Month 12 (March) 2016
Indica
tor
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Indicator
Target
Target Met
Comments
IPR Section
Page No.
7 Day Follow - Ups
CPA Review within 12 Months
Mental Health Delayed Transfers of Care
EIS in place for New Psychosis Cases
RTT - Consultant Led (Completed Pathway)
RTT - Consultant Led (Incomplete Pathway)
IP Access to Crisis Res. Home Treatment
MH Data Completeness - Identifiers
MH Data Completeness - Outcomes
CIDS Completeness - Referral Information
CIDS Completeness - RTT Information
CIDS Completeness - Activity Information
2 week wait for treatment for EIP programme
RTT - IAPT 6 weeks
RTT - IAPT 18 Weeks
Total OAT Occupied bed days
OAT Average number of patients
95%
95%
≤7.5%
95%
95%
95%
95%
97%
50%
50%
50%
50%
50%
75%
95%
310
10
98.3%
96.7%
7.31%
132.8%
99.8%
99.7%
95.8%
99.6%
80.5%
100.0%
99.2%
90.0%
60.2%
82.6%
95.7%
1051.00
33.90
Section 1 .1
Section 1.1
Section 1.1
Section 1 .1
Section 1.1
Section 1.1
Section 1 .1
Section 1.1
Section 1.1
Section 1 .1
Section 1.1
Section 1.1
Section 1 .1
Section 1.1
Section 1.1
Section 1.1
Section 1.1
7, 10
7, 10
7, 9, 11, 22
7
7, 12
7, 12
7, 11
7
7
7
7
7
7, 26
7, 13
7, 13
14
20
18
Adult Mental Health LCFT & OATS Occupied Bed Days
95%
111.99%
Section 1 .1
TBC
19
Adult Mental Health LCFT Occupied Bed Days
95%
98.75%
Section 1.1
TBC
20
21
Older Adult LCFT & OATS Occupied Bed Days
Older Adult LCFT Occupied Bed Days
95%
95%
103.07%
99.62%
Section 1.1
Section 1.1
TBC
TBC
22
Avg Length of Stay - Adult
30
33.3
Section 1.1
TBC
23
Avg Length of Stay - Older Adult
TBC
171.4
Section 1.1
TBC
24
Adult Inpatient 28 Day Readmissions
8.80%
9.09%
Section 1.1
14
25
26
27
28
29
30
Adult Inpatient 90 Day Readmissions
Mixed Sex Accommodation Breach
Never Events
Pressure Ulcers
Clostridium Difficile Infections
Zero tolerance MRSA
TBC
0
0
0
0
0
18.18%
0
0
0
0
0
Section 1.1
Section 3
Section 3
Section 3
Section 3
Section 3
14
60
59
60
60
60
31
Complaints
TBC
107
Section 3
61
32
33
34
35
95%
95%
90%
Submitted
91%
94%
79%
Submitted
Section 3
Section 3
Section 3
Section 2.2
61
62
62
N/A
36
37
Patient Friends and Family Test
Harm Free Care (Safety Thermometer tool) Physical
Harm Free Care (Safety Thermometer tool) Mental
KH03 (Quarterly Bed Availability and Occupancy) (UNIFY)
Part 1: Cardio Metabolic Assessment for Patients with Schizophrenia
(CQIUN)
Part 2: Communication with General Practitioners (CQUIN)
Monitor Target
Monitor Target
Monitor Target
Monitor Target
Monitor Target
Monitor Target
Monitor Target
Monitor Target
Monitor Target
Monitor Target
Monitor Target
Monitor Target
Monitor Target
Monitor Target
Monitor Target
Patient flow - New
Patient flow - New
Includes PICU & Functional adults
OATS
Includes PICU & Functional Adult
LCFT beds only.
Internal measure only. Includes
Advanced care and dementia LCFT
beds & OATS
Patient flow - New
Contract Target. Based on patients
discharged in month.
