Dr Alix Pryde (AP) Non-Executive Director Nick Moberly (NM) Acting Chief Executive Officer Dawn Brodrick (DB) Director of Workforce Development Colin Gentile (CG) Chief Financial Officer Jane Farrell (JF) Chief Operating Officer Toby Lambert (TL) – Non-voting Director Interim Director of Strategic Development (part) Judith Seddon (JS) – Non-voting Director Acting Director of Corporate Affairs Ahmad Toumadj (AT) – Non-voting Director Interim Director of Capital, Estates & Facilities Paula Townsend (PT) Acting Director of Nursing & Midwifery Julia Wendon (JW) Medical Director

In attendance: Tamara Cowan (TC) Board Secretary (Minutes) Helen Mothersole (HM) Speech & Language Therapist Elizabeth Allan (EA) Speech & Language Therapist Petula Storey (PS) Head of Volunteering Penny Dale (PD) Public Governor

Fiona Clark (FC) Public Governor Lisa Hollins (LH) Shadow Director of Transformation & ICT Robert Kettell Department of Health Andy Simmons Southwark Council Apologies: Erik Nordkamp (EN) Non-Executive Director Trudi Kemp (TK) – Non-voting Director Director of Strategic Development

Item Subject Action

16/69 Apologies Apologies for absence were noted.

16/70 Declarations of Interest There were no declarations on interest made at the meeting.

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Item Subject Action

16/71 Matters Arising/Action Tracking The action tracker was noted.

16/72 BEST QUALITY OF CARE

16/72.1 Patient Story The Board welcomed Speech & Language Therapists, Helen Mothersole (HM) and Elizabeth Allan (EA) who provided an overview of the treatment of a patient receiving speech and language therapy at the Trust. The following key points were reported:

The patient was admitted to the hospital through the major cardiac pathway and has a unstable spinal fracture;

The therapies team was brought in to support the patient whilst he was in the critical care unit (CCU);

The patient was frustrated because he could not talk and because of spinal cord injury, he could not write.

His swallowing ability was affected by the treatment of his major injuries;

The therapies team aim was to make his experience better and when his health deteriorated, he was returned to the high dependency unit (HDU) and put on nil by mouth. When he was able to start eating the therapies team supported the patient to eat again and avoid high risk foods; and

The patient is still in hospital waiting for rehabilitation and is on track. The following points were raised in discussion:

Three band 5 nurses provided support to the patient and the process took a long time because the team had lots of work to do to assure him. This equated to 2-3 sessions per week whilst he was on the critical care unit (CCU). Whilst he was on the neuro-step down ward he was seen three times but when his medical status deteriorated the team was seeing him for 45 minutes per day and when he stabilised he was seen for only 30 minutes per week;

The team react to changes in the medical status of the patient;

The caseload of the average case load of for team members can be circa 12-13 patients;

This patient story is a reflection of the complexity and intensity of work that is conducted in the Trust and the level of skills that is required to treat patients;

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Item Subject Action

The Trust can support the team by providing opportunities and resources for training such as study leave funding;

The multi-disciplinary team works well at the Denmark Hill site because therapies has been long established whilst at the Princess Royal University Hospital (PRUH) site the processes and systems are still being established; and

Patients’ carers can be core to the speech therapy sessions and the Trust encourages carers to be involved and conduct session when family are around in as much as possible.

16/72.2 Quarterly Patient Safety Report The Board received the quarterly patient safety report. The following key points were reported:

There were three never events in quarter four and a formal report has been commissioned to ensure that there are no concerns. The report would be presented to Board;

The never events related to one retain guidewire and two misplaced naso-gastric (ng) tubes.

Actions taken include, but not limited to, communicating the procedural checklist, development of a King’s Way standard operating checklist. Junior doctors are also required to sign-off as competent before being able to conduct procedure on their own;

Retained swabs incidents have occurred outside the traditional theatre setting where the clarity of process was not maintained necessitating the need to develop standard operating procedures (SOPs) for all procedures;

The Trust is looking at sepsis data to track any trends ad benchmark performance;

The number of hospital acquired pressure ulcers remain constant. There have been three grade three pressure ulcers;

The Trust needs to streamline processes in the management of people with learning disability with pressure ulcers; and

Hospital acquired thromboses (HATs) rates are also constant/ The following points were raised in discussion:

The Trust’s HATs are low in comparison to other trusts;

Volunteers are being used to support staff but are not conducting clinical activities and volunteers are properly trained to provide this support;

The issue with the ten-fold errors in paediatrics is not related to the dosage;

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Item Subject Action

Thought now has to be given to pharmacy delivered drugs to solve the issue with medication errors;

The quality and governance committee has discussed the number of never events and the norovirus incidents, noting that there is no clarity on what more can be done to address these issues.

Awareness as changed and people are taking ownership. The SOPs will enact a specific changes under the King’s Way Standards which the trust will be able to see impact over the next 3-6 months;

The Trust will track pressure ulcers to ensure that there are improvements;

The norovirus issues at the Princess Royal University Hospital (PRUH) is related to an endemic in the local community in the Bromley area and there structural issues on the site such as not having sinks where they should be.

The Trust has to look at its procedures and practices and ensure that people carry out basic hand washing. Defeating norovirus should be an organisational priority for the Trust;

An additional issue related to infection control is the lack of changing room facilities at the PRUH site resulting in staff wearing uniforms to work contrary to the Trust’s policy.

The following was agreed: 1) The Board would receive an update on structural issues at the PRUH and

the correlation to infection control issues; and

2) The Board would receive periodic updates on basic hand hygiene metrics.

JW/PT

16/72.3 Quality & Governance Committee Chair Update GM reported that the Quality & Governance Committee had two things to highlight from the recent meeting of the Committee:

There was a very good presentation on end of life care and it is clear there is a strategy going forward, namely iCare;

There is concerns about DNAR with the key issue being inconsistencies between the paper and electronic processes; and

It is important for the Committee review the executive attendees.

The Board noted the summary from the last meeting.

16/72.4 Volunteer Programme The Board received and discussed the report on the Trust’s volunteering programme welcoming Petula Storey, Head of Volunteering.

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Item Subject Action

The following key points were reported:

The Trust’s volunteering programme has been hailed by Simon Stevens as an example but the funding from the King’s Charity will end September 2017;

A King’s Fund review showed that with every one pound invested in volunteers there is a significant equivalent value return; and

To sustain what has been a successful programme the Trust now needs to invest in the programme.

The following key points were raised in discussion:

The Trust is pioneering a volunteering model for health and other sectors of which the Board is supportive. There is however, concerns about what volunteers will be pulled into and there needs to be clear policy statements as it is all too easy for risks to arise. The Board needs to be confident of the volunteering policy;

The volunteers are evidently doing a wonderful job but has the Trust begin to tackle the issue of integrated care it has to consider what role volunteers can contribute;

Since 2013, the Trust has been running its hospital-to-home programme which is helping to support people at home and connect with the relevant community care agencies. The Trust also works closely with the Red Cross and Age UK;

The Board is conscious and has some concerns about how comprehensive is the training in relation to volunteers work in the community and also the level of training;

The age profile of patients using the hospital-to-home services range from 70-90;

KE will have to make a decision about the volunteering programme and its continued funding; and

There is universal Board support for the programme but the Trust needs to be minded of the boundaries and keep constant vigilance on volunteers in the community.

It was agreed that the executive team would consider future investment in the volunteering programme and policy statements for community services.

16/73 Chief Executive's Report The Board received and noted the report from the Chief Executive Officer (CEO). The following key points were reported:

Progress has been made on the delivering the transformation programme;

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Item Subject Action

On the integrated care, agenda things are starting to move. The local care programme group and good work has already been done with lots of consistency of views;

The formal notification of tender for community services in Bromley has already been issued;

King’s Health Partners’ focus continues to be on development of the institutes with it expected that the strategic outline business case would be presented to the partner organisations boards in October;

In November the Trust will implement the new organisational restructure and the formal launch will conducted at the end of the week;

The Trust is driving CIPs and activity demand action plans; and

The deadline for the implementation of Electronic Patient Records has slipped.


It is now timely form the Trust to have an integrated strategy with the site strategy given that the university, King’s College London (KCL) will review the lab programme;

The Research Strategy will be ready in quarter two and in four month the Board will also have the clinical site strategy; and

The executive will also look at the things that can be done in the short term to align teaching and research.

16/74 TOP PRODUCTIVITY

16/74.1 Trust Performance Report 2016/17 (Month 02) The Board received and discussed the month 2-performance report which was also discussed at the Finance & Performance Committee meeting held on 28 June 2016. The following key points were reported:

The Trust met emergency department (ED) targets agreed with NHS Improvement and commissioners. In May, Princess Royal University Hospital (PRUH) ED was between 84-87% as a result of the norovirus and at Denmark Hill (DH) 89% which exceeded 400 patients per day;

The capital development for increasing beds are on track despite some challenges. This has been tough for the on the ground but these developments are the building blocks for future sustainability;

Referral to treatment (RTT) trajectory was at 89% but this may be at risk;

The Trust is 25 cases behind on its 52-day wait as at month two. This is the most challenges area;

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Item Subject Action

Bed and theatre pressures are driving the challenges faced by the Trust;

The Trust has ring-fenced capacity to support delivery of RTT targets.

Other plans include redesigning capacity between the PRUH and DH sites and utilise Orpington more;

There is a mixed picture in relation to cancer performance targets;

There have been significant increases in referral demand resulted in performance dipping slightly;

Whilst the Trust’s 2-week waits recovered in month two and three it will fail the quarter;

62-day dipped but the quarter one position is secured at 85%;

Diagnostic waits is highly challenged but there are robust recovery plans in place; and

There have been 10 clostridium difficile cases. The following key points were raised in discussion:

The finance and performance committee conducted a deep dive into the diagnostic waits and could not pinpoint a key issue which was driving the challenges in meeting the target;

If there are cost effective ways to address the issues facing the Trust they should be explored;

The Trust will have to evaluate where cancer sit and address any clinical issues; and

The Charity has £950k to spend on cancer.

16/75 SKILLED, ‘CAN DO’ TEAMS

16/75.1 Monthly Nurse Staffing Levels Report The Board received and noted the monthly nurse and midwifery staffing levels report. It was also noted that the Trust is not an outlier and that it would be good to understand what is driving red shifts.

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Item Subject Action

16/76 FIRM FOUNDATIONS

Sound Finance

16/76.1 Finance Report (Month 02) The Board received and discussed the month 02 finance report which was also discussed at the Finance & Performance Committee (FPC) meeting held on 26 June 2016. The following key points were reported:

The key financial issues are unidentified CIPs against the annual plan which provided for an indicative phasing of £2.8m and CIP slippage of £599k to date;

The Trust delivery against activity is down with a £3.1m shortfall in non-block contract income;

The Trust has received one twelfth of the sustainability funding from NHS Improvement (NHSI). This funding stream will be paid quarterly in arrears;

Cashflow is a significant problem for the Trust and there has been a 35% drawn down on cash in quarter one;

NHS England (NHSE) is paying the Trust based on previous years tariff and if the Trust is running a £6.7m deficit this needs to be supported by cash;

The Trust is focusing on debtors but as many people who owe the Trust the Trust also owes money;

The Board needs to be very aware of the implications of not meeting the operational performance targets;

The Trust will make another cash drawn down of £19m in July;

The trust is very close to signing the contract with NHS England and will get paid for fetal but the Trust will have to pay for the hepatitis C test kits;

The Efficiency Board is focusing on driving CIPs and whilst it is early days the Trust is getting to grips; and

The key now is focusing on delivering the activity for NHS England.


The Trust has submitted its letter relating to the control total which highlighted the risks and caveats. These are important caveats and the challenges facing the Trust should be communicated clearly in order to expedite the process for receiving the monies;

NHS Improvement is looking into a special purpose vehicle to fund transformation;

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Item Subject Action

The Trust has had lots of challenges which have impacted on the performance such the junior doctors strike, theatre developments, norovirus and meeting the referral to treatment targets;

The Trust is working on a plan to recover the activity;

There is high risk on numbers for the Trust, but CIPs are being driven by the executive team and there is a clear why ahead;

Focus is on mitigations and financial restructure to fill the profound gaps;

The operations team is very stretches;

The Trust needs to get in a good position to ensure that the operations are in a good place without compromising strategic quality;

If the Trust did not accept funding it would not have received the £30m funding application;

Everyone is doing their level best to support delivery of the plans;

The Trust may be criticised for its slow progress on improving agency spend. There is a project plan which includes a number of actions which will be implemented over the next few months to reduce agency spend overall.

The Education & Workforce Development Committee is monitoring the action plan;

Because the Trust is off trajectory it has to push hard in order to hit its targets; and

The Trust has to be minded of that whilst it is driving activity it has to drive the sort of activity which will generate income and not only activity related to the block commissioner contract.

16/76.2 Finance & Performance Committee Chair Update The Board received and noted the report from the Committee Chair.

Rigorous Governance

16/77 PwC Governance Review The Board reviewed and discussed the PwC Governance Review action list. The following key points were noted:

The Trust has made good progress on completing the actions from the PwC Governance Review;

The executive team has completed a review of the management governance structure;

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Item Subject Action

It is commendable that the Board has been very transparent about this process;

The Trust needs to get the controls for major projects and business cases better aligned;

The revised management governance structure, which includes transformation and efficiency boards would be circulated for information; and

Work is going to be completed on the standing financial instructions and scheme of delegation.

The Board noted the progress on implementing the actions from the PwC Governance Review and it was agreed that the revised management governance structure would be circulated.

NM

16/78 Council of Governors Report The Board received an update on the activities of the Council of Governors from Fiona Clark. On behalf of the governors she relayed the following key matters:

At the governor workshop, governors heard about the financial position and the transformation programme. Governors are concerned that the consultant body is disconnected from the process and encourage the development of ideas from the floor upwards;

Governors are also concerned with the turnover of administration staff;

The update on the 16/17 financial position and budgets was very useful and the governors were able to better understand the risks; and

The Joint KHP Event was also very useful and it was the first time that the Trust had such a wide body of experts across KHP on hand to provide insights in some very relevant areas.

16/79 Board Committee Annual Report

16/79.1 Audit Committee The Board noted and approved annual report from the Audit Committee and the revised terms of reference.

16/79.2 Finance & Performance Committee The Board noted and approved annual report from the Finance & Performance Committee and the revised terms of reference.

16/79.3 Quality & Governance Committee The Board noted and approved annual report from the Quality & Governance Committee and the revised terms of reference.

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Item Subject Action

16/79.4 Chair's and Non-Executive Director's (NEDs) Activity Report The Board noted the report on the Chair and NED's activity.

16/79.5 Confirmed Board Committee Minutes The Board noted and received the confirmed minutes of the Finance & Performance Committee held on 26 May 2016.

16/80 ANY OTHER BUSINESS

Junior Doctors Strike The Board noted that junior doctors vetoed the new contract. The Trust has no news about whether or not they will be further strikes but the contract will be implemented regardless.

16/81 DATE OF NEXT MEETING

Friday, 09 September 2016, 09:30, Dulwich Room, Hambeldon Wing

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Action Status as at: 09/09/2016 1

BOARD OF DIRECTORS (PUBLIC MEETING) ACTION TRACKER

Date Item Action Who Due Update COMPLETED

06/04/2016 16/34 Chief Executive's Report - It was agreed that the Trust would start to promote its Orthopaedics outcomes and the merits of the Trust hosting one of the centres in the interim.

NM 09/09/2016

06/04/2016 16/34 Chief Executive's Report - It was also agreed that FB, BK and JF would have a side meeting about hitting the 50% response to complaints.

JF/BK/FB 09/09/2016

NOT DUE 06/07/2016 16/77 PwC Governance Review - The Board noted the progress

on implementing the actions from the PwC Governance Review and it was agreed that the revised management governance structure would be circulated.

NM 05/10/2016 In private session but will be made public in October

06/07/2016 16/72.2 Quarterly Patient Safety Report - The following was agreed: 1) The Board would receive an update on structural issues

at the PRUH and the correlation to infection control issues; and

2) The Board would receive periodic updates on basic hand hygiene metrics.

JW/PT

05/10/2016

02/02/2016 16/8.2 Adult Safeguarding Report - It was agreed that the Trust would look at DoLs benchmarking data across the Shelford Group and get some qualitative data about the process being used elsewhere.

SD 05/10/2016

02/02/2016 16/8.3 Children Safeguarding Report - It was agreed that a progress report on the safeguarding training and the implementation of the new system would be presented to the Board in 6 months.

DB/SD 05/10/2016

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Date Item Action Who Due Update 06/04/2016 16/33.2 Quarterly Patient Safety Report – The following was

agreed:

1) The Board noted that whilst it is reassured people are not getting complacent and use to the current level of never events the Trust should test out its current position against other hospitals and garner any learning;

2) The Board also noted and endorsed the commitment from management to improve the position by quarter 3/4.

JW/NM 02/11/2016

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Report to: Board of Directors

Date of meeting: 09 September 2016

Subject: Patient Outcomes Report, 2016-17 Quarter 1

Author(s): Claire Palmer, Head of Patient Outcomes

Presented by: Prof. Julia Wendon, Patient Outcomes Committee Chair

Sponsor: Prof. Julia Wendon, Medical Director

History: Previously considered by Patient Outcomes Committee and Quality

& Governance Committee

Status: For Information

1. Summary of Report Patient outcomes are defined as ‘the results people care about most when seeking treatment, including longer life, symptom relief, quicker recovery and the ability to live normal, productive lives.’ Ensuring outcomes as good as the best in the NHS and globally is identified as one of the Trusts ‘BEST’ goals and is a key measure of Trust performance. This report includes Trust performance in relation to:

The Trust’s identified Quality Priorities for patient outcomes. King’s key patient outcomes indicators. National clinical audits and registries. Patient outcomes CQUINs. Governance indicators for patient outcomes.

2. Action required The Board is asked to note the Quarter 1 performance against the indicators provided.

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3. Key implications

Legal: Delivering good patient outcomes reduces risk of litigation.

Financial: • Contractual requirement to participate in the National Clinical Audit & Patient Outcomes Programme and the four Patient Reported Outcomes Measures (PROMs). Participation costs KCH approximately £25,000 pa.

• Commissioning increasingly outcomes-based. • Commissioners require compliance with NICE guidance. • Best Practice Tariffs associated with performance in an increasing

number of national clinical audits. • Cost implications in relation to implementation of NICE guidance –

NICE recommendations take into account cost-effectiveness across the system but can incur costs for acute care.

Assurance: • Assurance provided for: Trust Board, CQC, Monitor, commissioners. • Assurance provided by: external data including CQC Outliers

Programme, national clinical audit programme, Hospital Episode Statistics provided through Healthcare Evaluation Data (HED); internal data including that analysed for investigation reports, mortality monitoring, Trust Patient Outcomes Quality Priorities, CQUINs, NICE implementation, clinical governance.

Clinical: Patient outcomes and clinical quality indicators reviewed and improvement actions monitored.

Equality & Diversity:

Outcomes data will be provided for different population groups, where available, to provide assurance and/or identify opportunities for improvement in relation to health inequalities.

Performance: Performance information provided for Summary Hospital-level Mortality Index (SHMI), Trust patient outcomes indicators, national clinical audits.

Strategy: King’s Strategy 2016 goal to achieve ‘outcomes as good as the best in the NHS and globally.’

Workforce: None in this report.

Estates: None in this report.

Reputation: Risk and opportunity – results contribute to CQC rating and many are publically available e.g. Consultant Outcomes Programme and national audit results.

Other: None in this report.

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4. Key messages of this report New outcomes indicators in development:

Ensuring that the Trust’s outcomes are as good as the best in the NHS and globally is one of the recently-defined BEST goals (King’s Strategy 2016).

The Patient Outcomes Committee and its feeder committees are working to develop a comprehensive set of patient outcomes indicators to provide the Trust with a dataset that enables measurement of performance against this goal.

To facilitate rapid review of this increased quantity of data, a scorecard format has been developed. King’s performance against the indicators is provided and colour-coded against expected or peer performance. The default peer group has been set as the Shelford Group1.

Versions of these indicators are also in development at Divisional level, and reviewed and discussed with Divisional leads in the Patient Outcomes Committee’s Improvement Sub Group.

Performance this Quarter:

Indicators rated green (positive analysis): 73

Including all mortality indicators.

Indictors rated yellow (neutral analysis): 15

Indicators rated red (negative analysis): 5

Issues identified this Quarter:

1. Relative risk of readmissions for patients aged 75+ is higher than expected (3 red indicators). This is a new indicator and Clinical Effectiveness Committee has initiated a review to understand the reasons behind this result.

2. Key diabetes indicators (2 red indicators) – ‘Severe hypoglycaemic episode’ and ‘Management errors’ are significantly worse than national average at PRUH. The inpatient team at PRUH have made considerable effort to date to improve standards including:

Introduction of site-wide training in diabetes management and safe prescribing – junior doctor training on induction and during the year on safe insulin prescribing, a study day for all staff, training for midwives, ongoing registered nurse update sessions, acute care course for senior nursing staff, targeted sessions on identified wards e.g. orthopaedics, HASU.

Enhanced specialist input – appointment of a consultant (Dr Cheah) to enable three consultant-led inpatient diabetes ward rounds, including review of diabetic foot inpatients and liaison with Denmark Hill foot team, daily diabetes specialist nurse-led ward rounds on the emergency admissions unit, regular review of patients in ambulatory care to prevent hospital admissions and ‘virtual ward rounds’ for inpatients at Orpington.

Enhanced pharmacy support for diabetes – a prescribing pharmacists trained and specialising in diabetes medication, two training sessions in the pharmacy department.

Adaption of Denmark Hill protocols and associated paperwork – introduction of Denmark Hill Diabetic Keto Acidosis (DKA)/Hyperosmolar Hyperglycaemic State (HHS) protocol at PRUH, piloting of adapted variable rate intravenous insulin infusion (VRIII) prescription at PRUH, introduction of steroid-induced hyperglycaemia guidelines for haematology patients at PRUH.

Further developments are in the planning stage, including recruitment of a diabetes specialist nurse for pregnancy services, further work on improving safety

1 The Shelford Group comprises ten leading NHS multi‐specialty academic healthcare organisations: University College London, Sheffield Teaching Hospitals, Oxford University Hospitals, Newcastle‐Upon‐Tyne Hospitals, King’s College Hospital, Imperial College Healthcare, Guy’s and St Thomas’, Central Manchester University Hospitals and Cambridge University Hospitals.

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in insulin prescription, increased use of the simulation centre for training and a ‘Putting Feet First’ campaign to ensure compliance with the NICE standards on foot care.

The national audit will enable continued monitoring and feedback of information on quality of care, with the next round of the audit due in September 2016.

3. Data returns for National Percutaneous Coronary Interventions (PCI) Audit published April 2016 - only 60% cases were submitted to the audit in 2014, which affects the reliability of the audit results. Clinical Effectiveness Committee has received assurance that data submission issues have now been resolved, and is awaiting the announcement of the publication date for 2015 data.

Progress on actions will be reported back in future Patient Outcomes Reports.

Areas identified for improvement in previous Reports:

Dementia screening targets at PRUH fell in performance to 61% of patients screened and fully assessed for dementia (Jan and Feb 2016 data, reported in Patient Outcomes Report Q4, 2015-16), when the CQUIN funding for 1 wte nurse ended. There is currently only 1 WTE Dementia Nurse in post at the PRUH to screen all patients.

A business case is in development for an additional nurse. In the meantime, help has been sought from DH to cover the workload. In the longer term there is potential for EPR to facilitate data collection and analysis, once roll out has been completed on PRUH site.

Quality governance

1. Trust Quality Priorities for patient outcomes – Enhanced Recovery after Surgery, Emergency Laparotomy – project initiation completed.

2. NICE guidance, national clinical audits, mortality reviews – no issues for escalation.

3. Patient Outcomes Committee and its sub groups – no issues for escalation.

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5. Trust quality priorities – patient outcomes 5.1 Enhanced recovery after surgery Objective: To improve outcomes following surgery by ensuring that all interventions clinically proven to have a positive impact are provided, and working well, in our hospitals. Measurable outcomes deliverables:

Reduced length of stay. No increase in emergency readmission rate. Increased day-of-surgery admission.

Actions required: Enhanced recovery involves the whole pathway of care, before admission to after discharge. NHS Improving Quality has outlined the steps involved in the pathway. KCH actions will be to ensure the relevant steps have all been undertaken at KCH hospitals. In addition, KCH will review the discharge information provided to patients. Scope: Initially work will build on actions already taken in colorectal, orthopaedic and hepatobiliary surgery. The project will include all KCH hospital sites, at Denmark Hill and in Bromley. Actions to date:

Steering Group established, clinical lead appointed – Dr Tim Hughes, Clinical Lead for Perioperative Medicine.

Review of current ERAS programmes at KCH completed. Draft outcomes report produced. Integrated with Transformation Programme and now awaiting Transformation Programme

project initiation. 5.2 Emergency laparotomy Objective: To improve outcomes following emergency abdominal surgery by ensuring a well-coordinated, standardised care pathway is in place at Denmark Hill and PRUH. Measurable outcomes (including proxy outcomes) deliverables:

Improvement in key National Emergency Laparotomy Audit (NELA) criteria, including: Consultant surgeon review within 12 hours of admission. CT reported before surgery by a Consultant Radiologist. Documentation of risk preoperatively. Preoperative review by consultant surgeon and consultant anaesthetists. Consultant surgeon and consultant anaesthetist present in theatre. Postoperative assessment by care of the elderly specialist in patients aged over 70. Reduced length of stay. Reduced mortality.

Actions required: Key actions include developing internal outcomes monitoring, improving data entry to the NELA project and taking local action to improve against the key audit criteria. Scope: Emergency laparotomy surgery at both relevant hospital sites – Denmark Hill and PRUH. Actions to date:

Steering Group established, clinical lead appointed – Mr Duncan Bew, Consultant Trauma and General Surgeon

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Review of National Emergency Laparotomy Audit (NELA) data 2015 completed and key actions implemented, including:

o Improvements in completeness of data entered into national audit, including surgical registrar support at PRUH.

o Integration into Morbidity & Mortality meetings, DH & PRUH – including junior doctor involvement.

2016 NELA report due to be published June 2016 – further actions will be planned in response.

6. Performance against King’s key patient outcomes indicators

6.1 Quarterly indicators

As described in the Summary, the range of Trust outcomes indicators is being expanded and a new scorecard format has been developed to facilitate rapid review of this complex information.

Data to enable measurement of patient outcome is retrieved from the national Hospital Episode Statistics via the HED system, national clinical audits and national registries and, where data is available, brought together under the outcomes categories identified by Michael Porter2 from the Harvard Business School:

Survival / mortality

Degree of health / recovery

Time to recovery and return to normal activities

Disutility of the care process

Sustainability of health/recovery & nature of recurrences

Long-term consequences of therapy, e.g. care-induced illnesses. The Summary Hospital Mortality Indicator (SHMI) continues to be reported and more detailed breakdown is now included of weekend admissions, admission method, deprivation, gender and age 75+, to support the national and local priority of tackling health inequalities. Breakdown by ethnicity is planned following IT system developments. New indicators are provided for the Hospital Standardised Mortality Ratio (HSMR), which includes in-hospital deaths only, and risk-adjusted readmissions (adjusted for age, diagnosis and comorbidities) as well as outcomes data from two national audits (major trauma and stroke).

Outcomes Category

Specialty

Indicator Site see Key3

(95% Confidence Intervals)

Peer average

Period

Source

Comment

KCH DH PRUH


Trust SHMI4 86.6 (83.5, 89.8)

83.0 (78.6, 87.5)

90.7 (86.31, 95.2)

88.6

Feb-15 – Jan-16

HED SHMI Monthly

Peer = Shelford Group5

SHMI – national position

10th (top

7th (top

19th (top

- Of all 136

2 Porter ME. What is value in health care? N Engl J Med 2010; 363:2477‐81

3 Green = upper confidence limit < 100; Amber = upper confidence limit >100; Red = lower confidence limit >100. 4 Summary Hospital‐level Mortality Indicator (SHMI) is a hospital‐level indicator produced by NHS Digital (aka HSCIC) and is a ratio of observed number of hospital deaths to the expected number of hospital deaths, and includes deaths up to 30 days following discharge. SHMI includes all patients, including palliative care. 5 Average across Shelford Group, which includes: University College London, Sheffield Teaching Hospitals, Oxford University Hospitals, Newcastle‐Upon‐Tyne Hospitals, King’s College Hospital, Imperial College Healthcare, Guy’s and St Thomas’, Central Manchester University Hospitals and Cambridge University Hospitals.

7

Outcomes Category

Specialty



Peer average

Period

Source

Comment

KCH DH PRUH

decile) decile) quintile) English Trusts

HSMR6 – national position

6th (top

decile)

3rd (top

decile)

14th (top

decile)

Mar 15 – Feb-16

HED HSMR

SHMI – weekend admissions

89.9 (83.5, 96.7)

87.8 (83.5, 96.7)

92.3 (83.4, 101.8)

94.2

Feb-15 – Jan-16

HED SHMI Monthly

Peer = Shelford Group

SHMI – elective : non-elective

98.6 : 97.8

98.7 : 97.9

98.6 : 97.8

97.3 : 88.6

SHMI – deprivation quintiles

Q1 – most deprived

83.8 82.9 88.0 93.0 Oct 14 – Sep 15

HED SHMI Quarterly

Q5 – most affluent

89.1 90.2 89.3 90.9

SHMI – gender

Female : Male

84.6 : 88.4

84.2 : 82.0

85.7 : 95.9

87.2 : 89.8

Feb-15 – Jan-16

HED SHMI Monthly

SHMI – age 75+ 85.6 71.8 89.6 87.0

Major Trauma

Rate of survival: additional survivors out of every 100 patients

- 0.8 (0.07, 1.5)

2.9 (-0.2, 5.9)

St George’

s: 0 (-0.7,

0.7) Royal

London: -1.6 (-2.2, -0.92)

St Mary’s: 0.5 (-

2.8, 1.2)

01/01/12 – 31/12/15

TARN7

, Apr-16

Sustain-ability of health

Trust Relative Risk of Readmission (RRR)8

93.7 (94.0, 97.5)

94.6 (92.4, 96.9)

97.8 (95.1, 100.5)

101.3 (100.7, 101.9)

Feb-15 – Jan-16

HED RRR

Peer = Shelford Group

RRR – gender

Female : Male

98.4 : 93.1

95.3 : 94

102.8 : 92.2

102.4 : 100.2

6 Hospital Standardised Mortality Ratio (HSMR) is a ratio of the observed number of in‐hospital deaths to the expected number of in‐hospital deaths (multiplied by 100) for 56 diagnosis groups. It includes 80% of hospital deaths. 7 Trauma Audit & Research Network Online Survival Data 8 Relative Risk Readmission – is the relative risk of 30 day readmissions, that is the ratio (multiplied by 100) of observed number of emergency readmissions to the expected number of 30 day readmissions. It includes readmission to any other English hospital.

8

Outcomes Category

Specialty



Peer average

Period

Source

Comment

KCH DH PRUH

RRR age 75+ 108.4 (105.2, 111.6)

107.2 (102.3, 112.2)

109.8 (105.1, 114.0)

Stroke Hyper-Acute Stroke Unit (HASU) – SSNAP9 level

- 81.7 81.7 72.8 peer10

average

Oct-Dec 15

SSNAP

DH & PRUH joint 2nd best performance compared to peers

Stroke Unit (SU) – SSNAP level

- 83.7 70.8 79.9 peer11

average

DH 3rd;

PRUH 9th compared to peers

Issue/s identified:

Risk-adjusted readmissions in patients aged over 75 – this is the first time this analysis has been undertaken and the responses behind the ‘red’ results are not yet understood. An investigation has been initiated by the Clinical Effectiveness Committee.

9 Stroke Sentinel National Audit Programme.

10 Queens Hospital Romford, Royal London Hospital, Charing Cross Hospital, Northwick Park Hospital, St George’s Hospital, University College Hospital, Queen Elizabeth Hospital (Birmingham), Addenbrooke’s Hospital (Cambridge), Leeds General Infirmary, Royal Victoria Infirmary (Newcastle). 11 Queens Hospital Romford, Royal London Hospital (Bart’s), St Thomas’ Hospital, Charing Cross Hospital (Imperial), Royal Free Hospital, Northwick Park Hospital, St George’s Hospital.

9

6.2 Indicators reported annually, or at another frequency When all Trust sites are taken into account, King’s participates in nearly 100 national audit projects, registries and confidential enquiries. Results are reported in a wide variety of formats and at different frequencies and this makes comparative analysis challenging. For example, the Trust can perform poorly against one or two key indicators within a national audit but perform well overall, as can be seen this Quarter in the National Audit of Inpatient Diabetes. Conversely, performance might be poor against key process indicators whilst patient outcomes remain good. To support the Trust in the identification of potential issues, and to ensure continuous improvement of clinical quality, the Clinical Effectiveness Committee is working to identify key Trust patient outcomes indicators and standardise the approach to reporting. The following performance against key outcomes indicators has been identified by Clinical Effectiveness Committee over the past Quarter:

Outcomes Category

Specialty

Indicator Site Expected/ National / Peer average

Period Source Comment

DH PRUH


Cardiology

Mortality – Percutaneous Coronary Intervention (PCI) - %

2.5% Within expected range.

01/01/14 – 01/12/14

National Audit of PCI (Apr 2016)

Peer results not available.

Degree of health/ recovery

Cardiology

Overall PCI success (%)

88.8 Within expected range.

01/01/14 – 01/12/14


Peer results not available.

Diabetes

‘Good Diabetes Days’ – out of 7 days

4.8 4.6 4.512 21/09/15 – 25/09/15

National Diabetes Inpatient Audit (Mar 16)

Action plan in development

Severe hypoglycaemic episode (<3mmol/L) - %

8.5 18.2 9.9 21/09/15 – 25/09/15

Diabetes / maternity

Women with diabetes – babies born ≥4kg - %

7 1413 01/01/2014 – 31/12/2014

National Pregnancy in Diabetes Audit (Nov 15)

Sustainability of health

Diabetes / maternity

Women with diabetes – preparedness for pregnancy (5mg folic acid +

Type 1 18

12 01/01/2014 – 31/12/2014

National Pregnancy in Diabetes Audit (Nov 15)

Type 2 15 13

12 England average 13 England & Wales average

10

Outcomes Category

Specialty

Indicator Site Expected/ National / Peer average


DH PRUH

HbA1c < 48 mmol/mol) - %

Women with diabetes – live birth (pregnancy continuing at 24 weeks)

100 99

Key evidence-based process measures

Cardiology

Patients receiving primary PCI within 90 minutes of arrival at the PCI hospital (%)

≥ 90%

National target: 90%

01/01/14 – 01/12/14


Diabetes

Management errors - %

23.9 51.0 23.0 21/09/15 – 25/09/15

National Diabetes Inpatient Audit (Mar 16)

Action plan in development

Issue/s identified: Two key indicators have been highlighted as requiring improvement relating to the care of patients with diabetes at the PRUH. A detailed investigation and action plan is currently being developed, led by Dr David Hopkins, Clinical Director.

7. Performance in national clinical audits

Key: Positive analysis: Outcome measures better than or within expected range; underperformance

against <50% process targets with no demonstrable impact on patient outcome. Neutral analysis: Outcome measures within expected range; underperformance against >50%

process targets with no demonstrable impact on patient outcome. Negative analysis: Outcome measures outside (below) expected range - negative

outlier; underperformance against significant key process targets. Not applicable: Service not provided at this location. Methodological issue: Issues with the study’s methods that prevent a rating, e.g. sample too small,

sample not representative, results do not provide a measure of performance. Division

- Specialty/i

es

Indicator Source Participation

Clinical Effectivene

ss Committee

Rating

Improvement plan in place

Comment

DH PRUH

Ambulatory Care & Local Networks

National Diabetes Inpatient Audit

Healthcare Quality Improvement

Sample size: DH: 137; PRUH: 67

In developm

ent

Positive analysis: • DH performed

in line with or

11

Division -

Specialty/ies



ss Committee

Rating


Comment

DH PRUH

- Diabetes

(NaDIA) Published Mar-16

Partnership (HQIP), Diabetes UK, Public Health England

Patient Group: Diabetic patients admitted to a hospital bed for 24 hours or more Period: 21/09/15 – 25/09/15

better than national average for most of the indicators. PRUH performed in line with national average for key indicator ‘good diabetes days’.

Negative analysis: • PRUH did not

perform in line with the national average for key indicators ‘management errors’ and ‘severe hypoglycaemic episode’ – but no evidence of impact on patient outcome.

Ambulatory Care & Local Networks - Palliative Care

National End of Life Care Audit – Dying in Hospital Published Mar-16

Royal College of Physicians, Marie Curie and HQIP

Sample size: 85 (100%), DH and PRUH combined Patient Group: All adult deaths (aged 18 years or older) where each patient had been under the care of the trust for a minimum of 4 hours.

In development

Positive analysis: • KCH performed

above national average across 5/5 key end of life quality indicators.

• KCH achieved 5/8 of the quality indicators in the organisational audit.

12

Division -

Specialty/ies



ss Committee

Rating


Comment

DH PRUH

Period: 01/05/2015 – 31/05/2015 (clinical audit) and data entry period for the organisational audit was between 06/07/15 to 31/07/15

Network Services - Stroke Trauma Emergency and Acute Medicine - Therapies

Sentinel Stroke National Audit Programme (SSNAP) Published Mar-16

Royal College of Physicians

Sample Size: DH: 90+% (227 patients) PRUH: 90+% (215 patients) Patient Group: Patients admitted with a stroke (or having stroke onset as an inpatient) and/ or discharged from hospital during the sample time period Period: 01/10/15 – 31/12/16

HASU

SU

HASU

SU

Integrated into ongoing specialty governance and improvement work.

Positive analysis: • DH and PRUH

Hyper Acute Stroke Unit (HASU) both scored A ratings and 2nd highest overall SSNAP score compared to national peers.

Ambulatory Care &

National Pregnancy

Diabetes UK and

Sample size: 56

Yes Positive analysis:

13

Division -

Specialty/ies



ss Committee

Rating


Comment

DH PRUH

Local Networks - Diabetes Women’s & Children’s - Maternity

in Diabetes Audit Published Nov-15

Health and Social Care Information Centre (HSCIC)

(100%), DH; PRUH not applicable – service provided by Bromley Healthcare. Patient Group: All women with diabetes who had pregnancies ended between 1st Jan-14 -31 Dec-14. Period: 01/01/14 – 31/12/14

• KCH performed in line with London and national averages across most of the standards.

• 20% of women were taking the recommended 5mg folic acid (national 13%)

• 20% of women had a first trimester HbA1C<48mmol/mol (national 13%)

• Proportion of macrosomia babies, 4000g and over has reduced from 8% in 2013 to 7% in 2014 (national 14%).

Neutral analysis: • KCH has a

15% (n=56) miscarriage rate (national average 5%). This is influenced by better identification at KCH than other centres. KCH stillbirth rate is 0 (n=56) (national is 1%).

Network Services - Cardiology

National Audit of Percutaneous Coronary Interventional (PCI) Procedures

National Institute for Cardiovascular Outcomes Research and British

Sample size: 1542 procedures, DH; PRUH not applicable - service not


Positive analysis: • DH performed

better than expected for most indicators, including patients

14

Division -

Specialty/ies



ss Committee

Rating


Comment

DH PRUH

Published Apr-16

Cardiovascular Intervention Society.

provided. Patient Group: All patients undergoing a PCI procedure.Period: 01/01/14 – 01/12/14

receiving primary PCI within 90 minutes of arrival.

Negative analysis: • Only 60%

cases submitted to the audit. Blue rating given due to insufficient data to rate performance.

Network Services - Cardiology

Congenital Heart Disease Published Apr-16

National Institute for Cardiovascular Outcomes Research (NICOR)

Sample site: DH: 11 cases; PRUH: Not applicable - Cardiology specialist service not provided. Audit Period: 01/04/14 – 31/03/15


Methodological issue: • Sample too

small to enable rating of performance.

Network Services - Neurosciences Trauma Emergency and Acute Medicine - Therapies

2015 UK Parkinson’s Audit Published: Apr-16 a) Elderly Care and neurology

Parkinson’s UK UK Parkinson’s Excellence Network

Sample Size: DH: 10 cases; PRUH 23 cases Patient Group: Patients referred from a GP with a diagnosis of Parkinson’s Disease Period: 2015

In developm

ent



15

Division -

Specialty/ies



ss Committee

Rating


Comment

DH PRUH

b) Occupational Therapy

Sample Size: KCH: 10 cases Period: 30/04/15 to 30/09/15

In developm

ent

Positive analysis: • Good

compliance with NICE Guideline CG35: Parkinson’s disease in over 20s: diagnosis and management and adherence to national standards for occupational therapy and physiotherapy.



c) Physiotherapy

Sample Size: KCH: 13 cases Period: 30/04/15 to 30/09/15

In developm

ent

d) Speech & Language Therapy

Sample Size: KCH: 63

Integrated into ongoing specialty governance and improvement.

Positive analysis: • Excellent

compliance with NICE Guideline CG35.

Trauma Emergency and Acute Medicine - Major Trauma

The Trauma Audit and Research Network (TARN) Online Survival Data Published Apr-16

The Trauma and Audit research Network (TARN)

Sample Size: DH 912; PRUH: 102 Patient Group: All trauma patients irrespective of age who meet specific length of stay criteria and whose isolated

Integrated into ongoing specialty mortality monitoring, governance and improvement work.

Positive analysis: • The TARN data

demonstrates that more trauma patients admitted to DH and PRUH are surviving compared to the number expected based on the severity of their injury.

16

Division -

Specialty/ies



ss Committee

Rating


Comment

DH PRUH

injuries meet specific criteria. Period: 30/04/15 to 30/09/15

Trauma Emergency and Acute Medicine - Major Trauma


TARN Clinical Report Clinical Report I: Core Measures - thoracic and abdominal injuries, patients in shock Published Apr-16


Sample Size: 2082; DH: 1952; PRUH: 130 Patient Group: All trauma patients irrespective of age who meet specific length of stay criteria and whose isolated injuries meet specific criteria. Period: 01/04/14 to 30/12/15

Integrated into ongoing specialty mortality monitoring, governance and improvement work.

Positive analysis: • The TARN data

demonstrates that DH and PRUH are within the expected range.

Liver, Renal & Surgery - Renal

UK Renal Registry (UKRR) Published Dec-15 & Apr-16

Renal Association

Sample size: 148 patients, DH and PRUH Patient Group: All patients starting Renal Replacement Therapy (RRT). Period:

In developm

ent

Positive analysis: • KCH one-year-

after-90-day incident survival (adjusted to age 60) from the start of renal replacement therapy is similar to the national average (KCH

17

Division -

Specialty/ies



ss Committee

Rating


Comment

DH PRUH

01/01/14 – 31/12/14

90.0%, national average 91.8%), even though King’s has the 2nd highest rate in England of patients starting on renal replacement therapy who have diabetes, and the highest in London, at 39.2%.

Women’s & Children’s - Child health - Neonatology

National Neonatal Audit Programme (NNAP)

Published: Dec-15

Royal College of Paediatrics and Child Health (RCPCH)

Sample size: 498, DH; 255 PRUH Patient Group: All episodes of neonatal care. Period: 01/01/14 – 31/12/14

In developm

ent

Positive analysis: • DH

performance is above the national average for 5/5 criteria audited.

• PRUH is above the national average for 3/5 audit criteria and has shown improvements in 2/5 audit criteria compared to the previous performance.

Ambulatory Care and Local Networks - Diabetes

National Diabetes Audit (NDA) Published Jan-16

Diabetes UK & Health and Social Care Information Centre

Sample size: 5323 DH; PRUH not applicable as no specialist diabetes service., Patient Group: All patients diagnosed with

Yes Methodological issue: • The results

combine both acute and primary care in the denominator. KCH performance not separately identified.

18

Division -

Specialty/ies



ss Committee

Rating


Comment

DH PRUH

diabetes during the audit period Period: 01/01/2013 - 31/03/15

Liver, Renal & Surgery - Surgery

National Bariatric Surgery Registry – Surgeon Specific Outcomes Published Feb-16

Clinical Outcomes Publication Programme National Bariatric Surgery Registry

Sample size: 419, DH; 519 PRUH Period: Apr-12 to Mar-15

Not required

Positive analysis: • Surgeon-

specific outcomes are within expected range across DH and PRUH.

Issue/s identified: Data returns for National Percutaneous Coronary Interventions (PCI) Audit published April 2016 - only 60% cases were submitted to the audit in 2014, which affects the reliability of the audit results. Clinical Effectiveness Committee has received assurance that data submission issues have now been resolved, and is awaiting the announcement of the publication date for 2015 data.

19

8. Performance in Commissioning for Quality and Innovation (CQUINs) – patient outcomes Patient Outcomes Committee will provide oversight for the following 2016-17 CQUINs indicators:

Health Promoting Hospital – screening and advice to patients and staff for smoking, alcohol and physical activity; Denmark Hill and PRUH.

Integrated Care – improving the frailty pathway; PRUH. Hepatitis C – improving the pathway; Denmark Hill and PRUH. Haemoglobinopathy – improving care in sickle cell disease; Denmark Hill and PRUH.

Performance will be reported in subsequent Patient Outcomes Reports.

9. Performance against key patient outcomes governance indicators The new format has been applied to the governance indicators. Peer performance is not available as this information is not collected nationally.

Key governance Indicators

Site see Key14



KCH DH PRUH

National clinical audits and confidential enquiries - participation

100% (89/89)

100% (47/47)

100% (42/42)

2016-17

Audit providers

Required by NHS Standard Contract and KCH Clinical Effectiveness Committee

National clinical audits and confidential enquiry reports - improvement actions in place

56% (25/44)

52% (23/35)

61% (21/34)

Clinical leads

Mandatory15 NICE guidance – all implementation actions completed

100% (307/307)

100% (307/3

07)

100% (307/30

7)

Non-mandatory NICE guidance – all implementation actions completed

74% (586/791)

77% (611/7

91)

79% (628/79

1)

Local clinical guidelines within review date

54% (539/997)

n/a n/a King’s Clinical Guidelines System

New clinical procedures - outcomes feedback reported to NCPC 16

95% (157/166)

95% (157/1

66)

n/a – no applicati

ons

Aug 2008 – Jun 2016

NCPC papers

Specialty mortality review reported at Mortality Monitoring Committee

94% (32/34)

95% (18/19)

93% (14/15)

12 months to Jun-16

MMC papers

Ambulatory Care and Local Networks (ACLN) mortality not reviewed –

14 Green = upper confidence limit < 100; Amber = upper confidence limit >100; Red = lower confidence limit >100. 15 Includes Technology Appraisals and Highly Specialised Technologies 16 New Clinical Procedures Committee. NB. This does not represent all applications to the committee, just those procedures that have been approved for use at KCH.

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22

2

1



Subject: Summary Record of Quality & Governance Committee Meeting

Presented by: Prof Ghulam Mufti, Non-Executive Director & Committee Chair


Introduction This report provides the Board of Directors with a summary of all the key issues considered by the Quality & Governance Committee at its meeting on 26 July 2016.

Deep Dive: Quality Priority – Safer Surgery The Committee conducted a deep dive into safer surgery and the Trust’s plans to minimise the risk of such errors. The following key points were noted: There has been an increase in ‘never events’ since 2014; Analysis shows that more ‘never events’ occur outside of the traditional theatre environment; Evidence shows that the number of incidents increases when there are changes of procedures; The Trust is establishing an overarching safer surgery policy which encompasses all of the

separate policies on safer surgery and invasive procedures outside of the traditional theatre setting. This policy will be used to engage with the organisation; and

Training programmes will be refreshed and methods for accessing relevant documentation and capture data will be improved.

Deep Dive: CPE Prevalence The Committee conducted a deep dive into the prevalence of carbapenemase-producing enterobacteriaceae (CPE) at the Trust. The following key points were noted: Carbapenem-resistant infections are resistant to most types of antibiotic; Since it was first detected in 2003 the spread of CPE internationally has been rapid; Trust data shows a large increase in the number of CPE cases in 2015-16 compared to 2014-15;

Recently there has been a rise in some previously much rarer CPE genes such as CPE Imp; and

Action taken by the Trust includes weekly universal screening in vulnerable areas. Caldicott Guardian Report The Committee received the Caldicott Guardian Report. The following key points were noted: Under the Information Governance Toolkit the Trust’s overall score was 74% across a range of

information management and assurance measures. This is average for major trusts;

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Although small, confidentiality breaches represented a higher proportion of adverse incidents than expected in 2015. The position is however stable;

There have been a number of incidents in 2015-16 which have been reported to the Information

Commissioner’s Office but no action was taken against the Trust; and The Trust is minded of the governance challenges which may arise as a result of the expansion of

the Local Care Record scheme to include local primary care staff and potentially social care and community pharmacy staff. The Trust will continue to work with partners to ensure security of patient information.

CQC Action Plan Update The Committee received the progress update on the Trust’s Care Quality Care (CQC) Action Plan. The following key points were noted: The Trust has been working hard to implement and complete the items on its action plan. Between

September 2015 and June 2016 40% of ‘requirement notices’ and 47% of ‘should do’ actions were completed;

The governance structure and accountability arrangements have been strengthened. The CQC Steering Group was relaunched as the CQC Board with revised membership and terms of reference to enable effective monitoring of the action plan. The action plan is now aligned to the new divisional structure;

The Trust engaged KPMG to conduct a mock CQC inspection. The Trust accordingly refreshed its CQC action plan incorporating the KPMG recommendations. The risks in delivering the action plan were noted; and

There will be a 7-week rolling Back-to-Basics programme to address concerns over meeting the basic standard of care.

Quarterly Patient Outcomes Report The Committee received the Quarterly Patient Outcomes Report for quarter 1 of 2016-17. The following key points were noted: The risk of readmission for patients over 75 is higher than expected and further analysis is

required on the discharge process;

The Princess Royal University Hospital (PRUH) performed below average for the key indicators ‘management errors’ and ‘severe hypoglycaemic episodes’, however there was no evidence of negative impact on patient outcomes;

Performance against dementia targets at the PRUH decreased, with 61% of at-risk patients being screened and fully assessed for dementia;

The quality priority ‘enhanced recovery after surgery’ is being integrated into the Trust’s Transformation Programme;

The Trust has performed well against stroke targets;

Analyses from clinical audits have been mostly positive; and The Trust is compliant with Commissioning for Quality and Innovation indicators for patient

outcomes

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Nursing Performance Report & Nurse Revalidation The Committee received the Nursing Performance and Nurse Revalidation Report. The following key points were noted: Recent guidance from the National Quality Board set out a series of suggested metrics to ensure

safe nurse staffing levels;

In addition, a Care Hours Per Patient Day (CHPPD) requirement has been introduced to assist in the planning of qualified to unqualified nurse staffing;

There is a 14% vacancy rate at the Denmark Hill (DH) and PRUH sites for nurses between bands 2 and 7. The Trust has been deploying a number of different recruitment methods to reduce this number;

Scrutiny of agency staff levels continues;

E-Rostering remains a challenge but work continues to improve on related key performance indicators; and

To date 194 nursing staff have revalidated.

Infection Control Annual Report The Committee received the Infection Prevention and Control Annual Report 2015-16. The following key points were noted: There were a number of norovirus and MRSA incidents during the reporting period; Of the seven MRSA bacteraemias reported, four were Trust-apportioned;

There has been an increase in the number of CPE cases; There were 82 Trust-apportioned cases of Clostridium difficile against a trajectory of 72;

The Trust’s capacity and infrastructural constraints have attributed to the challenges with infection

control; and

An annual work plan has been devised to help prevent and manage infection.