Contract Target. Based on patients
discharged in month. (February
94.3)
No official target however
nationally accepted to achieve
≤8.8%
No target exists, to be agreed
locally (February 19.89%)
Contract Target
Contract Target
Contract target
Contract Target
Contract Target
Local target to be agreed (February
94)
Feburary Data only (month in
arrears)
March data from BBSC
March data from BBSC
Q1, Q2, Q3 & Q4 submitted
Submitted
90%
63.00%
100.00%
Q4 submitted to commissioners
Q4 submitted to commissioners
Section 2.2
Section 2.2
54
54
38
39
CAMHS Unplanned admissions and care planning - quarterly submission Submitted
Stop Smoking - secure services (quarterly submission)
Submitted
100.00%
100.00%
Q4 submitted to commissioners
Q4 submitted to commissioners
Section 2.2
Section 2.2
54
54
40
41
MAS - RTT in 6 weeks
AHP RTT
70%
95%
58.30%
96.07%
Contract Target
Contract Target
Section 1.1
Section 1.1
25
TBC
50%
<=2wks
95%
100.00%
171
88.51%
Contract Target
Contract Target
Contract Target
Section 1.1
Section 1.1
Section 1.1
15
29
23
42
Advancing Quality - Dementia
43
Secure: 2 week GP waits
44
Adult Community: 12 week Dentist waits (Prisons)
45
46
47
48
49
50
Summary
Future Inclusions
PBR Clustering
Unallocated Patients
4 Hour A&E targets
IAPT Prevelance
IAPT Recovery
Community Dental Waits
GP DNA's
CPA Reviews 6 Month (SMHBU)
Future Exclusions
Integrated Quality and
Performance Report –
Corporate View
M12 – March 2016
18th April 2016
Performance Management
Performance Management
Board Balance Score Card
Performance Management
2
Integrated Performance Report:Corporate View
Section 1:- Performance and Data Quality
Section 1.1:- Executive Level Report
•
•
•
•
•
Monitor Indicators Dashboard
Key Exceptions
CCG level data
Network level summary
Key Network Exceptions
Section 1.2:- Performance Data Quality
•
•
Section 2.1:- Financial Activity
FSRR CIN Full
Summary I&E Position
Summary of Clinical Services
CIPS
Capital Expenditure
Section 2.2:- Community Contract Activity
•
•
•
•
•
•
•
•
•
•
•
•
Quality Tile
Quality Surveillance - Safety
Quality Surveillance - Experience
Quality Surveillance - Effectiveness
Leadership
Delivering the Strategy
To be included
• Schedule 4 Detail
PBR Clustering
Unallocated Patients
Section 2:- Finance and Contracting
•
•
•
•
•
Section 3:- Quality
Network Planned Detailed Activity - Summary
Network Planned Detailed Activity – Adult Community
Network Planned Detailed Activity – Children and Families
CQUIN Executive Summary
2015/16 CQUIN Schemes
2015/16 CQUIN Schemes Quarter 4 Position
Section 4:- Workforce – REPORTING PAUSE IN PLACE
•
•
•
•
•
•
Actual Workforce Costs Compared to Budget
Sickness Absence Rates
Appraisals and Mandatory Training Compliance
Vacancy Management and Active Recruitment
Core Workforce Headcount
Workforce Turnover
To be included
• Personal Development Reviews
• Salary Bill
• Professional Registration
• DBS Checks
Performance Management
3
Section 1
Performance and Data Quality
Performance Management
4
1. Performance and Data Quality
Section 1:- Performance and Data Quality
Section 1.1:- Performance Activity
• Monitor Indicators Dashboard
• Key Exceptions
• CCG level data
• Network level Summary
• Key Network Exceptions
Section 1.2:- Data Quality
• PBR Clustering
• Unallocated Patients
Performance Management
5
Section 1.1
Performance Activity
Performance Management
6
1.1 Performance Activity
Monitor Indicators Dashboard
Trust Performance in March 2016 (M12)
Monitor Indicator Risks:
Target
This
Month
(Mar 16)
Last
Month
(Feb 16)
Jan-16
Q1
Q2
Q3
Q4
MR01 - 7 Day Follow Up
95.00%
98.20%
99.17%
97.78%
96.21%
95.81%
96.33%
98.37%
MR02 - CPA Review within 12 Months
95.00%
96.64%
96.89%
96.70%
96.05%
96.62%
96.51%
96.75%
MR03 - Mental Health Delayed Transfers of Care
≤ 7.50%
7.37%
7.76%
6.85%
4.88%
8.86%
7.45%
7.31%
MR04 - EIS in place for New Psychosis Cases
95.00%
133.45%
132.51%
132.37%
130.56%
133.53%
138.82%
132.81%
MR05 - RTT - Consultant Led (Completed Pathway)
95.00%
100.00%
98.82%
97.62%
100.00%
98.54%
98.84%
98.80%
MR06 - RTT - Consultant Led (Incomplete Pathway)
92.00%
100.00%
100.00%
99.32%
99.77%
99.73%
99.66%
99.77%
MR07 - IP Access to Crisis Res. Home Treatment
95.00%
96.97%
95.12%
95.33%
96.47%
98.46%
95.17%
95.82%
MR08 - MH Data Completeness - Identifiers
97.00%
99.65%
99.71%
99.64%
99.66%
99.56%
99.66%
99.66%
MR09 - MH Data Completeness - Outcomes
50.00%
79.07%
80.76%
81.70%
88.18%
86.76%
83.86%
80.51%
MR10 - CIDS Completeness - Referral Information
50.00%
100.00%
100.00%
100.00%
99.99%
99.78%
99.70%
100.00%
MR11 - CIDS Completeness - RTT Information
50.00%
99.58%
99.13%
99.06%
99.34%
99.48%
98.66%
99.28%
MR12 - CIDS Completeness - Activity Information
50.00%
91.99%
91.83%
84.52%
83.07%
86.68%
85.11%
90.03%
MR13 - 2 Week wait for Treatment for EIP Programme
50.00%
66.67%
61.76%
50.00%
44.00%
47.83%
60.22%
MR14 - RTT - IAPT 6 Weeks
75.00%
79.17%
83.73%
85.07%
83.69%
82.62%
MR15 - RTT - IAPT 18 Weeks
95.00%
95.75%
96.29%
95.15%
95.45%
95.79%
Indicator
All Monitor Indicators have been compliant with
Performance for this Month, Quarter and the Year
(2015/16).