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Report To: Board of Directors Date of Meeting: 09 September 2016 By: Nick Moberly, Chief Executive Officer Presented By: Nick Moberly, Chief Executive Officer Subject: Chief Executive’s Board Report OVERVIEW As at Month 4, the Trust is making good progress in driving forward its “King’s Way” transformation approach. We are on track to implement our new organisation structure during November, and making good progress on developing our “King’s Academy” training offer which includes the roll out of continuous improvement training. Progress on our front line Clinical Transformation Programme has been encouraging, and we have now successfully implemented our new Allscripts Sunrise EPR at Denmark Hill. Clinical performance remains generally strong. We continue to focus intensively on delivering the operational performance trajectories which were agreed at the start of the year; and whilst there is still a great deal to do to stabilise and improve operational performance there are some encouraging early indicators of progress. Finance is the key risk for the Trust at Month 4, with a significant variance emerging against our plan, mainly driven by shortfalls in activity-related income and CIP slippage relating to “flow through” schemes from last year. Stabilising and improving our financial position is a key priority, and we are developing a recovery plan for discussion with our regulators later this month. MISSION Integrated Care Integrated care remains a key area of focus across the whole NHS. Locally, work is continuing to develop in Lambeth and Southwark to develop the Local Care Networks as the vehicle for integrated care delivery in the 2 boroughs. In Bromley, work continues to focus on the development of 3 Integrated Care Networks. In parallel, the tender process for community services in the borough has been launched. King’s Health Partners/Institutes Work continues on the revisions to the Strategic Outline Cases for the Cardiovascular and Haematology Institutes, with the aim of being able to present these for Board approval by the end of Q3. Work is also progressing on the initial draft for the Institute for Diabetes, Endocrine and Obesity; and work on the Institute for Neurosciences will start in October. Pathology Following the successful transfer of pathology services at the PRUH to our Viapath Joint Venture, work is now underway to develop a future strategy for Viapath. We believe that Viapath is well placed to play a key role in the consolidation of pathology services that has been flagged as a national priority.

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Sustainability and Transformation Plans Feedback has been received from NHS England and NHS Improvement on the Sustainability and Transformation Plan for South East London. While there are a number of areas where further clarity is being sought, overall the STP is being viewed as one of the most robust in the country. A key priority is to fully scope and start developing robust delivery plans for the opportunity areas identified. The Committee In Common between the six South East London CCGs will consider a recommendation on the location of South East London’s two elective orthopaedic centres on the 2nd November, before moving to formal consultation. King’s will be notified beforehand on whether our bid will be recommended. BEST QUALITY OF CARE Outcomes The Patient Outcomes Committee is developing an expanded set of patient outcomes indicators and a scorecard format to facilitate rapid review of complex outcomes performance information. Performance is reported in the quarterly Patient Outcomes Report to Quality & Governance Committee and the Board. A priority is to identify outcomes indicators that support monitoring of health inequalities, and reporting now includes mortality breakdown by deprivation, gender and age 75+ and will shortly include breakdown by ethnicity. Pleasingly, the Trust continues to perform better than expected against all mortality indicators and better than peer (Shelford Group) average. Overall, Relative Risk of Readmission (RRR) is below expected and below peer. It was recently identified, however, that RRR is above expected in the over 75 age group, and this is now under investigation. There is continued good performance in Stroke; PRUH and DH Hyper-Acute Stroke Units were ranked joint 2nd compared to peer against national indicators (Oct-Dec 15). King’s performed poorly against 2 key national audit diabetes indicators at PRUH – ‘severe hypoglycaemic episode’ and ‘management errors’. A detailed improvement plan is in place including training, enhanced specialist input, enhanced pharmacy support and adaption of Denmark Hill protocols. KCH performed better than peer average for key indicators relating to pregnancy in women with diabetes. KCH performed within expected range for mortality and overall success of percutaneous coronary interventions (PCI), and above national target for patients receiving primary PCI within 90 minutes of arrival. KCH performance in the following national audits received positive analysis (outcome measures better than or within expected range): National Diabetes Inpatient Audit at DH, National End of Life Care Audit – Dying in Hospital, Sentinel Stroke National Audit Programme (SSNAP), National Pregnancy in Diabetes Audit, Trauma Audit and Research Network (TARN), UK Renal Registry, National Neonatal Audit Programme (NNAP), National Bariatric Surgery Registry – Surgeon Specific Outcomes. KCH performance in the National Emergency Laparotomy Audit (NELA) will be reported in detail next quarter. Overall performance appears to have improved but remains below target in key areas on both sites. A detailed investigation into mortality following emergency laparotomy is underway, to be completed by end September 16. A working group has been established to drive improvement, chaired by the Medical Director. Experience and access

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We continue to focus on customer care and respond to the feedback obtained ensuring the clinical areas are engaged with the process. Complaint response times remain a challenge and continue to be an area of active focus. We expect the new organisation structure, due to be implemented in November, will be helpful in enabling us to drive improvement in this area. The 2015 National Cancer Patient Experience survey showed good improvement in some areas which have been a focus in our improvement work, including ease of access to Clinical Nurse Specialists, how we involve patients in their care and patients feeling that there were sufficient nurses to care for them. However, there remain significant challenges to improve patient experience of cancer care and to align King’s with the best performing trusts nationally. King’s overall rating of care was 8.5 compared to a national average of 8.7 and with top performing trusts achieving a rating of 8.9. Existing action plans will be reviewed and further improvement plans put in place both service wide and for individual tumour groups. For quarter 2, performance for the Friends and Family Test was mixed. Inpatient satisfaction remains on a par with average recommendation rates for both London and nationally. However, satisfaction with our Emergency Departments continues on a downward trajectory with satisfaction rates some 10% below the average for both London and England. There was some improvement in maternity, though both maternity and outpatients are trending below the national average. The Trust’s performance against key access targets is described in the separate performance report. In brief:

Compliance against the 95% 4 hour waits target worsened slightly in Month 4 to 83.51%, which was below the Q2 STF trajectory of 88.11%. Performance has however improved during Month 5 and the early part of Month 6, with the Trust meeting or exceeding trajectory in a number of weeks

Compliance against the 92% RTT incompletes target was 82.03% in Month 4, in line with the Q2 STF trajectory of 82%. There were 154 patients waiting 52+ weeks at the end of June, compared with 137 in Month 3

Cancer targets were delivered with the exception of the 62 day referral to treatment and 62 day screening targets

Diagnostic waits continued to show substantial improvement – with 6+ week waiters down from 9.4% in Month 3 to 6.4% at the end of Month 4. Further progress has been made during Month 5 and the early part of Month 6, with 6+ week waits now standing at 1.7% (marginally behind the STF trajectory of achieving 1% by end of Month 5)

Safety There were no MRSA cases in Month 4 so we have reported a total of 2 MRSA cases YTD. 7 C Diff cases were reported in Month 4, giving a YTD total of 21 cases, which is below the Trust’s trajectory of 24 cases. There were 35 Serious Incidents (SIs) reported in Q1 (Apr-Jun 16) (down from 39 in Q4). In July 16 there were only 7 SIs reported which is below trajectory. One Never Event was reported in Q1 (feed administered through a misplaced Naso-Gastric Tube) – there have been no further Never Events reported as at the time of writing. The rate of incident reporting has not changed significantly in 2016 and continues at around approximately 2750 incidents per month (of which less than 0.5% involve significant harm). Care Quality Commission (CQC)

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The Trust has refreshed the governance process around the monitoring and implementation of the CQC action plan. The revised plan has been aligned with the new divisional structures and incorporates the actions related from the KPMG internal audit. A 7-week rolling programme to address concerns on meeting basic standards of care on wards – Back to Basics was commenced in early June. The results from the back to basics programmes are the responsibility of heads of nursing. EXCELLENT TEACHING & RESEARCH Research income Following a successful bid, King’s has been awarded £198K funding for an 18 month research project on mental health and erectile dysfunction via the Burdett Trust, working in partnership with the clinical psychology team and the KHP Mind & Body programme. This is the first ever funding we have received for a non-medical research project. Part of the income will be used to fund two fixed-term posts: a band 8a research nurse and a band 5 assistant clinical psychologist. SKILLED, “CAN DO” TEAMS Organisation restructure The design of the new leadership structures at Tiers 1 and 2 was finalised in early July and communicated to all senior leaders. Post-filling has commenced for the senior roles at Tier 1 of the new structures, with further interviews taking place during September and October. The formal consultation processes for individuals at Tier 2 who are affected by the new structures is currently in progress, with internal post-filling for these roles due to take place in late September. Regular communications will be sent out during this period to update staff on appointments as and when they are made. The aim is to transition to the new structure during November 2016. Talent Management and succession planning A session on the proposed approach for Talent Management and Succession Planning will take place with KE during September. Staff Engagement The Q3 Staff Friends & Family test closed on 3rd September. We now have 9 quarters worth of data which shows the trend in terms of staff recommendations of King’s as a place to work and be treated. The data shows that King’s tracks the national average as a place to be treated, but has consistently fallen below the national average in terms of a place to work since Q2 2015/16. It should be noted however that the average response rate is approx. 300 staff each quarter. In order to validate these results with a larger sample of staff, therefore, we will be conducting a full census of staff views via the annual Staff Survey. All staff will be invited to complete the survey, which will be open for an 8 –week period from early October to early December 2016. The majority of staff will receive the survey by email, and we will be tracking the number of responses by staff group, site and division during the response period. The results will be available to us in February/March 2017 and will enable us to establish a baseline of staff views that can be fed into our workforce strategy and transformation programme for 2017 onwards. King’s Academy and continuous improvement training

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The first cohort of 16 people to undertake the King’s Academy continuous improvement training will start their programme in September. The cohort will be drawn from the transformation team and leaders from Waves 1 and 2 of the clean sheet redesign process. The Green Belt training course and group mentoring sessions will cover topics such as problem solving, stakeholder influencing, continuous improvement, data analysis and presentation skills. It is anticipated that a number of this cohort will then progress to Blue Belt so that they can train, mentor and support others across the organisation. Equality, Diversity and Inclusion The Trust has recently submitted its 2016 Workforce Race Equality Standard (WRES) return and Improvement Plan to NHS England; this is also available on the Trust external website. The Education and Workforce Development Committee (EWDC) also received the annual Workforce Equality, Diversity and Inclusion report and although King’s does have some areas for further development, we have an extremely diverse workforce. The EWDC also approved the following two equality objectives for King’s on behalf of the Board:

• To fully implement the Workforce Race Equality Standard (WRES) during 2016 • To fully implement the Equality Delivery System 2 (EDS2)

Progress against these objectives will be monitored via the EWDC. Recruitment & Retention A Trust Recruitment Approach and Plan was presented to the Board on the 6th July. As planned there are large volumes of new employees joining the Trust in September, October and November Volumes of new starters were high in July with 179 new starters compared with 122 in July 2015. The number of leavers in July reduced slightly in July 2016 (153) compared with July 2015 (187). The Trust vacancy rate remained behind trajectory to reach 8% by 31 March 2017 but additional recruitment activity is underway. International recruitment campaigns will help supplement national recruitment. A campaign in India at the end of August 2016 has proved successful in identifying c.80 new nurses. The specific push on PRUH recruitment will see an extensive recruitment marketing launched in September. Work continues on improving the employment offer. The recently launched car leasing scheme has proved to be popular with 66 cars ordered since the July launch and 10 cars delivered. Roadshows highlighting the full range (cycle scheme, technology, cars, childcare) of salary sacrifice benefits roadshow were held in July. Retention initiatives are being developed as part of the three-year Workforce Strategy. TOP PRODUCTIVITY Our Clinical Transformation Programme, which was launched in June (Month 3), is making encouraging progress. There has been excellent clinical leadership and engagement across the programme. The first 3 “clean sheet redesign” work streams focusing on pre-assessment and theatres, bariatrics and emergency and acute medicine up to 72 hours, are nearing the end of their design stage, and are on track to deliver detailed implementation plans by the end of Month 6. Good progress has also been made on shaping and launching our “King’s Way For Wards” accreditation and continuous improvement initiative; and on designing and rolling out our continuous improvement training plans as part of the King’s Academy (referred to above). A second wave of clean sheet redesign work streams will launch towards the end of November, focusing on radiology, elective orthopaedics and HPB cancer. The new Allscripts Sunrise EPR is now live at Denmark Hill; and we are planning to implement the system on our other sites in the first half of 2017. We are also developing a roadmap for the implementation of the Allscripts ED and Theatres modules, as well as configuring the system to support paperless working on wards and underpin new care

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pathways in bariatrics and other areas, with the aim of implementing many of these changes in late summer of 2017.

FIRM FOUNDATIONS Sound Finances At month 4, the Trust is reporting a £41.1m deficit. This is a £18.9m adverse year to date variance against a planned deficit of £22.3m. The current position is an in month deficit of £8.8m against a planned in month deficit of £2.7m (an adverse in month movement of £6.1m). A number of income issues in months 1 to 4 have contributed towards the adverse variance as well as a CIP/QIPP gap mainly relating to “flow through” schemes from last year. The month 4 position reflects the recent Sustainability and Transformation Fund (STF) criteria to access the funds determined by NHSI (£30m for KCH). The Trust is not achieving the financial control total and has not accounted for the STF of £10.0m in M4. The full details of the Trust’s financial performance can be found under agenda item 6.1. Compelling Communications New and events can be found on the Trust’s website: https://www.kch.nhs.uk/news. Some noteworthy media coverage and events include:

Medium Summary

The Daily Mail A new procedure being carried out at King’s that uses high speed pressure waves to break down calcium in patients’ coronary arteries prior to stent insertion was covered by the Daily Mail. Roger Holmes, the first patient in Europe to undergo the procedure, and Dr Jonathan Hill, consultant interventional cardiologist at King’s, were both interviewed for the article.

Daily Mail There was coverage of King’s in the Daily Mail’s Me & My Operation. Stephen Lee, 71, had surgery at King’s using a laser to dissolve part of his enlarged prostate. Dr Christian Brown, a Consultant Urologist at King’s, explained in the piece why an enlarged prostate can be a problem and how the GreenLight XPS laser works.

Daily Mail International Business Times People Magazine Women’s Day The Herald The Southwark News

There was extensive press coverage of Prince Harry’s visit to King’s. Harry visited specialists to speak about their work in diagnosing and treating people with HIV.

https://www.kch.nhs.uk/news

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Medium Summary

The Guardian King’s was mentioned in an article in The Guardian about NHS Trusts needing to borrow money from the government in order to pay staff wages, energy bills and medicines. Barts Health NHS Trust received the biggest loan – £191.9m – on top of its expected £1.5bn annual budget. King’s was recorded as borrowing the second largest amount – £145.8m – and London North West Healthcare NHS Trust was given the third biggest loan of £125.3m.

The Daily Mail The Lambeth GP Food Co-op was mentioned in an article in the Daily Mail about the benefits gardening has on health. The Lambeth GP Food Co-op is a cooperative of patients, doctors, nurses and local residents who build gardens in GP surgeries to enable its members to learn how to grow food. King’s has supplied a location and planters to the Co-op, and the food grown is sold at a market stall held at Denmark Hill.

The Kent Online

There was coverage of King’s in The Kent Online about an inquest which found King’s failed to give a blood transfusion to Abimbola Babatola, after a caesarean section, which sadly led to her death. Mrs Babatola suffered from sickle cell disease and the inquest found that she died from hypoxic-ischaemic encephalopathy - a brain injury caused by lack of oxygen, collapse after caesarean section, post-partum haemorrhage, and sickle cell disease. We provided a statement to the journalist, which was used in the article.

BBC One Kypros Nicolaides, Professor of Fetal Medicine at King’s, appeared on Sunday Morning Live, giving an expert comment on non-invasive pre-natal screening tests for Down’s syndrome. The programme is available to watch on BBC iPlayer, and the feature starts at 17:45 minutes.

http://www.bbc.co.uk/iplayer/episode/b07r24yr/sunday-morning-live-series-7-episode-9

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Subject: Trust Performance Report 2016/17 Month 4

Author(s): Steve Coakley, Acting Assistant Director of Performance &

Contracts

Presented by: Jane Farrell, Chief Operating Officer

Sponsor: Jane Farrell, Chief Operating Officer

History: None


1. Summary of Report This report provides the details of performance achieved against key national performance and quality indicators, and governance indicators defined in the Monitor Risk Assessment framework for the interim Q2 position in 2016/17. 2. Action required The Board is asked to approve the M4 performance reported against the governance indicators defined in the Monitor Risk Assessment framework for the interim Q2 position in 2016/17. 3. Key implications Legal: Statutory reporting to Monitor and the DoH. Financial: Trust reports financial performance against published plan. Assurance: The summary report provides assurance that the Trust has met the

performance targets as defined within the Monitor Risk Assessment framework (RAF) for the July position with the exception of the A&E 4-hour target, the 62-day GP referral and 62-day screening treatment targets, and the RTT incomplete pathway target.

Clinical: There is no direct impact on clinical issues. Equality & Diversity: There is no impact on equality & diversity issues. Performance: The summary report demonstrates that the Trust has achieved the

performance indicators for the July position as defined in the RAF with the exception of the A&E 4-hour target, the 62-day GP referral and 62-day screening treatment targets, and the RTT incomplete pathway target.

Strategy: Performance against the Trust’s annual plan forecasts and key objectives.

Workforce: None. Estates: There is no direct impact on Estates. Reputation: Trust’s quarterly and monthly results will be published by Monitor

and the DoH. Other:(please specify)

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Key Messages of this Report

Trust performance against the 4-hour target worsened slightly further from 83.79% reported in June to 83.51% in July. Therefore, we have also not achieved the STF trajectory of 88.11% which was agreed for July with commissioners and NHSI.

RTT incomplete pathways performance improved further from 81.34% in June to 82.03% in July which is better than the 82.0% performance trajectory. There were 154 patients waiting 52+ weeks at the end of July 2016, which is higher than the 137 patients waiting at the end of June. There were 103 patients on admitted pathways and 51 patients on non-admitted pathways.

Cancer indicators are exceeding national targets with the exception of 62-day GP referral and 62-day screening treatment targets. Performance compared to the 85% target for 62-day GP referrals to treatment is 81.8%, and for the 62-day screening treatment target performance is 79.7% compared to the 90% target for the July position.

Diagnostic waiting time performance improved from 9.4% of patients waiting over 6 weeks for tests at the end of June to 6.8% in July. We have not though achieved the STF performance trajectory of 1.7%

There were no MRSA cases in July so we have reported 2 MRSA cases reported YTD. 7 c-difficile cases were reported in July – 5 on the DH site and 2 on the PRUH site. 21 cases YTD which is below the Trust quota of 24 cases for July YTD position.

Introduction/Background

The performance report for July 2016 includes updates for the Emergency Care 4-hour performance Action plans for PRUH and DH, the Trust-wide RTT programme and HCAI.

Trust Priorities

Emergency 4-hour performance at Princess Royal Hospital (PRUH): All types attendance performance worsened from 86.5% reported in June to 84.5% in

July, which is below the internal site STF trajectory of 86.3% for the month. Type 1 ED attendance performance also worsened from 78.1% in June to 74.3% in July.

There was a slight 0.7% increase in type 1 attendances to ED in July compared to June. The number of type 1 breaches increased from 1,145 to 1,352.

However, there was a 5.5% increase in UCC attendance. The number of type 3 breaches in UCC increased from 94 to 119, and the number of breaches due to late UCC handover increased from 167 to 195.

Emergency 4-hour performance at Denmark Hill (DH): All types performance improved from 81.8% in June to 88.7% in July, which is below the

internal site STF trajectory of 89.52% for the month. Type 1 ED attendance performance improved from 78.5% to 79.8%.

The number of type 1 attendances in ED increased by over 5.5% in July compared to June. The number of type 1 breaches reduced from 2,585 to 2,453.

Referral to Treatment (RTT) Incomplete pathway performance: The number of 52+ week breach patients increased from 137 patients reported in June to

154 patients reported in July based on the new operational Patient Tracker List (PTL) reports. Whilst we are ahead of our overall 52-week trajectory of 183 breaches, we are 91 cases ahead in neuro specialties but 62 cases behind in our non-neuro specialties and are required to reduce these to zero by the end of October. There are 14,909 patients waiting over 18 weeks at the end of July so our incomplete performance is 82.03% which is a further improvement compared to the 81.34% reported for June.

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Key Issues

Clinical Effectiveness: The national Summary Hospital Mortality Index (SHMI) worsened slightly but is better than

the expected index of 100 at 85 for the DH site and 92 for the PRUH site, based on the latest 12-months data available from the ‘HED’ benchmarking tool.

The number of diagnostic 6-week waiting time breaches reduced by 376 cases reported at the end of July to 765, which represents 6.8% of the total number of patients waiting. This is above the performance improvement trajectory of 1.7% for July which was agreed with commissioners. The improvement was largely due to a reduction of 337 breaches reported in non-obstetric ultrasound across both the DH and PRUH sites, and a reduction of 29 MRI breaches, mainly on the PRUH site. Progress against the revised action plan to reduce the backlog to 1% by the end of August is now being monitored daily.

Safety: There have been 2 MRSA cases reported to-date, both within the TEAM/medical division.

Seven c-difficile cases were reported in July which is above the quota of 6 cases for the month. Five cases were on the DH site – so there have been 17 cases YTD on the DH site which is just below the quota of 18. Two cases were on the PRUH site – so there have been 4 cases YTD on the PRUH site which is still better than the quota of 6 cases.

Hand hygiene audit scores have improved to 93.4% on the DH site and 90.8% on the PRUH, but remain below the internal 95% target.

The number of hospital-acquired pressure sores remains high with 30 cases reported in July. There were 22 cases on the DH site of which 4 were classified as grade 3 (two on LITU, 1 on Christine Brown CCU and 1 on David Marsden ward). There were 8 cases reported at the PRUH site, of which there were 3 on surgery wards and 2 on TEAM/medical wards.

Patient Experience: The HRWD Inpatient survey score improved again and is better than the target of 89 on

both the DH and PRUH sites. The Friends and Family (FFT) scores for Inpatient/Day cases is 95 for both sites, better than the target score of 93. FFT scores for ED improved on both sites to 78 for DH, above the target of 61, and to 82 for PRUH but is below the target of 89.

The number of inpatient cancellations on the day reduced from 69 cases in June to 52 in July – with 29 cancellations at the DH site and 23 cancellations at the PRUH. There were however 20 breaches of the 28-day cancellation standard for July – with 9 breaches on the DH site including 2 cancellations due to endoscopy machine failure. There were 11 breaches at the PRUH with 4 cancellations due to clinical staff being off-sick.

The number of patient complaints increased from 99 in June to 117 in July, of which 15 were rated high/severe. The number of complaints still open or not responded to within 25 working days also increased from 40 to 55 cases.

Finance & Operational Efficiency: Financial position - please see the Finance report for further details. The proportion of inpatients discharged at weekends improved on both acute sites: from

19.4% in June to 23.3% in July on the DH site, and from 18.8% in June to 21.1% in July on the PRUH site; but both indicators remain below the 28% target.

Utilisation in main theatres at DH remains above the 80% target at 81% in July. DSU utilisation on the DH Site improved from 73% to 76% in July. On the PRUH site, main theatre utilisation improved from 66% to 69%, and DSU utilisation improved from 67% to 70%. Utilisation in Orpington main theatres remained at 73%, but DSU utilisation at Sidcup worsened from 70% to 48% with only 250 cases performed in July compared to 383 in June.

Staffing: Vacancy rate worsened slightly from 11.7% for June to 11.9% for July on the DH site, but

worsened from 14.6% to 16.2% for the PRUH sites, so above the internal 5-8% target. Compliance against mandatory and statutory training and induction courses remains above

the target of 80, at 82 for DH.

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Regulatory Performance/Monitor compliance

Monitor – Q1 2016/17 update: In our Q1 performance assessment to Monitor, we submitted a position indicating that we

had not achieved the 62-day screening target of 90%. However, due to late validation prior to submission of our Q1 upload of cancer returns via the OpenExeter system, our position had improved to 91.0%. This therefore means that have achieved the 90% target. We are writing to Monitor to confirm if we are able to amend our original Q1 performance position.

Monitor – interim Q2 2016/17 position: The Trust has achieved the performance indicators in the Monitor Risk Assessment

Framework for July with the exception of the A&E 4-hour performance target, the 62-day GP referral and 62-day screening treatment targets, and the RTT incomplete pathway target.

Our RTT incomplete performance is better than our agreed performance trajectory of 82.0% at 82.03% for July 2016.

Performance compared to the 85% target for 62-day GP referrals to treatment is 81.8%, and for the 62-day screening treatment target performance is 79.7% compared to the 90% target.

We have reported 21 c-difficile cases for Q1 2016/17 which is below the quota of 24 cases for the YTD cumulative position.

We therefore have a score of 4.0 based on the latest RAF for our interim Q2 2016/17 reported performance.

#### #### #### ####

Metric Units WeightingYTD

ThresholdQtr 1 Qtr 2 Qtr 3 Qtr 4

Acute targets - National requirements

Clostridium difficile year on year reduction YTD Number 1.0 72 14 21

31 day wait for second or subsequent treatment 1.0

Surgery % 94 95.8 96.8 #DIV/0! #DIV/0!

Anti cancer drug treatments % 98 100.0 100.0 #DIV/0! #DIV/0!

Radiotherapy % 94 98.6 100 #DIV/0! #DIV/0!

62 day wait for first treatment 1.0

from urgent GP referral to treatment: all cancers % 85 85.8 81.2 #DIV/0! #DIV/0!

consultant screening service referral: all cancers % 90 90.0 73.3 #DIV/0! #DIV/0!

Acute targets - minimum Standards

31 day wait from diagnosis to first treatment: all cancers % 1.0 96 98.3 96.6 #DIV/0! #DIV/0!

Two week wait from referral to date seen: 1.0

all cancers % 93 94.1 95.8 #DIV/0! #DIV/0!

for symptomatic breast patients (cancer not initially suspected) % 93 88.5 100.0 #DIV/0! #DIV/0!

Maximum time of 18 weeks from point of referral to treatment in

aggregate – patients on an incomplete pathway% 1.0 92 76.1 82.0 #DIV/0! #DIV/0!

A&E:

Maximum waiting time of 4 hours in ED from arrival to admission,

transfer or discharge% 1.0 95 84.13 83.51 #DIV/0! #DIV/0!

Self‐certification against compliance with requirements regarding access

to healthcare for people with a learning disability% 1.0 N/A Achieved Achieved

Total Score 3 4

Kings Monitor Scorecard Jul-16

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Trust Performance Scorecard – DH site

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Trust Performance Scorecard – PRUH sites

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Trust Emergency Care 4-hour performance and ED Recovery Programme

Highlights – July 2016 Trust performance for all types attendances against the 4-hour target worsened slightly from 83.79% reported in June to 83.51% in July. This is below the national 95% target and is also below the STF performance target of 88.1% for July which we have agreed with commissioners and submitted to NHSI for 2016/17. The charts below compare monthly and quarterly Trust performance against the 4-hour target.

89.89%91.84%

89.34%

83.39%84.13% 84.70%

70%

75%

80%

85%

90%

95%

100%

Qtr 1 Qtr 2 Qtr 3 Qtr 4

KIngs ‐ Quarterly All Types Performance

2015/16 2016/17

70%

75%

80%

85%

90%

95%

100%

Kings‐ Monthly All Types PerformanceJul 2014 ‐ Jul 2016

Jul 2014 ‐ Jul 2015 Jul 2015 ‐ Jul 2016

Capacity Plan Update Denmark Hill – additional 23 beds A two floor modular unit was delivered on-site at DH in mid-July. The internal fit out will be completed by 19 August which will enable offices to move from 9th floor Ruskin Wing on 22 August 2016. Other moves within the Ruskin wing have been undertaken in parallel to move the neuropsychology clinic currently located on the 9th floor by 22 August. The vacated floor space will be handed to the building contractor on the 23 August, in order to commence a 17-week construction programme to re-develop the floor and to create the planned 23-bedded ward. The completed ward is due to be handed back to the Trust prior to Christmas, when it will be commissioned over the Christmas period and become operational at the beginning of January 2017. Orpington wards – additional 40 beds/chairs The Diabetes and Dermatology services were relocated from 1st floor of Orpington Hospital to Beckenham Beacon on 22 July 2016. One Dermatology clinic and the eye screening service provided by GSTT are remaining at Orpington and have been re-located to the general outpatient area on the ground floor. The vacated area on the 1st floor at Orpington Hospital was handed to the building contractor on 23 July to commence a 22-week construction programme, in order to create 2 new wards each comprising of 18 beds and 2 chair spaces. The completed wards are due to be handed back to the Trust prior to Christmas. They will be commissioned over the Christmas period and are planned to be operational at the beginning of January 2017.

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Emergency Care 4-hour performance Action Plan Update @PRUH

Highlights – July 2016 All types attendance performance worsened from 86.5% reported in June to 84.5% in July. Type 1 ED attendance performance also worsened from 78.1% in June to 74.3% in July. Performance was also lower compared to the 92.7% achieved in July last year as demonstrated in the charts below.

88.54%91.50%

89.26%

81.27%83.74%

86.02%

70%

75%

80%

85%

90%

95%

100%


PRUH Quarterly All Types Performance

2015/16 2016/17

70%

75%

80%

85%

90%

95%

100%

PRUH Monthly All Types PerformanceJul 2014 ‐ Jul 2016

Jul 2014 ‐ Jul 2015 Jul 2015 ‐ Jul 2016

STF performance and ED Action Plan Update The STF performance trajectory was achieved in April, May and June for the PRUH site, despite the 2 norovirus outbreaks impacting on bed capacity and flow. Higher than planned type 1 non-admitted breaches and an increased number of type 3 breaches contributed to the July target not being achieved. The table below summarises actual versus planned activity, breach and performance.

ED UCCAll

AttendsAdm

Breach

Non-adm

BreachUCC

Breach

UCC Handover Delay

Apr-16 Plan 5535 5549 11084 1282 634 95 160 80.41%

Actual 5086 5203 10289 1109 522 146 212 80.67%

Var -449 -346 -795 -173 -112 51 52 0.26%

May-16 Plan 5858 5896 11754 1197 563 99 179 82.66%

Actual 5133 5626 10759 969 472 95 189 83.97%

Var -725 -270 -995 -228 -91 -4 10 1.31%

Jun-16 Plan 5595 5856 11451 1197 352 75 118 84.79%

Actual 5224 5225 10449 757 388 94 167 86.54%

Var -371 -631 -1002 -440 36 19 49 1.76%

Jul-16 Plan 5615 5808 11423 1139 317 35 78 86.26%

Actual 5260 5513 10773 911 441 119 195 84.54%

Var -355 -295 -650 -228 124 84 117 -1.73%

PRUH

The PRUH ED recovery plan was taken to the Tripartite meeting held with commissioners and NHSI on 10 August 2016. The immediate actions for June-August 2016 have been based around leadership, process of patient flow and implementation of the Trust-wide bed re-configuration plan to lay the foundations for the earliest sustainable performance improvement by: Multiple incremental changes to remove delays Bolstering leadership teams with clarity on roles and outcomes Collaborative working with CCG, Community providers and Social services to set up out of

hospital model of care for frail elderly patients to support the internal hospital actions detailed here

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Emergency Care 4-hour performance Action Plan Update @DH

Highlights – July 2016 All types performance improved from 81.8% in June to 82.7% in July, and type 1 ED attendance performance improved from 78.5% to 79.8%. Performance also remains below the levels achieved in July 2015 as shown in the charts below.

90.78%92.51%

89.41%

85.04%84.41% 83.69%

70%

75%

80%

85%

90%

95%

100%


DH Quarterly All Types Performance

2015/16 2016/17

70%

75%

80%

85%

90%

95%

100%

DH Monthly All Types PerformanceJul 2014 ‐ Jul 2016

Jul 2014 ‐ Jul 2015 Jul 2015 ‐ Jul 2016

STF performance and ED Action Plan Update The STF performance trajectory was achieved in April and May for the DH site, but was not achieved in June. Our plan was to de-escalate the winter pressure beds on Matthew Whiting ward to enable re-delivery of acute care hub. This would deliver a step change in admitted breaches using referral to assessment protocol and give ED capacity by flowing referred patients out sooner to allow better allocation of resource in-department. However, patient acuity, demand and LOS remained high which meant that Matthew Whiting opened to additional beds to support flow with minimal ambulation. The table below summarises actual versus planned activity, breach and performance.

All Attends

Adm Breach

Non-adm

BreachT2

BreachBreache

s Perf

Apr-16 Plan 13972 1285 1183 10 2478 82.26%

Actual 13791 1004 973 11 1988 85.58%

Var -181 -281 -210 1 -490 3.32%

May-16 Plan 14468 1163 1051 1 2215 84.69%

Actual 14809 1074 1000 20 2094 85.86%

Var 341 -89 -51 19 -121 1.17%

Jun-16 Plan 14781 1020 657 1 1678 88.65%

Actual 14228 1136 1449 10 2595 81.76%

Var -553 116 792 9 917 -6.89%

Jul-16 Plan 14908 971 591 0 1562 89.52%

Actual 14225 1167 1285 2 2454 82.75%

Var -683 196 694 2 892 -6.77%

Denmark Hill

The DH ED recovery plan was also taken to the Tripartite meeting held with commissioners and NHSI on 10 August 2016. To address the increased foot-fall through the Emergency Department at Denmark Hill, the Trust’s capital plan includes the expansion of the department into Suite 1. Whilst plans have been completed for the plaster room, suite 1 re-development and the works to open the new entrance, there has been a delay in re-locating the suite 3 clinics. A feasibility of two options are currently being assessed.

10 of 12

RTT Update

End-July 2016 Incomplete pathway position There were 14,909 incomplete pathways with a waiting time over 18 weeks, which is a decrease of 586 pathways compared to our position at the end of June. The number of admitted incomplete pathways increased by 210, and the number of non-admitted pathways reduced by 796. Our incomplete performance for July 2016 was therefore 82.03% which is a slight improvement of 0.69% compared to June. This is also better than the performance improvement trajectory of 82.0% which was agreed between the Trust, commissioners and NHSI. The waiting time position for July 2016 compared to June 2016 is summarised below:

Patients waiting end-July (June position in brackets)

18-39 weeks 40-51 weeks 52+ weeks

Incomplete -Admitted 4,544 (4,422) 445 (375) 103 (85)

Incomplete – Non-admitted 9,051 (9,864) 715 (697) 51 (52)

Total Incomplete pathways 14,286 (14,286) 1,160 (1,072) 154 (137)

52-week Waiting Time position There were 154 patients waiting over 52 weeks that we have reported in our July 2016 month-end position to Unify, of which there were 103 patients waiting on admitted pathways and 51 patients waiting on non-admitted pathways. This is a reduction compared to the 137 patients that we reported for the end of June position. We are therefore 29 patients ahead of our agreed trajectory of 183 for the month. The number of Neuro-specialty breaches reduced from 61 to 59 and remain 91 ahead of trajectory. Non-neuro breaches increased from 76 to 95 and are 62 cases behind trajectory. Outsourcing Progress Update Kings currently has contracts in place to send Neurosurgery patients to 3 providers: HCA, Kent Institute of Medicine and Surgery (primarily for Kent patients) and BMI Clementine Churchill (with limited success as 60 patients have been returned to the Trust out of 72 referred). An initial batch of 120 General Surgery cases and 100 Gynaecology cases has been identified to go to BMI hospitals. We have also entered into early discussions with regards to sending ENT patients to BMI hospitals. Demand and Capacity Modelling Diagnostic models have been completed for all DH and PRUH services using the IST models, and have been sent to the South East Commissioning Support Unit for review. They are planning to come on-site to hold a review meeting on 25 August 2016. Overall specialty models completed for phase 1 specialties: in T&O, Ophthalmology, Neurology and Neurosurgery including sub-specialty models with the exception of Neurology. Specialty models also completed for phase 2 specialties including Dental, Gynaecology, Plastic Surgery, Dermatology, Urology and Endocrine. MBI Health Group The Trust has engaged the support of MBI Health Group to undertake a rapid assessment of 3 specialties: Neurology, Neurosurgery and T&O. Key areas of focus are: To establish the baseline data position, undertaking an assessment of each service

against the MBI provider assessment framework over a 4 week period To provide a detailed assessment report highlighting their recommendations for

improvement and the sequencing of these improvements to make gains in RTT performance as quickly as possible.

11 of 12

Cancer – July 2016 Performance Update

The table below summarises the achievement of cancer targets at Trust-level for the latest July 2016 and interim Q2 position. Despite an increase in 2WW referrals, the two-week wait suspected cancer referral target is being achieved at 95.8% for July compared to the national 93% target, and at 94.24% for the latest Q2 position. The two week-wait symptomatic breast performance has maintained its strong performance in Q2 at 100% for July and 99.2% for August. The 62 day GP referral target of 85% is not being achieved at 81.82% for July but is being achieved for the latest Q2 position at 85.32%. The 62-day screening target of 90% is not being achieved at 81.8% for July and 81.9% for Q2.

62-day GP Referral The number of treatments recorded in July has increased but there are currently 19 breaches recorded for the month. A full validation of the July position is being undertaken as well as ensuring that all treatments are entered onto the PCS cancer system, and verifying that all breaches are for confirmed cancer diagnoses. Tumour groups have refreshed their action plans, and weekly meetings continue with the Director of Operations to review plans and the latest performance position. 62-day Day Screening The cancer team are also performing further validation work for the 6 screening breaches that are currently being reported for July, given the current position for Q2 is just under 81% compared to the 90% target. Inter Trust Transfers (ITT) In April, 41.2% of pathways were referred to GSTT by day 38 which was worse than the average of 62.3% achieved for January – April 2016. The final position for May improved to 65.5%, but worsened to 50% for June. Our July position has improved though to 56.2% but is below the trajectory of 73.7% that we shared with commissioners. We have also committed to achieving 85% by October. Key actions for the Trust to implement in 2016/17 include: Root cause analysis of all late ITTs to enable tumour groups to identify trends and causes

of delays Minimise delays at the start of the pathway Work with diagnostics to improve access to diagnostic testing and availability of reports.

12 of 12

Healthcare Associated Infection (HCAI) Update (1/1)

MRSA (post 48 hour bacteraemia: 1 case in June 2016 at DH site; 2 cases YTD at DH site which is above the zero quota.

C-difficile: 7 new cases reported in July (5 cases at DH and 2 cases at PRUH); 21 cases YTD which

is below the quota of 24 cases for July YTD position and better than the 35 cases reported by July last year.

VRE bacteraemia: 2 new cases at DH and 1 new case at PRUH in July; 20 cases YTD which is above the

target of 9 cases for the July position and higher than the 13 cases reported by July last year.

E-Coli bacteraemia: 10 new cases reported in June at DH and 2 new cases at PRUH; 46 cases YTD which is

above the target of 31 cases, but below the 37 cases reported by July last year. C-Difficile (CDI) Action Plan Update: Reviewing of current practice and integration of policies and practice:

Work is on-going to align policies and protocols across sites. This work will be overseen by the HCAI Operations Committee.

Policies approved and published: Infection Prevention and Control, Intravascular Catheters, Waste Management and Trust Decontamination.

Protocols approved and published: Isolation Precautions, Infectious Death Handling,

Management of Gastrointestinal Infection, Respiratory Virus and Atypical Bacterial Infections Treatment and Infection Control, Varicella Zoster Virus (VZV), Transmissible Spongiform Encephalopathy, Blood Cultures, Standard Precautions, Hand Hygiene, Linen and Laundry, Guidelines for Animals on Hospital Premises and Aseptic Non Touch Technique.

Protocols under consultation: MRSA, Clostridium difficile, Multiple Resistant Gram

Negative, Tuberculosis protocols are under consultation. Protocols outstanding: Control of Outbreaks of Infection, Pandemic Influenza Protocol,

Coronavirus including MERS-CoV & SARS-CoV and Streptococci and Enterococci. Centralisation of endoscope reprocessing:

A project on-going to plan and develop a central reprocessing facility for endoscopies. The unit at DH site is being used as a template for the PRUH unit. This project is still very much in the planning stages, but should allow for a much higher level of decontamination than is currently the case.

Monthly Unify Staffing Report

(June & July 2016)

9th September 2016

Board Meeting

Report to: Board Directors

Date of meeting: 9th September 2016

Subject:

Monthly Unify Staffing Report (June & July 2016)

Author(s): Maria Donbavand

Presented by: Paula Townsend

Sponsor: Paula Townsend

History: Monthly Nursing, Midwifery and Care staff numbers to the Board


Legal:

Patients have a right to be cared for by appropriately qualified and experienced staff in safe

environments. This right is enshrined within the national Health Service (NHS) Constitution, and the

NHS Act 1999 makes explicit the board’s corporate accountability for quality. Nurses’ responsibilities

regarding safe staffing are stipulated by the Nursing and Midwifery council (NMC).

Financial: Nursing is the largest professional group in the Trust and consumes a large amount of resource.

Cost efficiency is therefore paramount

Assurance:

This report provides assurance and evidence on nursing workforce.

Clinical: Nursing is a key component in provision of good patient experience and harm free care

Equality & Diversity: There are no issues or implications relating to equality and diversity within this report

Performance: This report highlights achievements against national and local key performance indicators

Strategy: The contents of this report is directly aligned to the Trust Nursing and Midwifery Objectives

Workforce: This report will inform Trust’s Nursing and Midwifery Workforce Strategy.

Estates:

There are no implications

Reputation: Poor nursing care would have a deleterious effect on the reputation of the Trust

Other:(please specify)

n/a

Key Implications

This report provides assurance to the Board of Directors on the safety of the Nursing and Midwifery staffing levels across the Trust during June and July 2016

and provides details of the actual hours of Nursing, Midwifery and Health Care Assistant (HCA) time on day and night shifts versus planned staffing levels.

We are also submitting Nursing Hours Per Patient Day (NHPPD) as per Department of Health requirements. The benchmark is still to be agreed but

the details of these hours are recorded on appendix 5-8.

KEY POINTS

• The number of staff required per shift is calculated using an evidence based tool, based on the level of Acuity of the patients. This is further informed by

professional judgement, taking into consideration issues such as ward size and layout, patient dependency, staff experience, incidence of harm and patient

satisfaction and is in line with NICE guidance. This gives us the optimum planned number of staff per shift ( NB 2 wards from the July submission, M

Whiting and Medical 4 have been excluded while their budgets are being worked through).

• For each of the 76 clinical inpatient areas in June and 74 inpatient areas in July, the actual number of staff as a percentage of the planned number is

recorded. The overall figures are shown below.

The report explores in detail where there was a variance of greater than 15% between actual fill rates and planned staffing levels.

Across the Trust, the (combined) average actual level of registered nursing staff was generally within 18% of the levels planned across all shifts.

At Denmark Hill

June - there were 18 clinical areas where the actual number of Healthcare assistants was more than 115% above the planned level, and 3 areas where the

levels were less than 85% of those planned. (numbers are based on combined day and night average)

July -, there were 22 clinical areas where the actual number of Healthcare assistants was more than 115% above the planned level, and 2 areas where the


At PRUH

June - there were 2 clinical areas where the actual number of Healthcare assistants was more than 115% above the planned level and 6 areas where the


July - there were 4 clinical areas where the actual number of Healthcare assistants was more than 115% above the planned level and 4 areas where the levels

were less than 85% of those planned. (numbers are based on combined day and night average)

Summary of Report 1/2

% Average fill rate

RN

% Average Fill rate

HCA

Denmark Hill 94% 125%

PRUH 98% 104%

Safer Staffing Fill rate - June 2016

SiteDay and Night

% Average fill rate

RN

% Average Fill rate

HCA

Denmark Hill 92% 165%

PRUH 96% 107%

Safer Staffing Fill rate - July 2016

Site

Day and Night

Summary of Report 2/2

Understaffing

• On average across the Trust staffing levels for Registered nurses did not fall below 85% over the month with the exception of a few wards. The exception

reports at the end of the presentation highlight reasons for this and how the shift was made safe and all are reported on our red shift reporting system (

appendix 1 - 4) . A red shift occurs when fewer Registered Nurses than planned are in place, or when the number of staff planned is correct but the patients

are more acutely sick or dependent than usual requiring a higher staffing level. In total there were 120 red shifts declared in June and 169 red shifts

declared in July. The majority of these were at Denmark Hill and associated with increased acuity, vacancies or bank/agency failing to fill the shifts. In each

case local managers assess the situation and make a judgement about whether moving staff from a better staffed areas is required to maintain safety.

Where there are instances of hours exceeding those planned, the reasons particularly in relation to HCAs are as follows:

o Extra staff required on an ad hoc basis to “special” high risk/vulnerable patients which has increased

o Overseas Nurses awaiting their NMC registration are recorded as unregistered,

o HCA usage is increased to minimise the impact of reduced RN fill rates

o Where the planned staffing level is only one person, an increase of one member of staff on a few occasions generates a large percentage increase.

In summary the actual number of additional healthcare assistants used is less than the percentage would suggest, usage is

subject to controls and is decreasing.

ACTION REQUIRED

• The Board is asked to note the report.

0102030405060708090

100110120130140150160

Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16

No. of Red Shifts between Dec 15 - Jul 16 PRUH

Red

Linear (Red)

0102030405060708090

100110120130140150160170180190200


No. of Red Shifts between Dec 15 - Jul 16 Denmark Hill

Red

Linear (Red)

6

Trends and patterns, Nursing hours:

Planned Vs. Actual – Denmark Hill

The summary below is based on 46 in-patient wards across the Denmark Hill site

for June and 45 wards in July.

June 2016

RN Day and Night Shift - The overall planned versus actual RN nursing hours

for June was 6% below plan. This is the same as the previous month and is

within acceptable limits.

HCA Day and Night Shift - The average overall planned versus actual HCA

nursing hours for June was 25% above plan. This is a decrease of 7% from the

previous month.

July 2016

RN Day and Night Shift - The overall planned versus actual RN nursing hours

for July was 8% below plan. This is an increase of 2% compared to the previous

month and is within acceptable limits.


nursing hours for July was 65% above plan. This is an increase of 40% from the

previous month.

70%85%

100%115%130%145%160%175%190%205%220%235%250%265%280%295%310%325%


AVG - RN Day and Night

AVG HCA Day and Night

Over

Planned vs Actual by month - Denmark Hill

Hospital % Against Planned (RNs) Day/Night

St Thomas Hospital 99%

Imperial (St Mary's) 96%

Kings College Hospital - DH 92%

Safe Staffing levels - taken from NHS choices - 15.08.2016

7

Trends and patterns, Nursing hours:

Planned Vs. Actual – PRUH

The summary below is based on 30 in-patient wards across the PRUH site in

June and 29 wards in July.

June 2016

RN Day and Night Shift - The overall planned versus actual RN nursing

hours for June was 2% below plan. This is an increase of 3% from the

previous month and is within acceptable limits.


nursing hours for June was 4% above plan. This is an increase of 11% from

the previous month.

July 2016

RN Day and Night Shift - The overall planned versus actual RN nursing

hours for July was 4% below plan. This is a decrease of 2% compared to the

previous month and is within acceptable limits.


nursing hours for June was 7% above plan. This is an increase of 3% from the

previous month.

70%

85%

100%

115%

130%

145%

160%

175%

190%


% Avg Fill rate RN Day and Night

% Avg Fill rate HCA Day and Night

Over

Under

Planned Vs Actual by month - PRUH

Hospital % Against Planned (RNs) Day/Night

Croydon University Hospital 95%

University Hospital Lewisham 98%

Kings College Hospital - PRUH 96%

Safe Staffing levels - taken from NHS choices - 15.08.2016

Appendix 1

Exception Report – Denmark Hill

HCA and RN staffing levels – Lower than Planned - June

Ward NameReview by HON/Matron/Ward where 15% or more of nursing hours did not meet agreed staffing

levels

Dawsonwe are currently filling the RN vacancies with HCAs where possible to ensure that patient care is not

affected.

Coptcoat Ward High level of Maternity Leave – unfilled RN shifts compensated with HCAs

Marjorie Warren Ward operating at safe staffing levels (amber / green). Additional HCA staffing at night to support 1:1 care

ListerHigh RN vacancy rate – unfilled shifts to cover compensated with HCAs in addition to increased number

of specials both RMN & HCA

Fisk and Cheere WardThis is due to shortage of registered staff therefore HCAs used to cover nurse vacancy Ward Mananger

often covers short shifts on the ward

Waddington

RN shortfall due to movement of staff to other haematology ward, diluting skills across the unit. ward run

in amber shift with additional HCA to cover RN shortfall and support staff nurse bedside. Senior nurses

(ward manager/matron) work on the front line to ensure safety.

Derek Mitchell Unit

RN shortfall due to long term sickness; Senior nurses (ward manager/matron) work on the front line to

ensure safety. Other heamatology ward staff moved around aiming to dilute skill acroos haematology

unit.

Byron Additional HCAs provided to support the shortage in RNs at Night.

Thomas Cook CCCCRecruitment plan in place for current vacancies however staff moved around to ensure that patient safety

is not affected.

Brunel HCA vacancy recruited to ensure HCA up to establishment on day shifts as well as night duty

Rays Of Sunshine Additional staffing due to patient being specialled.

Paediatric Short StayRecruitment plan in place for current vacancies however staff moved around to ensure that patient safety

is not affected.

Kinnier Wilson HDUHCA vacancy but only use HCA bank if specialling or cover band 5 sickness if RN not available. Also

continental travel nurses awaiting pin are paid and work as an HCA.

Liver Intensive Care Unit HCA underfilled -safe in ITU setting, nursing hours increased reflecting the increased acuity.

Appendix 2

Exception Report – Denmark Hill

HCA and RN staffing levels – Lower than Planned - July

Division Ward Name Review by HON/Matron/Ward where 15% or more of nursing hours did not meet agreed staffing levels

Cardiac Sam Oram Additional HCAs used due to increased specialling requirements.

Children's Thomas Cook CCCC HCA vacancy

Children's Rays Of Sunshine PP patient specialled

Haematology ELF & LIBRA WardThe additional HCAs in haem have been used to compensate where RN shifts are unfilled and/ or to special

patients

Haematology Derek Mitchell UnitThe additional HCAs in haem have been used to compensate where RN shifts are unfilled and/ or to special

patients

Haematology Waddington The additional HCAs in haem have been used to compensate where RN shifts are unfilled and/ or to special

Haematology DavidsonThe additional HCAs in haem have been used to compensate where RN shifts are unfilled and/ or to special

patients

Liver and Renal DawsonDawson ward has higher number of HCAs as they use HCA to supplement the RNs due to vacancy and long term

sickness. The ward operates moderately safe depending on the acuity of the patients.

Liver and Renal Fisk and Cheere WardFisk and Cheere ward has higher number of HCAs as they use HCAs to supplement the RNs due to vacancies.

The ward operates moderately safe depending on the acuity of the patients.

Liver and Renal Howard WardHoward has a very low RN fill rate due to vacancies on the ward. We have covered most of the nights but the days

have not been filled. We have left the days short due to the fact the ward manager works early shifts Monday to

Liver and Renal Liver Intensive Care Unit For LITU the staffing level was safe, ongoing HCA recruitment for 1.4 wte , we do not back fill the vacancy .

Neuro David MarsdenIncreased use of HCA's is due to 3 patients needing specialling and backfilling RN vacancies with HCA when

unable to fill RN bank shifts.

Neuro Kinnier Wilson Vacancies, mat leave at RN level. Generally filled with bank HCA Frequent need for HCA specials especially

Neuro Kinnier Wilson HDU There is currently a vacancy for a HCA - however staff are moved to ensure that patient safety is not affected.

Surgery Lister Large vacancy of RN covered at times by CSW. Again CSW increased for specialling.

Surgery Coptcoat Ward Opened new 10 bedded unit had to recruit agency nurses

Surgery Katherine Monk Increased need for patients that need specialing by CSW & RMN has a vacancy of 11RN. Having to cover other

TEAM Marjorie Warren Ward operating at safe staffing levels (amber / green). Additional HCA staffing at night to support 1:1 care

TEAM Byron Ward operating at safe staffing levels (amber) with occasional red shifts. Additional HCA staffing at night to

TEAM Lonsdale Ward operating at safe staffing levels (amber / green). Additional HCA staffing at night to support 1:1 care

Appendix 3

Exceptions Report – PRUH

HCA and RN staffing levels – Lower than Planned – June

Division WardReview by HON/Matron/Ward where 15% or more of nursing hours did not

meet agreed staffing levels (Highlighted in red)

Cardiac PRUH - Coronary Care Unit (CCU) Additional HCAs required to support the Confused patient's.

CCTD Intensive Care UnitSome sickness amongst HCAs, not all shifts backfilled by NHSP however staff

moves ensured patient safety was not affected.

Children's Special Care Baby Unit Awaiting new HCA starters - ward operating safely with the current numbers

Children's Children's Ward Awaiting new HCA starters - ward operating safely with the current numbers

LRS Boddington (ORP)We adjust staffing due to patient numbers and generally the reduced staffing is

because we have a lower number of patients on the ward.

LRS Quebec (ORP)We adjust staffing due to patient numbers and generally the reduced staffing is


Network Ontario (ORP)We adjust staffing due to patient numbers and generally the reduced staffing is


Network HASU - Hyper Acute Stroke UnitThere are vacancies that exist for HCAs however the ward manager and TIA

nurse have supported where possible to ensure patient care is not affected.

Neuro Frank CookseyVacancies within the HCAs however staff were moved around to ensure that

patient safety was not affected.

Appendix 4

Exceptions Report – PRUH

HCA and RN staffing levels – Lower than Planned – July

Division WardReview by HON/Matron/Ward where 15% or more of nursing hours did not

meet agreed staffing levels (Highlighted in red)

CCTD Intensive Care Unit

6 night shifts not covered by HCA due to sickness and mandatory training. Shifts

assessed individually as to whether NHSP backfilling required to ensure safe

staffing

Children's Special Care Baby UnitCurrently awaiting HCA's to start - ward operating safely with regard to number of

patients, acuity and staffing levels

Children's Children's WardCurrently awaiting HCA's to start - ward operating safely with regard to number of

patients, acuity and staffing levels

LRS Boddington (ORP)We adjust staffing due to patient numbers and generally the reduced staffing is


LRS Quebec (ORP)We adjust staffing due to patient numbers and generally the reduced staffing is


LRS Surgical Ward 4There is currently someone on Mat leave and we have moved staff around when

required to ensure patient safety is not affected.

Network Ontario (ORP)We adjust staffing due to patient numbers and generally the reduced staffing is


Network Stroke UnitWard operating safely -Lower RN number reflect vacancies -using HCA to

maximize care safety.

TEAM Farnborough WardLower RN usage at night is due to reduction of beds from 25 - 20 and therefore

skill mixed with additional HCAs instead.

Women's Maternity Unit (PRU) The lower actual RN numbers at night reflect sickness and also staff being taken

Appendix 5

New Return NHPPD – Denmark Hill

This is calculated by taking the Actual hours of Day and Night combined for each staff type and dividing by the number of patients on the ward at

23:59 – June 2016

Division Ward Name

%

Average

fill rate

RN - Day

%

Average

Fill rate

HCA -

Day

%

Average

fill rate

RN -

Night

% Average

Fill rate

HCA -

Night

Patients at

Midnight

23:59

Registered

midwives/

nurses

Care Staff Overall

TEAM Annie Zunz 95% 115% 99% 147% 735 6.0 3.0 9.0

Women's Brunel 94% 81% 100% 100% 470 4.8 1.9 6.7

TEAM Byron 87% 103% 76% 113% 910 3.5 2.5 6.0

CCTD Christine Brown CCU 98% 90% 96% 100% 511 23.4 1.3 24.7

Surgery Coptcoat Ward 79% 120% 89% 122% 379 5.8 1.9 7.7

Cardiac Cotton 92% 125% 95% 256% 787 3.6 3.1 6.7

Neuro David Marsden 87% 149% 85% 156% 962 4.1 4.3 8.4

Haematology Davidson 85% 93% 86% 138% 518 5.2 2.2 7.4

Liver and Renal Dawson 78% 140% 85% 143% 665 3.7 2.8 6.5

Haematology Derek Mitchell Unit 83% 103% 98% 100% 429 5.8 1.7 7.5

Cardiac DH - Coronary Care Unit (Sam Oram) 99% 102% 100% 800% 216 9.5 2.0 11.5

Children's DH-The Children's Surgical Ward 92% 93% 97% 133% 551 7.5 1.4 8.9

TEAM Donne 96% 99% 98% 132% 920 3.5 3.0 6.5

Haematology ELF & LIBRA Ward 86% 86% 89% 142% 489 5.7 2.2 7.9

Liver and Renal Fisk and Cheere Ward 81% 126% 83% 124% 646 5.9 3.0 8.9

CCTD Frank Stansil Critical Care 108% 100% 99% 107% 372 25.1 1.8 26.9

Private Patients Guthrie Ward 86% 97% 99% 100% 468 6.1 1.4 7.5

Liver and Renal Howard Ward 94% 108% 98% 103% 490 4.6 2.3 6.9

CCTD Jack Steinberg Critical Care 102% 100% 102% 93% 534 22.5 1.2 23.7

Surgery Katherine Monk 88% 116% 85% 145% 653 6.5 4.8 11.3

Neuro Kinnier Wilson 99% 117% 91% 140% 624 4.7 3.5 8.2

Neuro Kinnier Wilson HDU 102% 41% 103% 33% 330 12.4 0.3 12.7

Surgery Lister 80% 153% 76% 138% 830 3.7 2.5 6.2

Liver and Renal Liver Intensive Care Unit 107% 63% 102% 45% 439 29.5 0.6 30.1

TEAM Lonsdale 86% 92% 91% 104% 682 4.8 2.6 7.4

TEAM Marjorie Warren 79% 133% 102% 152% 921 3.7 3.5 7.2

TEAM Mary Ray 103% 124% 87% 135% 899 3.6 2.8 6.4

TEAM Matthew Whiting 91% 102% 100% 110% 494 4.4 3.1 7.5

Neuro Murray Falconer 91% 92% 97% 99% 821 4.9 2.4 7.3

Children's Neonatal Intensive Care Unit 125% 100% 122% 100% 943 12.9 0.0 12.9

TEAM Oliver 88% 98% 94% 120% 921 3.3 2.4 5.7

Children's Paediatric Short Stay 100% 73% 102% 93% 127 11.0 4.5 15.5

Women's Postnatal William Gilliat 92% 98% 103% 98% 1351 3.7 2.2 5.9

TEAM R D Lawrence 95% 106% 95% 100% 745 5.7 2.6 8.3

Children's Rays Of Sunshine 95% 163% 104% 43% 492 7.9 1.4 9.3

Cardiac Recovery Ward 94% 100% 94% 100% 90 28.0 0.1 28.1

Cardiac Sam Oram 90% 108% 88% 180% 527 4.0 2.4 6.4

Neuro The Friends Stroke Unit 98% 115% 99% 117% 809 7.0 3.4 10.4

Children's Thomas Cook CCCC 94% 90% 95% 83% 391 20.0 1.5 21.5

Liver and Renal Todd 104% 99% 96% 98% 638 5.6 2.5 8.1

Children's Toni & Guy 90% 144% 93% 225% 371 9.2 2.0 11.2

Surgery Trundle 98% 113% 100% 131% 437 5.3 4.8 10.1

Surgery Twining 97% 102% 86% 122% 770 3.7 3.1 6.8

Cardiac V&A HDU Ward 96% 100% 97% 107% 326 8.8 2.2 11.0

Cardiac Victoria & Albert 107% 145% 99% 133% 519 4.9 1.2 6.1

Haematology Waddington 82% 130% 94% 500% 279 6.6 1.8 8.4

Appendix 6

New Return NHPPD – Denmark Hill

This is calculated by taking the Actual hours of Day and Night combined for each staff type and dividing by the number of patients on the ward at

23:59 – July 2016

Division Ward Name

%

Average

fill rate

RN -

Day

%

Average

Fill rate

HCA -

Day

%

Average

fill rate

RN -

Night

%

Average

Fill rate

HCA -

Night

Patients

at

Midnigh

t 23:59

Register

ed

midwive

s/ nurses

Care

Staff

Overall

CHPPD

No. of

Beds

TEAM Annie Zunz 92% 117% 98% 130% 731 6.0 3.1 9.1 28

Women's Brunel 93% 90% 96% 109% 466 4.8 2.2 7.0 18

TEAM Byron 81% 100% 74% 118% 902 3.7 2.7 6.4 30

CCTD Christine Brown CCU 98% 94% 98% 90% 525 24.0 1.2 25.2 17

Surgery Coptcoat Ward 73% 183% 92% 181% 416 5.2 2.5 7.7 15

Cardiac Cotton 91% 120% 94% 202% 778 3.8 3.1 6.9 26

Neuro David Marsden 76% 150% 83% 161% 941 3.9 4.7 8.6 31

Haematology Davidson 87% 100% 82% 138% 519 5.3 2.4 7.7 17

Liver and Renal Dawson 72% 170% 78% 141% 610 3.8 3.7 7.5 21

Haematology Derek Mitchell Unit 83% 147% 98% 184% 425 6.0 2.9 8.9 14

CardiacDH - Coronary Care Unit

(Sam Oram)97% 115% 99% 500% 215 9.7 2.1 11.8 8

Children'sDH-The Children's Surgical

Ward89% 100% 95% 100% 584 7.3 1.4 8.7 21

TEAM Donne 90% 101% 98% 121% 923 3.5 3.2 6.7 30

Haematology ELF & LIBRA Ward 83% 86% 92% 139% 464 6.0 2.4 8.4 16

Liver and Renal Fisk and Cheere Ward 83% 139% 85% 159% 775 5.2 3.0 8.2 29

CCTD Frank Stansil Critical Care 108% 93% 97% 103% 402 24.1 1.7 25.8 30

Private Patients Guthrie Ward 89% 100% 95% 100% 510 5.8 1.4 7.2 21

Liver and Renal Howard Ward 84% 102% 100% 91% 513 4.3 1.9 6.2 16

CCTDJack Steinberg Critical

Care101% 97% 102% 94% 527 23.4 1.3 24.7 16

Surgery Katherine Monk 80% 119% 77% 164% 672 5.9 5.2 11.1 28

Neuro Kinnier Wilson 89% 117% 79% 159% 608 4.4 4.0 8.4 20

Neuro Kinnier Wilson HDU 97% 43% 100% 300% 335 12.5 0.4 12.9 11

Surgery Lister 72% 165% 89% 160% 842 3.6 2.9 6.5 25

Liver and Renal Liver Intensive Care Unit 97% 0% 97% 14% 415 30.4 0.6 31.0 19

TEAM Lonsdale 85% 106% 86% 118% 686 4.7 2.9 7.6 25

TEAM Marjorie Warren 80% 111% 95% 132% 933 3.4 3.5 6.9 30

TEAM Mary Ray 95% 124% 89% 134% 905 4.0 3.1 7.1 30

Neuro Murray Falconer 95% 130% 93% 128% 932 4.6 2.9 7.5 31

Children'sNeonatal Intensive Care

Unit119% 400% 119% 200% 1006 12.3 0.1 12.4 34

TEAM Oliver 94% 104% 98% 103% 891 3.6 2.5 6.1 30

Children's Paediatric Short Stay 102% 110% 102% 116% 125 11.4 6.3 17.7 6

Women's Postnatal William Gilliat 89% 104% 98% 111% 1553 3.2 2.2 5.4 48

TEAM R D Lawrence 98% 107% 103% 115% 746 6.2 2.6 8.8 28

Children's Rays Of Sunshine 98% 166% 102% 66% 513 7.8 1.6 9.4 19

Cardiac Recovery Ward 99% 100% 98% 100% 127 20.2 0.0 20.2 17

Cardiac Sam Oram 88% 133% 84% 230% 527 4.2 3.3 7.5 17

Neuro The Friends Stroke Unit 100% 105% 99% 108% 767 7.7 3.4 11.1 29

Children's Thomas Cook CCCC 91% 77% 94% 65% 380 20.9 1.3 22.2 15

Liver and Renal Todd 91% 93% 94% 106% 620 5.6 2.7 8.3 22

Children's Toni & Guy 88% 175% 94% 2600% 371 9.6 2.3 11.9 15

Surgery Trundle 93% 102% 90% 127% 455 4.8 4.4 9.2 16

Surgery Twining 94% 94% 90% 133% 773 4.0 3.4 7.4 26

Cardiac V&A HDU Ward 99% 90% 98% 100% 347 8.7 1.9 10.6 10

Cardiac Victoria & Albert 99% 155% 98% 175% 516 4.8 1.4 6.2 18

Haematology Waddington 85% 132% 91% 900% 276 6.8 2.1 8.9 9

Appendix 7

New Return NHPPD – PRUH

This is calculated by taking the Actual hours of Day and Night combined for each staff type

and dividing by the number of patients on the ward at 23:59 – June 2016

Division Ward

%

Averag

e fill

rate

RN/RM -

Day

%

Averag

e Fill

rate

HCA -

Day

%

Averag

e fill

rate

RN/RM -

Night

%

Averag

e Fill

rate

HCA -

Night

Patients

at

Midnight

23:59

Registered

midwives/

nurses

Care

StaffOverall

No. of

Beds

LRS Boddington (ORP) 71% 61% 70% 68% 435 4.6 2.6 7.2 24

Network Chartwell Unit 96% 95% 97% 102% 369 5.4 3.1 8.5 12

Children's Children's Ward 102% 68% 96% 72% 309 7.6 1.4 9.0 12

TEAM Darwin 1 (S1) 95% 98% 99% 131% 575 3.9 5.4 9.3 20

TEAM Darwin 2 (S2) 100% 100% 99% 102% 609 3.4 4.5 7.9 20

TEAM Emergency Assessment Unit (EAU) 101% 99% 99% 93% 736 5.5 3.5 9.0 28

TEAM Farnborough Ward 115% 99% 119% 101% 771 3.5 3.0 6.5 25

Neuro Frank Cooksey 101% 80% 103% 92% 447 3.9 3.3 7.2 15

Network HASU - Hyper Acute Stroke Unit 98% 83% 94% 104% 386 10.2 3.2 13.4 20

CCTD Intensive Care Unit 101% 87% 102% 63% 247 25.6 2.1 27.7 10

Women's Maternity Unit (PRU) 96% 94% 87% 89% 652 4.8 2.5 7.3 30

TEAM Medical Ward 1 102% 111% 100% 109% 352 5.8 3.2 9.0 12






Cardiac Medical Ward 8 100% 97% 101% 98% 597 3.5 2.2 5.7 20


Network Ontario (ORP) 89% 69% 103% 97% 463 3.5 3.0 6.5 20

Cardiac PRUH - Coronary Care Unit (CCU) 74% 300% 100% 500% 329 6.9 0.5 7.4 12

LRS Quebec (ORP) 82% 86% 84% 72% 131 11.1 6.5 17.6 19

Children's Special Care Baby Unit 96% 36% 96% 36% 198 10.0 1.1 11.1 12

Network Stroke Unit 98% 101% 87% 110% 786 3.1 2.6 5.7 20

LRS Surgical Ward 3 97% 103% 101% 105% 507 4.6 2.8 7.4 20





Women's Surgical Ward 8 99% 99% 96% 99% 440 5.1 2.3 7.4 16

Appendix 8

New Return NHPPD – PRUH

This is calculated by taking the Actual hours of Day and Night combined for each staff type

and dividing by the number of patients on the ward at 23:59 – July 2016

Division Ward

%

Averag

e fill

rate

RN/RM -

Day

%

Averag

e Fill

rate

HCA -

Day

%

Averag

e fill

rate

RN/RM -

Night

%

Averag

e Fill

rate

HCA -

Night

Patients

at

Midnight

23:59

Registered

midwives/

nurses

Care

Staff

Overall

CHPPD

No. of

Beds

LRS Boddington (ORP) 79% 71% 85% 60% 330 6.3 3.2 9.5 24

Network Chartwell Unit 96% 95% 99% 103% 361 5.8 2.9 8.7 12

Children's Children's Ward 102% 31% 102% 17% 290 8.2 0.5 8.7 12

TEAM Darwin 1 (S1) 86% 105% 100% 129% 618 3.5 5.4 8.9 20

TEAM Darwin 2 (S2) 101% 103% 100% 116% 614 3.5 5.0 8.5 20

TEAM Emergency Assessment Unit (EAU) 95% 106% 99% 99% 737 5.8 3.9 9.7 28

TEAM Farnborough Ward 89% 179% 75% 300% 613 3.8 3.8 7.6 20

Neuro Frank Cooksey 98% 94% 98% 106% 458 3.9 4.4 8.3 15

Network HASU - Hyper Acute Stroke Unit 96% 97% 91% 108% 385 10.2 3.8 14.0 20

CCTD Intensive Care Unit 110% 106% 114% 81% 297 24.2 2.2 26.4 10

Women's Maternity Unit (PRU) 98% 87% 76% 95% 630 5.5 2.6 8.1 30






Cardiac Medical Ward 8 102% 94% 101% 102% 611 3.6 2.2 5.8 20


Network Ontario (ORP) 86% 80% 98% 102% 472 3.4 3.3 6.7 20

Cardiac PRUH - Coronary Care Unit (CCU) 98% 175% 101% 400% 350 6.9 0.4 7.3 12

LRS Quebec (ORP) 80% 84% 90% 78% 264 5.8 3.3 9.1 19

Children's Special Care Baby Unit 98% 80% 102% 50% 254 8.3 1.8 10.1 12

Network Stroke Unit 95% 101% 77% 123% 800 3.1 2.7 5.8 20






Women's Surgical Ward 8 93% 98% 99% 118% 414 5.6 2.7 8.3 16

Finance Report

Month 04 (July) 2016/17

Board of Directors 09 September 2016

Enc. .

Page 2 of 28

Enc. 6.1


Date of meeting: 09-Sep-16

Subject: Finance Report – Month 04 (July 2016)

Author(s): Simon Dixon, Nicola Hoeksema, Rita Ragunath, Iris Lewis

Presented by: Colin Gentile, Chief Financial Officer

Sponsor: Colin Gentile, Chief Financial Officer

History: First submission to Finance and Performance Committeein August

Status: Decision/Discussion/Information

1. Purpose The Finance Reports includes information on the Trust’s financial performance and position which support the in-year

submissions to Monitor on a quarterly basis.

This report covers the Income & Expenditure position, Cost Improvement Programme, Capital and Working Capital Plans.

2. Action required The Board is asked to note the Finance Report

Enc. .

Page 3 of 28

Enc. 6.1

Legal: Reporting to Monitor

Financial:Trust reports financial performance and position against published plan and notifies the committee

of financial risks, cost pressures and action plans to mitigate any material variance from financial

targets.

Assurance:The summary and appendices provide assurance that the Trust is meeting Financial targets

(internal and those set by Monitor) and is compliant with its terms of authorisation.

Clinical: There is no direct impact on clinical issues

Equality & Diversity: There is no direct impact on E&D

Performance: Financial Performance against annual plan, budgets, CIPs and Monitor Risk Ratings and Limits.

Strategy: Performance against the Trust’s Annual Plan including Risk Ratings

Workforce:There are implications for workforce recruitment in respect to service developments and

vacancies.

Estates: There are implication on the Trust’s estates strategy.

Reputation:Finance Committee Report is provided to Monitor and Commercial Bankers as additional

information to support the quarterly Monitor Return.

Other:(please specify) None.

3. Key implications

Enc. .

Page 4 of 28

Enc. 6.1

Page

Key Messages 5

Summary 6

Month 2 Surplus / (Deficit) £k 7

Income 8

Operating Expenditure 9

Run Rate 10

16/17 Annual Plan Budget Phasing 11

Cost Improvement Plans 12

16-17 CIP Programme Delivery Summary (£71M) 13

PMO CIP Green Phasing 14

Cash 15

13 Week Cash Flow Forecast 16

Statement of Financial Position (Balance Sheet) 17

Aged Debtors 18

Debtors Detail 19

Bad Debt Provision 20

Capital 21

Agency Run Rate 22

Agency Cap 23

Whole Time Equivalents 24

Income by Commissioner Contract 25

Income Activity Analysis 26

Surplus / (Deficit) (By Division) 27

Contents Enc. .

Enc. 6.1

Income and Expenditure

1

2

3

4

5

6

7

Cash

8

Capital

9

STF - adverse variance of £10.0m

The run rate was averaging a monthly deficit of £10.8m in Q1. The deficit in M04 was £8.8m, a £2m improvement on the Q1 average. The NHSI agency cap for the

Trust year to date was £10m and the Trust has spent £14m with increases predominately in medical and nursing staff categories.

The Trust’s cumulative operating deficit at month 4 is £41.147m. This is an adverse variance of £18.867m against the year to date planned deficit of £22.280m.

These figures exclude the estimated impairment costs of £2.574m to date.

The key cumulative variances at month 4 relate to:

The month 4 position reflects the recent Sustainability and Transformation Fund (STF) criteria to access the funds determined by NHSI (£30m for KCH). The Trust

is not achieving the financial control total and has not accounted for the STF of £10.0m in M4. From quarter 2 the STF allocation will be dependent on achieving

the finance target (70% weighting) and patient access standards (30% weighting). If the Trust meets its finance target in quarter 4, it can earn back parts of the

fund that they have failed to achieve in previous periods.

NHS Clinical Contract activity income – adverse by £7.3m

Cost Improvement plans - adverse variance of £2.3m

The Trust has agreed the NHSE contract and the month 4 contract activity position will be more precise as it will be measured against an agreed plan for each

clinical sub-specialty. At month 4 the Trust is estimated to be over-performing against the block contracts for Bromley and Bexley CCG due to high levels of

Emergency activity and Critical Care activity. The Trust is under-achieving against “non-block” CCG contracts and NCAs (Non contracted activity target).

The CIP adverse variance relates to the FYE of 15/16 schemes (£2m) in 16/17; a combination of pay and non-pay schemes related to proposed ward closures and

Procurement schemes. The Trust has currently identified £36m PMO Green schemes for implementation and potential mitigation schemes of £7m against the

£51.5m target for new schemes in 16/17.

The Trust will produce a formal financial projection as at month 4 which will be refreshed each month in line with the Trust’s recovery plan. The Trust is already

developing mitigations to meet the CIP unidentified shortfall and adverse variance. A number of business cases have been developed to deliver the income and

access targets at a positive margin.

The Trust has drawn down £19.7m against its Working Capital Facility (WCF) in July and a further in £4.5m drawdown in August in order to maintain a minimum

cash balance of £3m.

The total value of the Working Capital Facility drawndown as at Month 5 2016/17 will be £55.8m (62%) against a current approved facility of £89.6m.

As the WCF cannot be utilised to improve creditor payment days and the Trust's available cash is insufficient to maintain creditor days, outstanding debts are

increasing. This is putting pressure on supplier relationships and impacting on operational delivery. The Trust is awaiting approval from NHSI of additional working

capital support (£90m) as presented in the annual plan re-submission.

The planned capital expenditure for 2016/17 of £71.189m was approved by the board and assumes additional distressed capital funding of £39m will be received

from NHSI.

The underspend reflected at month 4 reflects the delay in confirmation of Distressed Capital funding from NHSI. Projects totalling £24m (including the additional

bed capacity and ED projects £10.9m) have been started at risk prior to formal NHSI approval of the distressed capital funding.

Key Messages Enc. .

Page 6 of 28

Enc. 6.1

Finance Report Month 04 2016/2017 Summary

Surplus / (Deficit) £k R Income £k R Operating Expenditure £k R

Plan Actual Variance Plan Actual Variance Plan Actual Variance

Year to Date £k (22,280) (41,147) (18,867) Year to Date £k 366,516 354,002 (12,514) Year to Date £k (367,763) (374,153) (6,389)

Run Rate £k R Cost Improvement Plans £k R Capital £k R

M1

Actual

M2

Actual

M3

Actual

M4

Actual 16/17 Total Plan Actual Variance Plan Actual Variance

Income £k 84,780 88,734 91,167 89,319 354,001 Year to Date £k 14,200 12,056 (2,144) Year to Date £k 10,930 8,080 2,850

Pay £k (52,174) (52,918) (54,465) (52,377) (211,934)

Non-Pay £k (45,297) (44,903) (47,299) (45,718) (183,217)

Deficit £k (12,690) (9,087) (10,597) (8,776) (41,150)

Cash £k R Key Risks R Mitigating Actions R

Plan Actual Variance

Year to Date £k 20,178 31,412 11,234

The Trust is reporting a £41.1m deficit at the end of M04 against a planned deficit of £22.3m resulting in a £18.9m adverse YTD variance. Following recent guidance from NHSI the trust is not acheiving its financial control total year to date so we are unable

to reflect any of the STF in our numbers, this is £10m of the YTD adverse variance.

The underlying deficit for 15/16 was £118m which equates to a monthly run rate deficit of circa £10m. The average run rate year to date was £10.3m. The run rate improved in M4 by £1.8m.

The programme overall achieved 85% of its YTD target with the flow through

element achieving 78% and the new schemes achieving 97%. The CIP

programme as at M4 has had a total scheme slippage of £2.1magainst target

(15%) of which £443k is slippage against procurement schemes which have

failed from the flow through from 15-16. There are substitute schemes

expected to start in Q2. The remaining slippages are a combination of failed

schemes in income, delayed implementations, failed recruitment and ward

escalation beds remaining opened. The reported slippage will recover from Q2

(approx. £300k).

1.

Mitigating CIP schemes totaling £7m of which 2 schemes are dependant on NHSI

capital funding approval (Finance Leases and Windsor Walk) with a net benefit of

£4m.

2. Implementing operational plans to acheive growth and RTT activity

3. Reduce agency spend through recruitment plans, master vendor suppliers to

control agency rates and increased use of bank staff.

The run rate improved by £1.8m compared to M3. Income worsened by £1.8m in month

mainly in off tariff drugs, M3 was higher than average due to a catch up on billing. Pay run

rate improved by £2m mainly in substantive pay this is due to pathology staff transferring

to Viapath, Urology staff transferring to Lewisham and non recurrent backpayments made

in M3. Nonpay improved by £1.6m, IFM VAT savings started in July and there were some

additional VAT savings this month.

1. CIP

achievement £51.5m new and £21m flow through. £56.3 approved 'greened'

schemes to date (week ending 12/08/16)

2. Income targets includes RTT backlog £4.8m and 2.3% growth, £20.7m.

3. The key income risks will be the NHSE QIPP target for 16/17 (£7.7m) and

Bromley CCG activity demand management (£3m). The Trust led CCG QIPP for

Lambeth, Southwark and Bromley CCG's is £5.3m and this is embedded in the

Block contract.

4. Cost control measures re: agency spend

5. Cash flow impacting on operational delivery

6. Income - the following have not yet been applied - agreed data challenges,

marginal rates on cost and volume lines for BMT & NICU, MRET adjustment,

gain share adjustment calculated on actual outsourced pharmacy savings, other

high cost drugs Gain Share Savings (TBA) and CQUIN (Quarterly performance)

which will drive down the over-performance

Month 4 is based on Month 3 spell/FCE activity and pro-rata for Month 3.

Bromley, Lambeth & Southwark contracts have been agreed and are reflected

within the plan. All other commissioners e.g. NHSE are based on KCH internal

income proposals, although the NHSE contract for 16/17 has now been agreed.

The adverse variance relates to clinical contract income, overseas visitors

income and other operating income. The Trust is over-performing against the

Bromley & Bexley CCG block contract values due to high levels of critical care

activity.

The Trust is reporting a £41.1m deficit at the end of M04 against a planned deficit of

£22.3m resulting in a £18.9m adverse YTD variance.

In respect to NHS clinical contract income : Off-tariff drugs and devices over-performance

of £6.5m YTD (£2m in M4); are being offset by activity income underperformance of

£7.3m YTD.

Pay is £1.3m underspent at the end of M04.

Nonpay is over spent due to off-tariff drugs and devices over performance which is mostly

offset by income. The trust is not acheiving its financial control total year to date so we

are unable to reflect any of the STF funding in our numbers, this is £10m of the YTD

adverse variance.

Pay is £1.3m underspent at the end of M04 including £1.3m of CIP slippage

(15/16 flow through). Admin and Clerical pay is underspent due to a number of

vacancies. This is partly offset by medical pay which is overspent due to

backdated banding payments and increased locum expenditure (covering

vacancies and on call) mainly in Orthopaedics,Urology and Neuroscience.

Nonpay is over spent due to off-tariff drugs and devices over performance which

is mostly offset by income. There is £553k of CIP slippage in M04 (15/16 flow

through)

The planned capital expenditure for 2016/17 of £71.189m was approved by the

board and assumes additional distressed capital funding of £39m will be received

from NHSI.

The underspend reflected at month 4 reflects the delay in confirmation of

Distressed Capital funding from NHSI. Projects totalling £24m (including the

additional bed capacity and ED projects £10.9m) have been started at risk prior

to NHSI approval of the distressed capital funding. Other projects are on hold

until external funding is confirmed.

The Trust has drawn down £19.7m against its Working Capital Facility in July and a further

in £4.5m drawdown is planned for August in order to maintain a cash balance of £3m.

The total value of the Working Capital Facility drawndown as at end of July 2016 was

£51.3m (57%) against a current approved facility of £89.6m.

As the WCF cannot be utilised to improve creditor payment days and the Trust's available

cash is insufficient to maintain creditor days, outstanding debts are increasing. This is

putting pressure on supplier relationships and risking availability of supplies.

Enc. .

Page 7 of 28

Enc. 6.1

Finance Report Month 04 2016/2017 Surplus / (Deficit) £k R

YTD Plan YTD Actual

YTD

Variance

Mvnt in

Month

£k £k £k £k

Surplus / (Deficit) (22,280) (41,147) (18,867) (6,092)

YTD Plan YTD Actual

YTD

Variance

Mvnt in

Month

£k £k £k £k

Income 366,516 354,002 (12,514) (4,424) £10m of the YTD variance relates to STF (£2.5m in month)

Pay (213,226) (211,934) 1,292 919 Underspent mainly in admin and clerical pay

Non-Pay (154,537) (162,217) (7,681) (2,578) Off-tariff drugs and devices over performance which is mostly offset by income

EBITDA * (1,246) (20,150) (18,903) (6,083)

EBITDA % -0.3% -5.7%

Profit/Loss on Disposal of Fixed Assets (33) 2 35 10

Interest Payable (9,775) (9,769) 6 (10)

Interest Receivable 44 35 (9) (9)

Depreciation (8,822) (8,818) 4 1

Impairments (3,433) (3,433) 0 0

Public Dividend Capital (2,448) (2,448) 0 0

Net surplus/(deficit) (25,714) (44,581) (18,867) (6,092)

Reverse Impairment 3,433 3,433 0 0

Performance against Control Total (22,280) (41,147) (18,867) (6,092)

Total (22,280) (41,147) (18,867) (6,092)

Surplus/(Deficit) % -6.1% -11.6%

* EBITDA Earnings before Interest, Taxation, Depreciation and Amortisation

The Trust is reporting a £41.1m deficit at the end of M04 against a planned deficit of £22.3m resulting in a £18.9m adverse YTD variance. The current month position is a £6.1m deficit.

In respect to NHS clinical contract income : Off-tariff drugs and devices over-performance of £6.5m YTD (£2m in M4); are being offset by activity income underperformance of £7.3m YTD. Also overseas visitor income is

adverse as well as misc operating income which are partly off-set by additional R&D and RTA income. The trust is not acheiving its financial control total year to date so we are unable to reflect any of the STF in our

numbers, this is £10m of the income variance.

Pay is £1.3m underspent at the end of M04 including £1.3m of CIP slippage (15/16 flow through). Admin and Clerical pay is underspent due to a number of vacancies. This is partly offset by medical pay which is overspent

due to backdated banding payments and increased locum expenditure (covering vacancies and on call) mainly in Orthopaedics,Urology and Neuroscience.

Nonpay is over spent due to off-tariff drugs and devices over performance which is mostly offset by income. There is £553k of CIP slippage in M04 (15/16 flow through)

See Appendix 3 for Divisional and Corporate Analysis.

Enc. .

(15,000)

(10,000)

(5,000)

-

5,000

10,000

15,000

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Mar

-17

£k

Deficit by Month 2016/17 Net Operating Deficit Actuals Net Operating Deficit Plan

Page 8 of 28

Enc. 6.1

Finance Report Month 04 2016/2017 Income R

YTD Plan YTD Actual YTD Variance

Mvnt in

Month

£k £k £k £k

Total Income 366,516 354,002 (12,514) (4,424)

YTD Plan YTD Actual YTD Variance

Mvnt in

Month

£k £k £k £k

Commissioning Contract Income 258,040 253,345 (4,695) (1,411)

NHS Acute: Drugs - Non Tariff 33,926 38,656 4,730 1,266

NHS Acute: Drugs (CDF) 2,233 2,233 0 12

NHS Acute: Devices - Non Tariff 4,348 6,083 1,735 675

Local Authority Income - GUM Services 2,134 1,727 (407) (391)

Other Clinical Income 3,007 761 (2,246) (1,416) Prior year net adjustments and work in progress income benefit

NHS Clinical Contract Income Total 303,689 302,805 (884) (1,265)

RTA Income 1,500 1,921 421 132

Other NHS Clinical Income 1,898 1,535 (363) (156)

Private Patient Income 5,020 5,317 297 (136)

Overseas (Reciprocal & Non-Reciprocal) 2,437 1,897 (541) 315

Education & Training Income 15,731 15,650 (81) (9)

Research & Development Income 3,490 4,268 778 29 Additional income offsetting expenditure in respect to new grants

Other Operating Income 32,751 20,610 (12,141) (3,334)

Total Trust Income 366,516 354,002 (12,514) (4,424)

In respect to NHS clinical contract income : Off-tariff drugs and devices over-performance of £4.7m YTD (£1.2m in M4); are being offset by activity income underperformance of £4.7m YTD. The trust is not acheiving its financial

control total year to date so we are unable to reflect any of the STF in our numbers, this is £10m of the income variance.

Elective income underperformance (non-block CCGs and NCA)

Pass through payments to Commissioners offsetting expenditure overspends

STF allocation, Urology theatre recharges to LGT, accomodation charges, donated income and salary

recharges all adverse in comparison to last years outturn.

80,000

85,000

90,000

95,000

100,000

105,000

110,000

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Mar

-17

£k

In Month Income 2016/17 Actual Plan

Enc. .

Page 9 of 28

Enc. 6.1

Finance Report Month 04 2016/2017 Operating Expenditure R

YTD Plan YTD Actual

YTD

Variance

Mvnt in

Month

£k £k £k £k

Pay (213,226) (211,934) 1,292 919

Non-Pay (154,537) (162,218) (7,681) (2,578)

Operating Expenditure (367,763) (374,153) (6,389) (1,659)

YTD Plan YTD Actual

YTD

Variance

Mvnt in

Month

£k £k £k £k

Pay

Nursing & Midwifery (83,604) (83,870) (267) (3)

Medical & Dental Staff (67,434) (68,031) (597) 303

Administration & Clerical / Senior Managers (34,846) (33,029) 1,816 313

PAMS / Scientific / Professional (27,343) (27,003) 340 305

Total Pay (213,226) (211,934) 1,292 919

Non-Pay

Drugs (incl. Medical Gases) (10,207) (11,302) (1,095) 670

Drugs : Non-Tariff (36,159) (37,835) (1,676) (2,954) Off tariff drugs income overperforming by £4.7m

Supplies & Services - Clinical (32,256) (34,271) (2,015) (1,058) Off tariff devices income overperforming by £1.7m

Supplies & Services - General (1,237) (1,448) (212) (114)

Establishment Expenses (2,050) (1,722) 328 127

Transport Expenses (3,023) (2,563) 460 167

Premises (12,694) (12,228) 466 298

Purchase of Healthcare from Non-NHS Provider (10,137) (11,057) (920) 49 Viapath contract overperformance

Services from other NHS Bodies (18,643) (18,708) (65) (78)

Consultancy (4,740) (4,468) 272 (20)

Private Finance Initiative (18,865) (18,746) 119 308

Other Non-Pay/Reserves (4,527) (7,870) (3,343) 28 R&D (offet by Income) and Overseas bad debt provision

Total Non-Pay (154,537) (162,218) (7,681) (2,578)

Total Expenditure (367,763) (374,153) (6,388) (1,659)

Pay is £1.3m underspent at the end of M04 including £1.3m of CIP slippage (15/16 flow through). Admin and Clerical pay is underspent due to a number of vacancies. This is partly offset by medical pay which is overspent due to

backdated banding payments and increased locum expenditure (covering vacancies and on call) mainly in Orthopaedics,Urology and Neuroscience.

Nonpay is over spent due to off-tariff drugs and devices over performance which is mostly offset by income. There is £553k of CIP slippage in M04 (15/16 flow through)

Enc. .

Page 10 of 28

Enc. 6.1

Finance Report Month 04 2016/2017 Run Rate R

Apr-16 May-16 Jun-16 Jul-16

£k £k £k

Deficit (13,548) (9,945) (11,455) (9,634)

Impairment 858 858 858 858

Operating Deficit (12,690) (9,087) (10,597) (8,776)

Apr-16 May-16 Jun-16 Jul-16

£k £k 0 £k

Income 84,780 88,734 91,167 89,319

Pay

Administration & Clerical / Senior Managers Agency (717) (743) (648) (692)

Bank (223) (230) (272) (259)

substantive (7,310) (7,288) (7,339) (7,308)

Medical & Dental Staff Agency (870) (1,104) (1,440) (1,290)

Bank (384) (486) (513) (438)

substantive (15,325) (15,620) (15,462) (15,100)

Nursing & Midwifery Agency (878) (872) (963) (1,099)

Bank (2,409) (2,295) (2,572) (2,577)

substantive (17,557) (17,336) (17,872) (17,441)

PAMS / Scientific / Professional Agency (343) (762) (849) (570)

Bank (190) (158) (246) (196)

substantive (5,967) (6,023) (6,290) (5,408)

Total Pay (52,174) (52,918) (54,465) (52,377)

Non-Pay

Drugs (2,905) (2,121) (2,658) (2,547)

Off-tariff Drugs Expenditure (9,726) (9,726) (9,726) (9,726)

Supplies & Services - Clinical (8,819) (8,412) (9,420) (7,621)

Non-Clinical Supplies (4,512) (4,704) (4,497) (4,248)

Purchase of Healthcare from Non-NHS Provider (2,355) (2,651) (3,043) (3,008)

Services from other NHS Bodies (4,601) (4,597) (4,837) (4,673)

Consultancy (626) (798) (1,195) (1,849)

Private Finance Initiative (4,716) (4,609) (4,701) (4,720)

Other Non-Pay/Reserves (1,784) (2,030) (1,962) (2,094)

Total Non-Pay (40,044) (39,649) (42,038) (40,486)

Total Financing (6,111) (6,111) (6,118) (6,090)

Deficit (13,548) (9,945) (11,455) (9,634)

Impairment 858 858 858 858

Operating Deficit (12,690) (9,087) (10,597) (8,776)

Non Recurrent Items

Non Recurrent PRUH Financial Support (700) (700) (700) (700)

Non Recurrent CIPs (60) (154) (436) (530)

Total Non Recurrents (760) (854) (1,136) (1,230)

Underlying Run Rate Deficit (13,450) (9,941) (11,733) (10,006)

The underlying deficit for 15/16 was £118m which equates to a monthly run rate deficit of circa £10m. The phasing of the CIPs should improve this run rate and reduce the deficit position. The run rate

improved by £1.8m compared to M3. Income worsened by £1.8m in month mainly in off tariff drugs, M3 was higher than average due to a catch up on billing. Pay run rate improved by £2m mainly in

substantive pay this is due to pathology staff transferring to Viapath, Urology staff transferring to Lewisham and non recurrent backpayments made in M3. Nonpay improved by £1.6m, IFM VAT savings

started in July and there were some additional VAT savings this month.

Month 1 income was potentially understated and month 2 overstated due to activity recording errors and the average run rate of £8.2m is reflective of quarter 1 (prior year run rate average was £10m).

Page 11 of 28

Enc. 6.1

Finance Report Month 04 2016/2017 16/17 Annual Plan Budget Phasing

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Cumulative

£k £k £k £k £k £k £k £k £k £k £k £k £k

Themes

Income 87,182 91,092 94,447 93,778 89,375 95,465 99,502 96,321 89,287 95,092 92,827 96,553 1,120,922

Pay (53,942) (54,961) (54,436) (55,091) (54,820) (54,363) (55,323) (55,856) (55,884) (55,510) (55,360) (56,127) (661,672)

Nonpay (47,524) (46,958) (47,039) (46,344) (44,778) (43,652) (46,101) (45,996) (45,659) (44,720) (43,371) (41,313) (543,454)

Flow Through CIP 2,430 2,299 2,126 2,634 2,288 1,992 1,351 1,327 1,209 1,079 1,016 1,003 20,753

16/17 CIP 805 1,084 1,221 1,483 1,576 1,745 6,293 6,346 6,581 7,120 7,188 10,057 51,500

Deficit (11,048) (7,445) (3,681) (3,540) (6,358) 1,188 5,722 2,143 (4,465) 3,059 2,301 10,172 (11,951)

Impairment 858 858 858 858 858 858 858 858 858 858 858 858 10,296

Operating Deficit (10,190) (6,587) (2,823) (2,682) (5,500) 2,046 6,580 3,001 (3,607) 3,917 3,159 11,030 (1,655)

Source: Extracted from Annual Plan re-submission which reflects deficit position for months 1-3

The phasing will be adjusted as the CIP delivery plans are materialised in robust and accountable schemes.

Enc. .

0

1000

2000

3000

4000

5000

6000

7000

8000

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

CIP Monthly Phasing

Flow Through CIP

16/17 CIP

0

10,000

20,000

30,000

40,000

50,000

60,000


Cummulative Total CIP

Flow Through CIP

16/17 CIP

-80000

-60000

-40000

-20000

0

20000

40000

60000

80000

100000

120000


I&E

Income

Pay

Nonpay

Operating Deficit

Page 12 of 28

Enc. 6.1

Finance Report Month 04 2016/2017 Cost Improvement Plans R

Year to Date Plan Actual Variance

£k £k £k

Cost Improvement Plans 14,200 12,056 (2,144)

Year to DatePlan Actual Variance

£k £k £k

Themes

Income

NHS Commissioner (NHSE) 683 522 (161)

NHS Commissioner (CCG) 184 184 0

NHS Provider to Provider 117 117 (0)

Private Patient 290 196 (94)

Other Operating 419 416 (3)

Research And Development 0 0 0

Training & Education 13 13 0

Total Income CIPs 1,707 1,449 (258)

Pay

Administrative and Clerical Staff Reduction 1,351 1,329 (21)

Medical Staff Reduction 351 335 (17)

Nursing Staff Reduction 2,292 1,578 (714)

Prof & Tech/PAMS/Other Reduction 728 723 (5)

Procurement 150 150 1

Recruitment - Agency Reduction 665 344 (321)

VAT 24/7 Payroll Service 550 547 (3)

Nurse Rotas 387 226 (161)

Vacancy Freeze 160 98 (62)

Theatre Savings 235 235 0

Reducing Clinical Services 1 1 0

Medical Job Planning 367 337 (30)

Total Pay CIPs 7,238 5,903 (1,334)

Non-Pay

Capital 2 2 0

Clinical Supplies and Services 752 696 (56)

Contracting Services Out 3 3 (0)

Drugs 642 642 0

Establishment Expenses 106 81 (25)

External Contract staffing and Consultants 268 268 0

General Supplies and Services 355 355 0

Miscellaneous 352 331 (22)

Non-Clinical Spend Reduction 76 76 0

Premises and Fixed Plant 706 706 (0)

Reserves 0 0 0

Reducing Services 50 45 (5)

Services Provided by non-NHS bodies 566 566 0

Sub Contracted Healthcare - NHS bodies 224 224 0

Transport and Moveable Plant 102 102 0

Procurement 1,052 607 (445)

Total Non-pay CIPs 5,256 4,703 (553)

Efficiency Plan Total 14,200 12,056 (2,144)Divisions YTD Plan Actual Variance

£k £k £k

Ambulatory 1,890 1,859 (31)

CCTD 2,643 2,474 (169)

Pathology 0 0 0

TEAM 2,335 1,304 (1,032)

LRS 1,142 851 (291)

NWS 2,267 1,784 (483)

W&C 1,360 1,326 (35)

Facilities 690 690 (0)

Corporate 1,872 1,768 (103)

Efficiency Plan Total 14,200 12,056 (2,144)

The programme overall achieved 85% of its YTD target with the flow through element achieving 78% and the new schemes achieving 97%. The CIP programme as at M4 has had a total scheme slippage of £2.1magainst target (15%) of which £443k is slippage against

procurement schemes which have failed from the flow through from 15-16. There are substitute schemes expected to start in Q2. The remaining slippages are a combination of failed schemes in income, delayed implementations, failed recruitment and ward escalation

beds remaining opened. The reported slippage will recover from Q2 (approx. £300k).

Enc. .

Page 13 of 28

Enc. 6.1

Finance Report Month 04 2016/2017 16-17 Programme Delivery Summary (£71M) R

Plan Actual Variance

£k £k £k % Achievement

In Month 4,712 4,224 (488) 90%

Year To Date 14,200 12,056 (2,144) 85%

The information on this report includes all schemes sent across to finance as at 27/07/2016. The PMO have converted more schemes since that time so the numbers will not reconcile against the weekly report.

The programme in M4 slipped by £0.5M. Overall the programme is achieving 85% of its YTD target with the flow through element achieving 78% and the new schemes achieving 97%. The in month achievement was 90%.

The CIP programme as at M4 has had a total scheme slippage of £2.1M against target (15%) of which £443k is slippage against procurement schemes which have failed from the flow through from 15-16. There are substitute schemes

expected to start in Q2.

The remaining slippages are a combination of failed schemes in income (private patients), delayed implementations, failed recruitment and ward escalation beds remaining opened. The reported slippage will recover from Q2 (approx.

£300k).

The total slippage is made up of Income (£258k), Pay (£1,334k) and Non pay (£553k) and split £2M in flow through and £150k from new schemes.

Enc. .

Page 14 of 28

Enc. 6.1

Finance Report Month 04 2016/2017 PMO Green Phasing R

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 Total

Income 46 86 84 241 232 228 196 196 187 152 152 152 1,952

Pay 1,430 1,418 1,304 1,663 1,433 1,210 766 755 662 599 540 529 12,309

Non Pay 954 795 738 327 523 453 288 275 258 227 222 1,432 6,492

Total: 2,430 2,299 2,126 2,231 2,188 1,891 1,250 1,226 1,108 978 915 2,113 20,753

Income 220 199 413 526 563 564 515 541 495 566 627 1,565 6,795

Pay 490 753 786 956 1,147 6,370 1,492 1,514 1,642 1,642 1,671 3,438 21,902

Non Pay 304 280 342 583 431 546 610 644 624 729 730 1,048 6,871

Total: 1,014 1,233 1,540 2,065 2,140 7,481 2,617 2,700 2,762 2,936 3,028 6,051 35,567

3,444 3,532 3,666 4,296 4,328 9,372 3,866 3,926 3,869 3,914 3,943 8,164 56,320

A total of £56M has been signed off as ‘PMO Green’ from the programme as at the 12th August made up of both flow through schemes from 15/16 and new schemes from this financial year. The phasing is shown on

the left graph below. There remains approx. £19M in pre-pod and POD received status which continue to be worked up. The graph on the right shows the current phasing against the phasing that was submitted on the

trusts annual plan. Note all the above has not been removed from financial budgets yet as a large proportion was converted during month 5. There is approx. £6.3M to be adjusted.

16/17 PMO Green Phasing

15

-16

FY

E

Sch

em

es

16

-17

Ne

w

Sch

em

es

Grand Total:

Enc. .

0

1000

2000

3000

4000

5000

6000

7000

8000

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

Phasing Split By Type

15-16 FYE Schemes 16-17 New Schemes

0

2000

4000

6000

8000

10000

12000

14000

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

Combined 16/17 'PMO Green' Phasing

16/17 PMO Green Phasing 16-17 Annual Plan Phasing 16-17 Annual Plan Phasing

Original Revised

Page 15 of 28

Enc. 6.1

Finance Report Month 04 2016/2017 Cash R


£k £k £k

Cash Balance 20,178 31,412 11,234


£k £k £k

EBITDA (467) (6,570) (6,102)

Movement in Working Capital (4,840) 7,445 12,285

Provisions 0 0 0

Cash flow from Operations (5,307) 875 6,183

Capital Expenditure (5,301) (3,651) 1,650

Cash Receipt from Asset Sales 0 0 0

Other Cash Flows from Investing Activities 11 2 (9)

Cash Flow before Financing (10,597) (2,774) 7,824

PDC Received 0 0 0

PDC Repaid 0 0 0

Dividends Paid 0 0 0

Interest on Loans and Leases (1,959) (1,977) (18)

Drawdown of Debt 19,756 19,756 0

Repayment of Debt (325) (325) 0

Other Cash Flows from Financing Activities 0 0 0

Cash Flow from Financing 17,472 17,454 (18)

Net Cash Inflow/(Outflow) 6,875 14,680 7,806

Opening Cash Balance 13,303 16,732 3,429

Closing Cash Balance 20,178 31,412 11,235

The Trust has drawn down £19.7m against its Working Capital Facility in July and a further in £4.5m drawdown is planned for August in order to maintain a cash balance of £3m. This will bring the total value

drawndown against the Working Capital Facility to £55.8m (62% of the approved Working Capital Facility).

At month end the Trust’s cash balance was £11.2m above plan due to timing of receipt from NHSE.

The movement in working capital is due to payment received earlier than plan from NHSE and increase in payables balances which remain high as the Trust cannot use the facility to un-wind its payables,

putting pressure on supplier relationship and price negotiations. Capital expenditure for month 4 was £1.6m below plan due to delay in capital plan approval and NHSI capital funding not yet agreed.

Enc. .

Page 16 of 28

Enc. 6.1

Finance Report Month 04 2016/2017 Rolling Cash Flow (13 Week) R

Week ending 29-Jul-16 05-Aug-16 12-Aug-16 19-Aug-16 26-Aug-16 02-Sep-16 09-Sep-16 16-Sep-16 23-Sep-16 30-Sep-16 07-Oct-16 14-Oct-16 21-Oct-16

Actual Actual Actual Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast

£k £k £k £k £k £k £k £k £k £k £k £k £k

Balance B/F 45,180 31,705 51,386 40,509 43,029 10,789 29,035 21,061 46,917 (10,846) (18,185) (242) 34,286

Receipts (inflows)

LSB receipts 1 27,444 0 0 0 27,443 0 0 0 0 27,443 0 0

SLA receipts 118 1,815 138 12,088 0 146 0 13,638 0 0 146 13,638 0

Patient SLA Over performance 2014/2015 0 0 0 0 0 0 0 0 0 0 0 0 0

Patient SLA Overperformance 2015/2016 (8) 0 0 0 0 0 0 0 0 0 0 0 0

Private Patients receipts 292 224 400 400 400 400 400 400 400 400 400 400 400

Training & Education receipts 0 0 0 0 0 0 0 0 0 0 0 0 10,250

NHSE Inflows 0 82 0 31,139 0 0 0 31,927 0 0 0 29,881 1,758

DoH - National RTT, ED Monies & Project Diamond 0 0 0 0 0 0 0 0 0 0 0 0 0

VAT reclaims 0 4,232 0 0 0 3,150 0 0 0 0 4,000 0 0

Income Generation CIPs

Other 1,528 1,733 790 2,406 413 420 370 2,867 370 420 370 2,567 1,090

Total Receipts 1,931 35,531 1,328 46,033 813 31,559 770 48,832 770 820 32,359 46,486 13,498

Payments (outflows)

Pay monthly (incl Pay Awards) 15 83 0 0 24,375 0 70 0 24,375 0 70 0 0

PAYE/NIC/SUPER (CHAPS) 0 0 20,075 0 0 0 0 20,075 0 0 0 20,075

Agency Spend 1,334 1,063 1,421 1,239 1,214 1,048 1,780 1,300 1,300 1,300 1,300 1,300 1,300

Agency CIP 0 0 0 0 0 0 0 0 0 0 0 0 0

PFI project 0 4,315 0 4,100 0 4,300 0 0 4,100 0 4,300 0 4,100

Trade Creditors 8,200 8,028 8,201 8,122 5,175 5,536 5,175 5,582 5,175 5,435 5,325 5,355 5,325

Other 4,882 1,515 1,022 14,293 1,032 2,138 1,063 13,311 1,230 1,000 2,430 4,656 10,714

Total Payments 14,431 15,004 10,644 47,829 31,796 13,022 8,088 20,193 56,255 7,735 13,425 11,311 41,514

Cash from operations (12,500) 20,527 (9,316) (1,796) (30,983) 18,537 (7,318) 28,639 (55,485) (6,915) 18,934 35,175 (28,016)

Capital & Financing Items

Capital expenditure (outflow) 977 845 1,561 215 1,257 291 656 1,139 2,278 424 991 647 214

Commercial Services (Inflow)

PDC Dividends (TDR) (outflow) 0 0 0 0 0 0 0 1,108 0 0 0 0 0

Revolving Working Capital Facility 0 0 0 (4,531) 0 0 0 0 0 0 0 0 0

Interest Paid on Revolving Credit Facility 0 0 0 0 0 0 0 537 0 0 0 0 0

Loans Repaid (outflow) 0 0 0 0 0 0 0 0 0 0 0 0 0

Interest on Loans (outflow) 0 0 0 0 0 0 0 0 0 0 0 0 0

Other (inflow) (2) 0 0 0 0 0 0 0 0 0 0 0 0

Total Capital & Financing 975 845 1,561 (4,316) 1,257 291 656 2,784 2,278 424 991 647 214

Net Inflow / Outflow (13,475) 19,682 (10,877) 2,520 (32,240) 18,246 (7,974) 25,855 (57,763) (7,339) 17,943 34,528 (28,230)

Forecast Balance C/F 31,705 51,386 40,509 43,029 10,789 29,035 21,061 46,917 (10,846) (18,185) (242) 34,286 6,056

The rolling cash flow forecasts forward for a 13 week period currently to the 3rd Week of October.

The 13 week cash flow allows the Trust to forecast its requirement for drawdown against the agreed Workng Capital Facility over the following 2 months.

Enc. .

Page 17 of 28

Enc. 6.1

Finance Report Month 04 2016/2017 Statement of Financial Position (Balance Sheet)

Year to Date 31-Mar-16

Actual Plan Actual Variance Notes

£k £k £k £k

Property, Plant & Equipment 532,001 544,892 528,416 (16,476) 1

Intangible Assets 3,670 2,944 2,864 (80)

Other Assets 11,145 10,800 10,596 (204)

Non Current Assets 546,816 558,636 541,876 (16,760)

Inventories 17,748 19,200 17,072 (2,128)

Trade & Other Receivables 118,917 116,880 118,782 1,902 2

Cash and Cash Equivalents 18,982 20,178 31,412 11,234 4

Current Assets 155,647 156,258 167,266 11,008

Trade and Other Payables (151,607) (146,734) (158,464) (11,730) 3

Borrowings (7,960) (57,751) (53,412) 4,339 4

Other Financial Liabilities 0 0 0

Provisions (1,473) (1,600) (1,259) 341

Other Liabilities (10,139) (7,000) (9,300) (2,300)

Current Liabilities (171,179) (213,085) (222,435) (9,350)

Borrowings (314,651) (312,217) (314,652) (2,435)

Other Financial Liabilities 0 0 0 0

Provisions (5,455) (5,000) (5,455) (455)

Non Current Liabilities (320,106) (317,217) (320,107) (2,890)

TOTAL ASSETS EMPLOYED 211,178 184,592 166,600 (17,992)

Financed by:

Public Dividend Capital (223,838) (223,838) (223,838) 0

Retained Earnings 109,055 135,639 153,633 17,994

Revaluation Reserve (96,395) (96,393) (96,395) (2)

TOTAL TAXPAYERS' EQUITY (211,178) (184,592) (166,600) 17,992

The Statement of Financial Position reflects changes in asset values as well as movements in liabilites. The plan figures reconcile to the Annual Plan submitted to Monitor in June 2016.

1. Capital expenditure is behind plan at month 4 due to delay in NHSI approval of Distressed Capital funding. Once funding is confirmed planned projects will commence.

2. Trade and Other Receivables balances are above plan but have decreased from Month 3 by £4.5m

3. Trade and Other Payables continue to increase due to restricted cash availability and restrictions in place on the use of the Working Capital Facility to reduce outstanding Creditor balances.

4. The differences in Cash and Borrowings are primarily due to £6.9m received from NHSE for the difference in the 1617 Contract value. Schelduled in the Plan to be received in August but received in July

2016.

Year to Date

Enc. .

Page 18 of 28

Enc. 6.1

Finance Report Month 04 2016/2017 Aged Debtors

Invoiced Debtors Within

Terms

1 Month

Overdue

2 Month

Overdue

3 Month

Overdue

Total Current

Month Prior Month Notes

Other Receivables

Notes

Current

Month

Prior

Month

1-30

Days

31-60

Days

61-90

Days

Over 90

Days Over 30 Days Over 30 Days £k £k

£k £k £k £k £k £k £k

CCG's/NHSE 3,942 5,159 2,184 3,733 15,018 11,076 12,561 1 Accrued Income

Trusts 993 1,427 337 4,721 7,478 6,485 6,167 2 Work in Progress 20,015 13,639

Other NHS 234 358 472 678 1,742 1,508 1,277 CCG/NHSE SLAs 3 1,662 7,237

Other Debtors 3,201 1,687 1,528 11,317 17,733 14,532 14,930 Injury Cost Recovery Fund 2,438 1,828

Private Patients 625 339 160 2,935 4,059 3,434 3,832 NHSE Drugs Accrual 4 3,409 7,810

Overseas Visitors 879 345 101 8,313 9,638 8,759 8,800 Clinical Income accrual 16,246 7,487

Total Invoiced Debtors 9,874 9,315 4,782 31,697 55,668 45,794 47,567 Other 3,482 13,780

Total Accrued Income 47,252 51,781

Provision for Bad Debts (Incl. RTA Provision) (10,355)

Accrued Income 47,252

Prepayments 4,814

Other Debtors 20,202

Total Trade & Other Receivables 117,581

The Trust debtors are a mixture of invoiced debtors, accrued income and prepayments. The level of invoiced debtors' balance has decreased by £7.2m and private and overseas patients balance has

remained static at the end of the month. Overdue debts (those >30 days old) have decreased by £1.7m in month.

1. CCG's/NHSE - Outstanding debt has decreased by £7.5m due to crediting the NHSE Overperformance Invoice and payment from other CCGs. Debts over 30 days old has decreased by £1.5m.

2. Trusts - Outstanding debt from Trusts has decreased by £0.3m. The overdue debt has increased by 0.3m.

3. CCG SLA Accruals - Due to the finalisation of SLA contracts with CCG's, income accrual figures are confirmed and are higher than month 3.

4. NHSE Drugs accrual - Monthly accruals relating to months 1-4. Data validation was in progress resulting in increased accrual values. Months 1 to 3 have been invoiced.

Enc. .

Page 19 of 28

Enc. 6.1

Finance Report Month 04 2016/2017 Debtor Detail

Organisation Over 30 days

NHS Organisations

CCGs £3.7m

NEL CSU (12 CCGs) £0.119m

West Sussex CSU (7 CCGs) £2.370m

Cambridge and Peterborough CCG £0.366m

Slough CCG £0.442m

Guildford & Waverley CCG £0.214m

Bedfordshire CCG £0.219m

NHS Trusts £4.9m

Lewisham and Greenwich NHS Trust £1.561m

Guys & St Thomas NHS Foundation

Trust

£1.446m

Dartford & Gravesham NHS FT £0.603m

Oxleas NHS FT £0.482m

Maidstone & Tunbridge Wells NHS

Trust

£0.403m

South London and Maudsley NHS FT £0.374m

Other NHS Bodies £7.763m

TOTAL NHS ORGANISATIONS £19.069m

Non-NHS Organisation

Viapath LLP £2.8m

KCH Commercial Services Ltd £3.8m

Kings College London £2.7m

Bromley CIC £1.039m

ISS Mediclean £1m

Sainsburys £0.064m

Councils £0.490m

Other Non-NHS Bodies £2.063m

TOTAL NON-NHS ORGANISATIONS £14.532m

Ongoing queries with remainder of NEL NCA's 15/16 hope to resolve end of Sept 16

NHS England (Central) £2.7m

£487k relates to Cancer Drugs Fund for Mar 2016

£356k relates to Month 1 Freeze data for 2016/17

£464k relates to NHS Area Teams NCA data for 2015/16

Finalising 15/16 FYE of NCAs

Data relating to patient has been provided and awaiting agreement from NHSE

No queries advised as yet currently reviewing the data

Numerous queries around backing data and finalisation of year end figures

No payments are being received from KCS Ltd

Reciporal payment agreement in place. KCH pay more to KCL weekly

Disputes have been cleared and invoices released for payment. No payment due to amounts

owed by KCH. To be followed up and referred to Director of Finance for agreement.

Periodic reciprocal payments are agreed to reduce this balance.

Invoice against contract raised in March; invoice still to be approved for payment by ISS

Queries have been referred to Contracts to provide proof of agreements in place. With

regards to two councils, we are pursuing urgent resolution and are looking to charge interest

on the outstanding debt.

To be referred to Business Analyst to follow up with cantract parties.

Payment not being recieved due to outstanding invoices owed to Sainsburys

Payment of £184k to be made 15/8/16

Bedfordshire has raised £5,951k worth of queries against Diagnostics, credit to be raised.

Reciprocal payments agreement in place. KCH payments higher.

Reciprocal payments agreement in place. KCH returning payments to GSTT when received

KCH has agreed weekly payments to D&G to reduce outstanding balance. No payments being

received from D&G.

KCH has agreed weekly payments to Oxleas to reduce outstanding balance. No payments

being received from Oxleas.

Director of Finance has issued a letter confirming withdrawal of Neurosciences services if

invoices are not paid. M&TW have agreed to pay, but receipt of payments has been slow.

Reciprocal payments agreement in place and payments being made weekly. KCH payments

higher.

Contracts have agreed to provide credits for any Diagnostics queries which will release the

remainder for payment. Credit notes have been raised for 3 CCG's (£1.5m) and payment dates

to be confirmed.

Credit of £64k raised to close 2013/14 accounts, now reviewing 2014/15 for closure and

finalised payment

Contracts attempting to resolve outstanding challenges, looking to return to SLA contracts for

16/17.

KCH owe L&G £5.9m

KCH owe Viapath £4.5m

KCH owe GSTT £2.8m

KCH owe D&G £3.1m

KCH owe Oxleas £3.4m

Challenges raised against 15/16 NCA invoices

Challenges relating to patient identifiable data

CCG unresponsive to chasing debt

KCH owe KCS Ltd £46k

KCH owe KCL £2.5m

Neurosciences invoices disputed by M&TW, do not agree that these invoices should be paid

as included in contract. KCH disagree.

KCH owe SLAM £271k

Rental for Beckenham Beacon as well Community Diabetes Service invoices are outstanding

as previously disputed. Payments not being received as Bromley CIC expecting payment of

their outstanding debt (£0.339m)

KCH owe Sainsburys £5.2m

Disputes relating to the set tariff rates agreed by South East CSU.

Resolutions and Follow up

Contracts Department is currently discussing with NHSE regarding backing data for these

invoices

Provided data to NHSE and awaiting confirmation from NHSE

Current queries relating to Diagnostics Invoices (percentage of NCA invoices)

Challenges relating to patient identifiable data

Issue

£900k relates to IFRs 15/16 - current dispute on how these are being invoiced.

£480k relates to Overseas Patients 15/16 debts - specific details required by NHSE

Enc. .

Page 20 of 28

Enc. 6.1

Finance Report Month 04 2016/2017 Bad Debt Provision

M1 16/17

£'000

M2 16/17

£'000

M3 16/17

£'000

M4 16/17

£'000

Provision For Bad Debts : Current Year 244 133 111 425

Provision For Bad Debts : Prior Year 2,124 2,124 2,124 2,484

2,368 2,257 2,235 2,909

23% 25% 24% 30%

M1 16/17

£'000

M2 16/17

£'000

M3 16/17

£'000

M4 16/17

£'000

Provision For Bad Debts : Current Year 25 25 25 25

Provision For Bad Debts : Prior Year 282 282 282 383

307 307 307 408

6% 7% 7% 10%

M1 16/17

£'000

M2 16/17

£'000

M3 16/17

£'000

M4 16/17

£'000

Provision For Bad Debts : NHS 2,514 2,514 2,514 2,434

Provision For Bad Debts : Non-NHS 830 830 830 1,112

3,344 3,344 3,344 3,546

6% 9% 7% 8%Percentage of Bad Debts Provision against Outstanding Debts

Overseas Visitors

Total Provision

Percentage of Bad Debts Provision against Outstanding Debts

Private Patients

Total Provision

Percentage of Bad Debts Provision against Outstanding Debts

Trust Debt

Total Provision

Enc. .

Page 21 of 28

Enc. 6.1

Finance Report Month 04 2016/2017 Capital R

Year to Date Plan Actual Variance Year End Forecast Plan Forecast Variance

£k £k £k £k £k £k

Major Works 8,314 6,216 (2,098) Major Works 52,344 53,285 941

Minor Works 220 121 (99) Minor Works 2,580 2,580 -

IT (Incl Intangibles) 1,436 1,106 (330) IT (Incl Intangibles) 8,025 6,879 (1,146)

Medical Equipment 960 637 (323) Medical Equipment 8,240 7,690 (550)

Total 10,930 8,080 (2,850) Total 71,189 70,434 (755)

Year to Date Plan Actual Variance Year End Forecast Plan Forecast Variance

£k £k £k £k £k £k

Major Works Major Works

Critical Care Unit 3,929 3,908 (21) Critical Care Unit 26,205 26,205 -

Cath Lab Developments 150 - (150) Cath Lab Developments 1,295 1,295 -

Helideck 1,055 460 (595) Helideck 1,550 1,550 -

Site Wide Infrastructure 0 - 0 Site Wide Infrastructure 1,500 1,500 -

Ruskin Wing - to increase bed capacity 542 38 (504) Ruskin Wing - to increase bed capacity 3,100 3,100 -

ED Additional Bed Capacity 0 35 35 ED Additional Bed Capacity 2,000 2,000 -

Portakabin enabling - to increase bed capacity 202 661 459 Portakabin enabling - to increase bed capacity 1,400 1,400 -

Orpington major works - to increase bed capacity 656 32 (624) Orpington major works - to increase bed capacity 4,100 4,100 -

Other - Denmark Hill 775 818 43 Other - Denmark Hill 5,932 6,713 781

Other - PRUH 521 14 (507) Other - PRUH 2,410 2,410 -

Other - Orpington 484 250 (234) Other - Orpington 2,852 3,012 160

Minor Works 220 121 (99) Minor Works 2,580 2,580 -

IT (Incl Intangibles) 1,436 1,106 (330) IT (Incl Intangibles) 8,025 6,879 (1,146)

Medical Equipment 960 637 (323) Medical Equipment 8,240 7,690 (550)

Total Capital Spend 10,930 8,080 (2,850) Total Capital Spend 71,189 70,434 (755)

Funded by: Funded by:

External Borrowing - - - External Borrowing - - -

Donations (332) (332) - Donations (4,203) (4,203) -

PDC Receipts - - - PDC Receipts (600) (600) -

Depreciation (8,818) (8,818) - Depreciation (26,100) (26,100) -

Total Funding (9,150) (9,150) - Total Funding (30,903) (30,903) -

Internal Cash Funding Requirement 1,780 (1,070) (2,850) Internal Cash Funding Requirement 40,286 39,531 (755)

The capital report shows capital expenditure year to date against plan and full year forecasts as agreed with Monitor.

The year to date plan is based on the revised annual plan profile submitted to NHSI in June 2016.

The underspend reflected at month 4 is due to the delay in confirmation of Distressed Capital funding from NHSI. Projects totalling £24m have been started at risk prior to formal NHSI approval of the distressed

capital funding. These include Additional Bed Capacity including ED (£10.6m), EPR Systems Development & Infrastructure (£1.5m), Site wide infrastructer and Minor Works (£4.6m), Link building (£3m) and other

approved business cases and major works (£4.3m).

It is expected that actual spend against the phased forecast plan will increase from quarter 3 once confirmation of agreed funding has been received from NHSI.

The planned capital expenditure for 2016/17 is £71.189m was approved by the board on the assumption that the Trust will be able to secure additional distressed capital funding of £39m from NHSI.

Enc. .

Page 22 of 28

Enc. 6.1

Finance Report Month 04 2016/2017 Agency Run Rate R

Year to Date Apr-16 May-16 Jun-16 Jul-16

£k £k £k £k

A&C Staff/Senior Managers (717) (743) (648) (692)

Medical Staff (870) (1,104) (1,440) (1,290)

Nursing Staff (878) (872) (963) (1,099)

PAMS/Scientific/Professional (343) (762) (849) (570)

Total Agency Spend (2,808) (3,481) (3,899) (3,650)

Enc. .

-

200

400

600

800

1,000

1,200

1,400

1,600

Ap

r-1

6

May

-1

6

Jun

-1

6

Jul-

16

Au

g-1

6

Sep

-1

6

Oct

-1

6

No

v-1

6

De

c-1

6

Jan

-1

7

Feb

-1

7

Mar

-1

7

£k

Agency Run Rate A&C Staff/Senior Managers Medical StaffNursing Staff PAMS/Scientific/Professional

Page 23 of 28

Enc. 6.1

Finance Report Month 04 2016/2017 Agency Cap R

Agency Cap Rules:

(1) Price caps for all staff from 1 April 2016 are calculated at 55%* above the hourly rate.

Key Dates:

01-Apr-16

01-Jul-16

01-Nov-16

*Change in cap/reporting

Nov 2016-Jan 2016 Junior Dr cap was 150%, all other staff was 100%

Feb 2016-Marc 2016 Junior Dr cap was 100%, all other staff was 75%

July 2016 wage cap takes effect

Rules on mandatory use of approved frameworks for trusts take effect

Maximum wage rates take effect

The latest date that approved framework agreements must have pricing structures that fully

reflect NHS Improvement’s conditions for approval, including contractually embedding the

price caps and maximum wage rates

(2) The price caps set by NHS Improvement apply to the total amount a trust can pay per hour for an agency worker (exclusive of VAT and including all related costs eg holiday

pay for the worker, employer National Insurance, employer pension contributions, administration fee/agency charge). Trusts must not pay more than the price caps to secure an

agency worker. Trusts can override the price caps in exceptional patient safety circumstances only.

(3) From 1 April 2016, trusts are required to procure all agency staff (nurses, doctors, other clinical and non-clinical staff) via framework agreements that have been approved by

NHS Improvement. Overrides to the rule are permitted on exceptional patient safety grounds only.

(4) NHS Improvement is separately setting the maximum amount an agency worker receives per hour. Trusts are encouraged to comply with the maximum rates from 1 April

2016. Trusts are required to comply with the maximum wage rates from 1 July 2016. Trust compliance with the maximum wage rates is required in addition to compliance to the

price caps. Trusts can override the maximum wage rates under exceptional patient safety circumstances only.

Enc. .

NHSI Agency Price Cap Monthly Trend Analysis

Staff group Control breachedDec 2015

(5 wks)

Jan 2016

(4 wks)

*Feb 2016

(4 wks)

March 2016

(5 wks)

*April 2016

(4 wks)

May 2016

(4 wks)

June 2016

(5 wks)

*July 2016

(4 wks)

Actual Reported Number of breaches each month

Nursing, Midwifery & HVPrice cap, wage cap and

framework 317 254 494 692 1,379 1,333 1,832 1,874

HCA and other support Price cap and framework 71 34 37 65 46 46 111 208

Medical and Dental Price cap and wage cap 1083 790 1571 1995 1,590 1,747 2,174 2,054

Sci, Ther & TechnicalPrice cap, wage cap and

framework 82 78 262 304 518 525 724 1,401

Healthcare science Price cap and wage cap 42 36 129 111 339 302 327 365

Admin & EstatesPrice cap, wage cap and

framework 386 354 397 466 365 325 350 1,037

Total 1981 1546 2890 3633 4237 4278 5518 6939

Breaches as a percentage of bookings

Nursing, Midwifery & HV 14% 13% 20% 22% 52% 54% 61% 65%

HCA and other support 57% 41% 44% 52% 37% 29% 49% 65%

Medical and Dental 62% 56% 92% 89% 81% 98% 93% 95%

Sci, Ther & Technical 5% 4% 19% 19% 35% 36% 40% 81%

Healthcare science 6% 7% 20% 16% 59% 52% 40% 62%

Admin & Estates 31% 28% 27% 22% 21% 18% 16% 54%

Total 29% 24% 38% 36% 50% 52% 53% 72%

Monthly Totals

Page 24 of 28

Enc. 6.1

Finance Report Month 04 2016/2017 WTEs R

Year to Date

Budgeted Substantive

Budgeted

Vacancies Bank Agency

Total Staff in

Post

Gap (Budget -

Actuals)

WTE WTE WTE WTE WTE WTE WTE

Ambulatory Services 1,380.1 1,249.9 130.2 26.7 23.5 1,300.2 79.9

Critical care, Theatres and Diagnostics 2,224.1 1,835.4 388.8 115.5 81.1 2,032.0 192.2

Liver, Renal and Surgery 1,791.1 1,559.8 231.3 157.0 59.1 1,775.9 15.2

Networked Services 1,591.5 1,346.2 245.3 146.2 53.3 1,545.8 45.7

Trauma, Emergency and Medicine 2,077.5 1,797.0 280.5 182.2 124.9 2,104.1 (26.6)

Women's and Children 1,507.8 1,359.8 148.0 111.8 34.5 1,506.1 1.7

Corporate Directorates

Corporate Services 94.5 89.2 5.3 0.1 1.3 90.6 3.9

Executive Nursing 115.4 114.8 0.5 0.6 115.5 (0.1)

Facilities 152.6 119.7 32.9 6.1 3.1 128.9 23.7

Finance, Procurement and Information 346.0 282.9 63.1 2.8 22.1 307.9 38.2

Human Resources 239.9 223.9 16.0 4.6 5.0 233.5 6.4

Medical Director 4.9 2.5 2.4 2.5 2.4

Operations 393.8 323.3 70.5 8.5 34.6 366.4 27.4

R&D 122.3 151.9 (29.6) 2.5 3.2 157.6 (35.3)

Strategic Development 8.1 8.2 (0.2) 8.2 (0.2)

Turnaround and Transformation 24.0 14.0 10.0 9.2 23.2 0.8

Total Corporate Directorates 1,501.3 1,330.5 170.8 25.1 78.5 1,434.1 67.2

Contract Services 49.7 41.3 8.4 1.0 1.9 44.1 5.6

Private Patients and Overseas Visitors 66.1 58.4 7.7 14.2 3.4 76.0 (9.9)

Total WTEs 12,189.1 10,578.1 1,611.0 779.7 460.3 11,818.2 371.0

The Trust is showing a budgeted vacancy level of 1611WTEs, of which 779.7 are covered by Bank and 460.3 are covered by Agency. This leaves a vacancy gap of 371 WTEs and

explains the YTD pay underspend. Details exclude Kings Kewitt ACU department (39.9WTE).

The Finance Department is working closely with Workforce to reconcile the WTE numbers

Enc. .

Page 25 of 28

Enc. 6.1

Finance Report Month 04 2016/2017 Income by Commissioner Contract

Row Labels

M4 Budget YTD M4 Actual YTDPrior Year QIPP

Adjustment16/17 QIPP Block Adjustment M4 Variance YTD

Block 147,503,486 150,388,294 -4,229,641 -1,775,000 3,119,833 -0

NHS BROMLEY CCG 55,627,824 57,106,133 -1,615,155 -1,000,000 1,136,846 0

NHS SOUTHWARK CCG 28,305,241 28,645,700 -1,294,805 -316,667 1,271,012 0

NHS LAMBETH CCG 23,361,567 22,655,493 -1,145,861 -458,333 2,310,268 0

NHS LEWISHAM CCG 10,512,625 11,209,654 -165,979 -531,050 0

NHS BEXLEY CCG 7,846,290 8,555,808 -709,518 0

NHS GREENWICH CCG 6,637,949 6,008,660 -7,841 637,131 0

Other CCGs 15,211,991 16,206,847 0 0 -994,856 -0

C&V 142,385,455 144,831,381 0 0 -1,288,000 1,157,926

LONDON COMMISSIONING HUB (£305.8m excl CQUIN) 101,676,448 111,539,518 9,863,070

LONDON COMMISSIONING HUB (Over-Performance) 9,175,802 0 -9,175,802

LONDON COMMISSIONING HUB (IFRs) 380,068 519,701 139,633

LONDON COMMISSIONING HUB (Hep C) 2,966,667 4,458,150 -1,288,000 203,483

LONDON COMMISSIONING HUB (CDF) 2,233,333 2,233,333 0

NHS ENGLAND LONDON (Dental & Screening) 10,326,656 10,284,744 -41,912

NHS CROYDON CCG 6,424,740 6,467,493 42,754

NHS WEST KENT CCG 3,108,737 3,087,036 -21,700

Other CCGs 6,093,005 6,241,406 0 0 0 148,401

NCA - CCGs 4,319,521 4,678,991 0 359,470

NCA - Local Authorities 1,060,562 640,396 -420,166

NCA - NHSE 254,921 312,269 57,348

CQUIN (CCG & NHSE) 6,000,000 6,000,000 0

Other 2,002,986 550,052 -1,452,934

Grand Total 303,526,931 307,401,383 -4,229,641 -1,775,000 1,831,833 -298,356

Key Income Headlines:

* Block CCGs Over-performance driven by Critical Care activity

* Primary reason for Elective under-performance driven by theatre closure for development/maintenance

* NHSE drugs (Hep C) and BMT activity over-performing against plan

* Business plans for activity growth are being implemented but are not fully operational yet.

Enc. .

Page 26 of 28

Enc. 6.1

Finance Report Month 04 2016/2017

Month 4 Actuals are based on month 3 flex activity extrapolated using straight-line method. Bromley, Lambeth & Southwark contracts have been agreed and are reflected

within the plan. All other commissioners e.g. NHSE are based on KCH proposals. There is always the potential for monthly variations between the estimate and actual patient

data. In comparison to last year inpatient activity is lower, primarily driven by theatre closure for development/maintenance. There has been a decrease in elective bed use and

an increase in emergency/tertiary activity in adult on-site bed occupancy in comparison to last year.

Income Activity Analysis Enc. .

Page 27 of 28

Enc. 6.1

Finance Report Month 04 2016/2017 Surplus / (Deficit) (By Division) R


£k £k £k

Surplus / (Deficit) (22,280) (41,147) (18,867) Key Variances (more details can be found in the appendix 3)


£k £k £k

Ambulatory Services (4,846) (5,432) (586)

Critical care, Theatres and Diagnostics (160) 558 719 Underspend mainly driven by Radiology vacancies

Liver, Renal and Surgery (7,362) (13,155) (5,793)

Networked Services (9,204) (9,617) (414) CIP Slippage

Trauma, Emergency and Medicine (9,976) (10,855) (878) CIP Slippage and SLR recharges (outliers and escalation beds)

Women's and Children (11,370) (11,264) 106

Corporate Income 17,057 2,597 (14,460) STF

Corporate Services

Capital charges and reserves (4,916) 564 5,480

Commercial Services 317 317 0

Corporate Services 7 501 495

Executive Nursing (0) (142) (142)

Facilities (151) 910 1,062

Finance, Procurement & Information (0) 641 641

Human Resources 0 297 297

Medical Director (0) 21 21

Operations 201 432 231

PFI (403) (304) 100

R&D (341) (326) 15

Strategic Development 0 (14) (14)

Turnaround and Transformation (0) (1) (1)

Corporate Services Total (5,287) 2,897 8,184

Contract Services (MSK, ACU, Pathology Services) 1,973 (1,222) (3,194) Contract Overperformance

Private Patients and Overseas Visitors 3,462 912 (2,550) Overseas and PP income underperformance and provision for bad debts (OV)

Surplus / (Deficit) (25,714) (44,581) (18,867)

Impairment 3,433 3,433 0

Operating Surplus / (Deficit) (22,280) (41,147) (18,867)

Clinical income underperformance due to elective cancellations and CIP slippage

Clinical income underperformamce (to be reviewed with contracts).

Enc. .

Page 28 of 28

Enc. 6.1

1 of 2



Subject: Summary Record of Finance & Performance Committee Meeting

Presented by: Chris Stooke, Non-Executive Director


INTRODUCTION

This report provides the Board of Directors with a brief summary of all the key issues considered by the Finance & Performance Committee on 26 July 2016.

STRATEGIES: TOP PRODUCTIVITY We were informed that Trust’s emergency department (ED) performance against the 4 hours target of 95% was not achieved. Trust wide performance was 83.79% a deterioration on the month before. While the national target was not achieved the commissioners agreed improvement trajectories were achieved for Quarter 1 (Q1) this is a positive sign that the recovery plan has begun to deliver; The Denmark Hill (DH) site is busy and the proposed capacity capital development measures should show improved performance by Q4; We were pleased to learn that the Trust cancer performance on the 62-day general practitioner referral for first treatment performance was achieved for Q1 at 86.14%, against target of 85%. The two week wait symptomatic breast referral target exceeded the national target in June, performance was 96.88% against target of 93%. The Q1 position however will not be achieved due to low performance in April. The Trust is expected to achieve this target in the following quarters; The Trust’s referral to treatment (RTT) incomplete pathways performance improved further from 80.9% in May to 81.34% in June which is better than the 81.31% performance trajectory. The Trust is continuing its RTT recovery programme for 2016/17 and plans to reduce the on-going validation of incomplete pathways down to 10 weeks, it is currently validating pathways under 14 weeks; and Diagnostics performance continues to remain challenging it is subject to an improvement plan and exceptional weekly reporting to monitor performance, work in this area is ongoing.

SUSTAINABILITY AND TRANSFORMATION FUND (STF) We were updated on the latest STF offer from NHS Improvements (NHSI). The revised offer contained an updated control total for the year(2016/17) and a number of performance targets that must be achieved to secure funding support; We noted all the financial modelling and trajectories carried out by the Trust to ensure it can achieve the financial and operational targets listed in the revised offer. While the Trust can plan and put in place measure to keep its performance on track there are limitations to what it can control relating to its partners; and The Trust response to NHSI offer was discussed in detail and agreed.

2 of 2

FIRM FOUNDATIONS: SOUND FINANCES We noted that the Trust’s financial position is challenging The Trust’s cumulative operating deficit as at month 3 was £24m. This is an adverse variance of circa £5m against the year to date planned deficit of circa £19m; The two key drivers of the adverse cash position are Cost Improvement Programmes (CIP) slippage and agency spend. To drive down agency spend the Trust has engaged the services of a master vendor who has a duty to fill all agency shifts with NHS framework agency staff; The Trust’s CIPs position has improved slightly but there is still a CIPs gap that is yet to be filled with identified and approved saving’s schemes. There is also a further review of CIPs schemes that were previously rejected. Work is ongoing. To maintain key operational function the Trust has made larger than planned cash withdrawals from the Working Capital Facility to pay off creditors and help mitigate the Trust’s cash position to ensure there is no disruption to service delivery; Committee Chair Chris Stooke, Non-Executive Director

Enc. 6.4.1

1

King’s College Hospital NHS Foundation Trust - Finance & Performance Committee Minutes of the meeting of the Finance & Performance Committee held at 09:00-11:00 on Thursday, 28 June 2016 in the Dulwich Committee Room, Denmark Hill.

Present:

Chris Stooke (CS) Non-Executive Director/ Committee Chair

Lord Kerslake (BK) Trust Chair

Sue Slipman (SS) Non-Executive Director/ Deputy Trust Chair

Nick Moberly (NM) Chief Executive Officer

Colin Gentile (CG) Chief Financial Officer

Jane Farrell (JF) Chief Operating Officer

Geraldine Walters (GW) Director of Nursing and Midwifery

Julia Wendon (JW) Medical Director

Toby lambert (TL) Interim Director of Strategy

Ahmad Toumadj (AT) Interim Director of Capital Estates and Facilities

Judith Seddon (JS) Acting Director of Corporate Affairs

In attendance:

Simon Dixon (SD) Director of Finance

Chris Goulding (CG) Deputy Director of Workforce

Jane Badejoko (JB) Corporate Governance Officer (Minutes)

Peter Fry (PF) Director of Operations (Items 2.2 & 2.3 only)

Komal Whittaker-Axon (KWA) Acting Divisional Manager (item 2.2 only)

Dan Gibbs (DG) Divisional Manager (item 2.3 only)

Phillip Burns (PB) Director of Turnaround (item 3.1 only)

Apologies:

Trudi Kemp (TK) Director of Strategic Development

Dawn Brodrick (DB) Director of Workforce and Development

Item Subject Action

016/70 Apologies

Apologies for absences were noted.

016/71 Declarations of Interest There were no declarations of interest reported.

016/72 Chair’s Actions/ Updates There were no actions to report.

Enc. 6.4.1

2

Item Subject Action

016/73 Minutes of the Previous Meeting The minutes of the meeting held on 28 May 2016 were approved as a correct record.

016/74 Action Tracker/ Matters Arising

The action tracker was noted, all due actions are covered on the agenda.

TOP PRODUCTIVITY

016/75 Monitoring Operational Performance – Month 02 The Committee received and discussed the performance report for month 02. The following key points were reported:

Trust emergency department (ED) performance against the 4-hour target improved from 83.48% in April to 85.06% in May. While this is above improvement trajectories agreed with commissioners, it is still below the national target of 95%;

The Princess Royal University Hospital (PRUH) performance improved in May despite the Norovirus infection outbreak which resulted in a number of ward closures. The Norovirus outbreak is now subsiding;

Denmark Hill(DH) performance improved in May but there are still capacity constraints affecting the site, attendance to ED remained consistently high;

The referral to treatment (RTT) recovery plan had 15,910 patients waiting over 18 weeks at the end of May. Performance on the incomplete pathway for May was 80.9% which is a further improvement compared to the 80.7% reported in April;

The over 52 weeks waiting patients increased from 155 patients reported in April to 197 patients reported in May, the Trust is however, performing above trajectory for patients in neurosurgery;

The 2 week breast symptomatic referral target performance exceeded the national target at 93.5% in May. June to-date performance is 98.4%, but this target will not be achieved in quarter one (Q1) due to poor performance in April;

The 62 day cancer referral target was not achieved in May as there have been a number of challenges in the patient pathway. The planned treatments for June are under review order to determine if the target will be achieved in Q1;

Over all cancer performance for the month was mixed, the Q1 position for 62 day referral is uncertain. There is a real risk to the successful delivery of this service and the Trust will need to become better at anticipating pathway issues as result of the increased demand, underlying service challenges and referrals volume; and

The Trust recorded 5 C-difficile cases reported in May which is below the quota of 6 cases for the month.

The following key points were discussed:

The Trust has good operational structures but there is need to focus on leadership and governance arrangement. There is need to review some processes and challenge the need for their implementation;

Enc. 6.4.1

3

Item Subject

Action

The increase in the number of over 52 week wait is concerning, it was noted that there is no single factor responsible for the increased numbers. It is a combination of industrial action delays and low theater capacity;

The increased number of patient waiting over 52 weeks are mainly in Orthopedics, the Trust will be looking to improve that figure by utilising the Orpington facility. Delivery of the RTT recovery plan is crucial; and

It was noted that there was no data on staff statutory and mandatory training information for the PRUH. The Trust will look into this and provide an update.

CG1 will look into why staff statutory and mandatory training information for the PRUH is missing and report back to the Committee.

CG1

016/76 Deep Dive Diagnostic Waits The Committee welcomed Komal Whittaker-Axon and Peter Fry who presented the deep dive into diagnostic waits. The following key points were reported:

The NHS constitution states that “patients waiting for a diagnostic test should not wait more than 6 weeks from referral for that test” the national performance target is a maximum of 1% waiting more than six week for a referral test. Trust performance is 8.4%;

Performance was affected by low staffing levels due to national shortage in radiographers, sonographers and difficulty in recruiting administrative staff;

The Trust has been receiving increased number of referrals in some areas are as high as 200 referrals per site per day;

The scale of the increase suggest that there must have been a change in policy that has triggered a wave of increase in demand;

The Trust delivers 25 diagnostic modalities across all its sites, 19 of which are delivering performance trajectory for the end of August 2016, the others will require longer to perform on trajectory;

General MRI, GE scanners on both sites have a breakdown rate higher then expected, resulting in reduction in capacity. The Trust has an outsourced contract to a third party Darent Valley, who have subsequently sub-contracted the work to Alliance, this has resulted in patients being booked outside the 6 week target. The Trust’s procurement team is in discussion with Alliance to sign a direct contractual agreement for the outsourcing of patients directly to them;

Neuro MRI, in the last month Neuro MRI has received an 18% increase in referrals (additional 150 referrals). The majority of the new referrals are in Neuro-oncology. The backlog is predominantly for patients waiting Neuro MRI under a general anaesthetic;

The Trust is getting additional capacity by procuring a second MRI scanner at Orpington site scheduled for delivery by Q4;

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Item Subject

Action

Cardiac MRI, Cardiac demand has increased since the service launched in 2015/16. The service is delivered by a single cardiac consultant, with not enough MRI time to meet the demand on his time. A period of leave has led to an increase in patients over 6 weeks. The service has received approval to employ a second cardiac consultant to ensure a more fluid and timely service delivery;

Weekend working rates have been agreed with staff for July and August, this should further reduce the 6 week backlog numbers; There are also discussions under way with London Bridge to see if they can provide additional capacity on an interim basis;

Ultrasound, the service had a decrease in capacity due to lack of sonographers, and the inability to recruit permanent staff. There were also backlog referrals due to lack of administrative staff resulting in a surge of referrals being added to the system. Increase in referrals of up to 69% at PRUH site and high level of did not attend (DNA) patients whom where not fully booked onto their scheduled appointment further increased the backlog; A fully booked patient will receive a letter informing them of their appointment followed by a telephone conversation with a member of staff. Not fully booked patient will only receive a letter informing them of their appointment and a possible reminded but there will be no confirmation telephone call, practice indicates that not fully booked patients have a higher rate of DNA;

The Trust must clear the backlog of over 1000 patient by the end of August. To work through the volume the Trust is in discussion with a private sector partner to add two ultrasound rooms to DH, which could provide up to 250 patients additional capacity per week;

The team has also agreed weekend working rates for permanent staff who are willing to work weekends and suitable agency staff to provide cover during normal staff annual leave. The Trust is also running training programmes to assist staff in getting appropriate qualification;

The Trust has also introduced full service booking for all patient to minimise DNAs;

Paediatric Gastroscopy, there has been a backlog of paediatric patients waiting over 6 weeks. Recently an additional 25 patients have been identified who were on the wrong waiting list increasing the backlog further;

Paediatric Sleep studies this service is delivered by one person, and therefore has limited capacity. Demand out strips capacity by 3 patients per week. A new staff member will be starting shortly to helps ease the volume of work;


The Committee noted that outsourced contract that are further outsourced to third parties are not ideal and the Trust should learn from the Alliance position;

It is also worth exploring other possibilities of management DNAs and if technology could provide support to make the process more streamlined it should be explored;

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Item Subject

Action

The Trust should carryout demand modelling and share the results with commissioners as the increase in patients does not seem to be a pan London problem but a wider national issue that must be highlighted;

The shortage of sonographers and radiographers as a professional group is a national shortage not limited to London; and

The Trust support of staff by providing training is an excellent tool for career progression and making staff feel valued, but there is need for some retention planning that will ensure that the Trust does not just train staff and then they leave and go elsewhere for a better pay package offered by other providers.

The Committee will receive data modelled on having the backlog based on 7 weeks delivery as oppose to 6 weeks.

JF/KWA

016/77 Emergency Department Recovery Plan The Committee received a presentation of the emergency department recovery plan. The following key points were reported:

The Trust’s emergency pathway is subject to a recovery plan programme agreed with commissioners. The improvements programme includes full pathway reviews into areas that are critical to delivery of emergency care to patients within the national targets;

The Trust operates two emergency department (ED) one at the Princess Royal University Hospital (PRUH) and one at King’s College Hospital, Denmark Hill(DH). In order to deliver an improved service the Trust reviewed internal Trust process and how they performed and interact with the whole emergency pathway to ascertain why the Trust’s EDs were failing to meet the national 4 hour target;

The DH ED experienced a larger than normal over 10% increase in winter pressure patient presenting to the ED. The additional pressure has continued into Quarter 1 (Q1) of 2016/17 and is yet to subside;

The in-depth review noted that the biggest issues for the DH ED are the wait for a patient to see first clinician, wait for a cubicle to carryout patient reviews and low bed availability;

The breaches in the majors area are acuity linked where clinicians are drawn to the most serious cases and the patient with less serious conditions are left to wait longer. Majors also frequently overflows into Minor;

The pathway is in need of a new model of care that provides clear separation between Major and Minors and provides a ring fenced Minors services. Southwark Clinical Commissioning Group (CCG) are looking at proving 24hr urgent care service;

Redevelopment plans for the Golden Jubilee Suite 1 to create expanded urgent care center (UCC) /Minor injuries facility with integrated Mental Health assessment and having a separate model for minors is underway;

Ultimately the transformation plan is to take Minors out of the main ED, this is still in its early stages and there are a lot of process and pathways work yet to be completed;

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Item Subject

Action

The DH site has a detailed plan on what is needed and how it will be achieved all of which is part of the Transformation programme. The separation of the Minors section from the main ED has been done elsewhere and it has been successful;

The PRUH was reviewed by an external consultancy McKinsey who were retained by Bromley CCG, they produced a report ‘One Version of the Truth’;

The report indicated that the PRUH’s ED largest issues were linked to non performing inpatient process, low discharge rates, bed shortage and longer waits for specialist consultation. The late patient handover from the UCC is another issue over which the Trust has less control;

Last year the Transfer of Care Bureau (TCB) was launched at the PRUH to address discharges and improve linkage between the hospital and community care teams. The TCB initiative is a partnership between the Trust, local social care providers and Bromley CCG. This year the TCB’s operational functionality and impact were reviewed by McKinsey to assess if it has had the desired impact of increased discharge rates and more joined up working between partners;


It was noted that there are a lot of moving parts to the redesign of the ED pathway, it is a complicated system that has a lot of moving parts, it is anticipated that there Trust may begin to see some results of the restructure in Q3 but the pathway should be stable and operational by Q4;

The Trust must be aware that there is a separate sector to care which is the out of Hospital care provided by other partners over who the Trust has no control; and

The challenges at the PRUH are different from those of DH ED. The strengthened leadership at the PRUH has already provided some improvements. The TCB will have a new lead shortly and they will report directly to JF in the Trust this should allow for the greater transparency and ease of oversight by the Trust.

SOUND FINANCES

016/78 Sustainability & Transformation Fund Update The Committee received a letter on the sustainability and transformation fund offer from NHS Improvements (NHSI). The following key points were reported:

The Trust has received a revised offer letter from NHSI regarding their proposal of one off financial support to the Trust in 2016/17. The financial support will be granted only if the Trust signs up to deliver an agreed control total. While the letter states an acceptance or decline is needed by Monday 27 July, internal governance process require the offer to be discussed at the appropriate level before a decision a made;

The offer was considered against the Trust financial performance which as at month 2 was £6.7m off trajectory due to slippage of cost improvement programmes (CIP), income under performance and pay and non-pay related expenditure;

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Item Subject

Action

Trust income underperformance was due to payment for speciality NHS England (NHSE) commissioning work which is still paid under last year’s rate. The NHSE contract is yet to be finalised;

The Trust underperformance in activity is protected by the block contract agreement with local commissioners, they have been informed of this issue;

The The Finance Directorate have been working through the revised sustainability offer and reviewing the numbers in line with the Trust’s annual financial plan;

The Trust has to deliver £71m worth of CIPs savings for the 2016/17. To facilitate better planning and provide mitigation, the finance directorate has provided for 10% slippage for in year schemes and a £11.7m on the CIP total due to uncertainty around scheme delivery. Against this mitigation measure to the tune of circa £12.9m have been identified and assigned:

The Trust’s loss of activity related to in and outpatients procedures will not be recovered before the end of the year. The referral to treatment (RTT) targets should be achieved but there will be not margin of growth delivered;

The Trust operational plan can accommodate the revised offer but its delivery is dependent on the contribution and performance of Trust partners in commissioning and social care;

While securing any finical contribution at this time would be vital, the Trust must ensure it does not sign up to an unattainable target which is beyond what it can deliver;


The Trust has loan obligations from last year to its CCG partners who have been patient and provided a more relaxed repayment schedule but even with a reduction in repay requirement delivery of the £65m target will be tasking;

Should the Trust sign up to the target it will receive funds quarterly subject to achievement of performance margins;

The Trust is aware of circa £10m risk already in the operational plan, this must be communicated to NHSI. The funding for the transformation programme is yet to be received, the Trust is currently funding the programme, for which there should be specialist funding allocation; and

The Trust has been experiencing unpredictable surges in demand for its services these always have a cost effect which must be considered should it occur. The Trust should only agree to the revised offer subject to a number of caveats that the Trust should be submitting along with its acceptance.

016/79 2016/17 CIP Planning/Stocktake The Committee received an update on the Trust’s CIPs position 2016/17. The following key points were reported:

The Trust CIPs value is moving in the right direction last week there were £25m worth of green CIPs, it is anticipated that at the end of quarter 1 (Q1) the Trust will have over £30m CIP schemes highlighted in green; and

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Item Subject Action

While the processes for CIP identification planning and approval are functioning it is getting harder to identify and approve large value CIPs.


It was noted that staff across the Trust are engaging with CIPs schemes planning, however what the Trust needs is more cross cutting schemes that move across more than one service area;

The agency CIPs requires a better grip, it is one that the Trust must drive through there is great potential for savings and permanent reduction in agency pay expenditure should these CIPs delivery; and

The CIPs linked to the interventional facility should start to delivery savings from 1 July 2016.

016/80 Interventional Facilities Update The Committee received a progress update on the set up of the Trust interventional facilities (IF): The IF vehicle has been set up, Trust representatives along with PwC meet with the HMRC. They did not provide no objections to the creation of the entity provided the Trust could provide evidence that:

The Trust will be at arm’s length from the running of the facility; and

The entity is set up to take advantage of commercial opportunity. This is ongoing.

016/81 STP/OHSEL Update The Committee received a update on the recent progress of the recent work in South East London. The work is very encouraging and the Committee decided that that this presentation/discussion should be presented in a different forum. There will be a side meeting between to discuss this further SS, CS, and BK to attend.

016/82 Update on Transformation Funding Mechanism This item was covered elsewhere on the agenda.

016/83 Finance Report – M02 The Committee receive month 2 finance report. The following key points were reported:

The deficit as at month 2 is £16.8m. This is an adverse variance of £6.7m against the year to date planned deficit plan of £10.1m. The figures exclude the estimated impairment costs of £1.7m to date;

Factors responsible for the variance are unidentified CIPs (£293k), CIP slippage (£94k), prior year income adjustments (£482k) and Private Patient income (£795k);

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Item Subject Action

Cash management is challenging. The Trust has held conversations with NHSI regarding low cash availability. The Trust has also paid off some of its creditors who have been waiting over 90 days as they had stated they would stop supplies; and

The cash position is further affected by the Trust debtors who have not paid the Trust for service owed. In some cases The Trust has not been paid because it has not paid them.

The Committee discussed the Trust’s cash position and that of the NHS as a whole and note that it might be worth sending a letter to Jim Mackey.

016/84 Finance Function

This item will be discussed at the next meeting.

016/85 Any Other Business There were no items of any other business raised for discussion.

016/86 Date of Next Meeting Tuesday, 26 July 2016, 09:00-11:00 in the Dulwich Committee Room.

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Date of report: 09 September 2016

Subject: Chair’s and Non-Executive Directors’ Activity Report

Presented by: Lord Kerslake, Chairman

Status: For information

1. Background/ Purpose

This report details the activities undertaken by the Non-Executive Directors of the Board for the period from 27 June 2016 to 19 August 2016.

2. Action required The Board of Directors is asked to note the contents of this report.

Lord Kerslake - Chairman

Date Activity

28 June Attended Finance & Performance Committee meeting

30 June

Chaired Remuneration & Appointments Committee meeting Met with Professor Ghulam Mufti re. Quality & Governance

6 July

Chaired Public Board meeting Undertook Go See Visit Attended NEDs’/Chairman’s Lunch Chaired Private Board Meeting Met with Sue Slipman for her annual NED appraisal

7 July

Met with Faith Boardman for her annual NED appraisal Chaired KCH Site Development Project Group meeting

8 July Attended Denmark Hill Site Strategy Masterplan Interview (Final Stage)

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14 July Met with Professor Jon Cohen for his annual NED appraisal

18 July

Met with Chris Stooke for his annual NED appraisal Hosted NEDs Dinner

25 July Met with Faith Boardman – received canvassed feedback / Chair's Appraisal

26 July Attended Finance & Performance Committee Meeting

Jon Cohen – Non-Executive Director, Lead for Improving Quality of Patient Care

Date Activity

28 June Attended Quality & Governance Committee meeting

6 July

Attended Public Board Meeting Undertook Go See Visit Attended NEDs’/Chairman’s Lunch Attended Private Board Meeting

14 July

Appraisal with Lord Kerslake Undertook ward visit (Haem & Renal OPD)

26 July

Attended Quality & Governance Committee meeting Attended Education & Workforce Committee meeting

Alix Pryde – Non Executive Director, Chair of Audit Committee, Lead for Move to Operational Sustainability

Date Activity

30 June

Attended Remuneration Committee meeting

Attended showcase for Dignity Week

6 July

Attended Public Board meeting

Attended Private Board meeting

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13 July

Presented awards and gave closing remarks at the Annual Presentation &

Medical Leadership Awards ceremony

18 July

Attended NEDs dinner

Chris Stooke – Non Executive Director, Chair Finance and Performance Committee, Lead for Delivering Financial Plans

Date Activity

28 June Chaired Finance & Performance Committee meeting Meeting with Toby Lambert

30 June Attended Remuneration & Appointments Committee meeting

4 July Attended Efficiency Board meeting

6 July Attended Public Board meeting Undertook Go See Visit – Twining Ward Attended Private Board meeting

14 July KCH Charity induction Attended KCH Charity board

18 July 1:1 with Chair Attended Efficiency Board meeting

26 July Chaired Finance & Performance Committee meeting KCH Charity meeting

11 August KCH Charity conference call

Faith Boardman – Non-Executive Director, Chair of Education Workforce and Development Committee, Lead for Organisational Development

Date Activity

07 July Meeting with Chair to complete Chair’s annual appraisal

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25 July Attended annual appraisal with Chair

Sue Slipman – Non Executive Director, Deputy Trust Cahir, Chair of Private Board

Strategy Focus, Lead for Trust Strategy

Date Activity

28 June

Attended Finance & Performance Committee meeting

30 June Attended Remuneration & Appointments Committee meeting

6 July

Attended Public Board meeting Undertook Go See visit Attended Private Board meeting Attended annual appraisal with Chair

15 July Chaired Consultant Appointment Panel

26 July Attended Finance & Performance Committee meeting

27 July

Attended GSST Public Board Attended GSST Board of Governors Meeting

26 August Contributed to Finance & Performance Committee – virtual meeting

Professor Ghulam Mufti – Non Executive Director, Chair of Quality and Governance Committee, Lead of Trust Strategy (KHP)

Date Activity

30 June Attended meeting with Chair – Quality & Governance Committee

23 August Attended annual appraisal with Chair

Erik Nordkamp – Non Executive Director, Cahir of Commercial Services Board , Lead for Commercial Services

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Date Activity

28 June Lunch meeting with Vijay Goel, Singhania & Co Solicitors and Simon Taylor,

Kings College

18 July

Attended the KCH NEDs'/Chair's monthly dinner

10 August Attended the Clinical Transformation Steering Board (Denmark Hill)

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