New Indicators and Targets for 2015/16:
Three new indicators have been introduced during
2015/16. The IAPT indicators began to be shadow
reported to Monitor in Q3 and officially reported since Q4.
The EIS indicator began shadow reporting to Monitor in Q4
and will commence official reporting from Q1 2016/17.
Recommendations:
As part of BAU, the ongoing SOP compliance audit has
commenced in line with the agreed programme. 7DFU
audit has now been completed.
The AC & AMH Networks continue to refresh their DToC
Action Plans to ensure delivery of the DToC measure. The
performance and information function are currently
reviewing processes to improve data collection and enable
"live" monitoring. Delivery against this measure is being
closely and jointly monitored by the Networks and the
Strategic Performance Function and weekly DToC meeting
between all providers to discuss each individual patient.
Performance Management
7
1. Executive Summary
Monitor Indicators reported by CCG
This section of the report analyses the Monitor indicator performance at CCG level.
8 of the Monitor measures are reported at CCG level.
There are then a number of indicators that currently are not reported by CCG for the reasons outlined below;
•
EIS in place for New Psychosis Cases: This indicator reflects planned against actual activity for EIS. Whilst actual activity can be split by CCG the plan is
currently not available at this level. This will need to be confirmed with Commissioners before the indicator can be presented in this way.
•
MH Data Completeness Identifiers and Outcomes (2 measures): These datasets cannot currently be reported by CCG. Whilst actual activity can be
split by CCG the plan is currently not available at this level. This will need to be confirmed with Commissioners before the indicator can be presented in
this way.
•
CIDs Completeness Referral, RTT and Activity Information (3 measures): These datasets cannot currently be reported by CCG. Whilst actual activity
can be split by CCG the plan is currently not available at this level. This will need to be confirmed with Commissioners before the indicator can be
presented in this way.
•
2 Week wait for Treatment for EIP Programme: Currently in shadow reporting format.
Confirmation from the Business Intelligence team has been received that with further development it would be possible to split these indicators by CCG.
However, it would be best to build this into the new monitor report within the new data warehouse. This will be incorporated into the project plan for
phase 2.
Performance Management
8
1.1 Performance Activity
Monitor Indicators
MR03 – Mental Health Delayed Transfers of Care
T his M o nt h
La s t M o nt h
Qtr 4
6.80%
6.99%
6.39%
20.78%
22.71%
23.25%
Children & Families
-
-
-
Specialist Services
0.69%
0.68%
0.68%
T rus t T a rge t %
≤ 7 .5 0 %
≤ 7 .5 0 %
≤ 7 .5 0 %
A dult M ental Health
A dult Co mmunity
Actual Performance Commentary:
The Trust has achieved the Target of ≤ 7.50% with a Performance of 7.37% for this Month.
The Adult Community Network continues to fail with a Performance of 20.78%, details of
which can be found on page 22 of this report.
Actions Required:
Review of current recording processes for DToC patients.
Ongoing work to address reasons for patients not being able to be discharged on a timely
manner.
Establishment of virtual ward for analysis and more transparent tracking of DToC and OATS
patients.
Performance Management
9
1.1 Performance Activity
Monitor Indicators reported by CCG
CPA 12 Month Review
7 Day Follow Up
% 7 Day Follow Up
Target Mar-16 Feb-16
Jan-16
Q1
Q2
Q3
Q4
% CPA 12 Month Review
Target Mar-16 Feb-16
Jan-16
Q1
Q2
Q3
Q4
NHS Blackburn with Darwen CCG
95.00% 94.12% 100.00% 100.00% 100.00% 97.87% 90.00%
98.39%
NHS Blackburn with Darwen CCG
95.00% 97.16% 97.08% 96.82% 97.01% 96.81% 96.79%
97.02%
NHS Blackpool CCG
95.00% 100.00% 100.00% 95.45% 100.00% 98.31% 96.36%
98.08%
NHS Blackpool CCG
95.00% 96.30% 95.60% 97.59% 94.79% 94.90% 94.79%
96.54%
NHS Chorley and South Ribble CCG
95.00% 83.33% 100.00% 100.00% 100.00% 93.10% 95.00%
96.77%
NHS Chorley and South Ribble CCG
95.00% 97.08% 96.36% 95.73% 97.57% 96.19% 95.38%
96.36%
NHS East Lancashire CCG
95.00% 100.00% 96.55% 100.00% 100.00% 98.59% 100.00%
98.98%
NHS East Lancashire CCG
95.00% 97.13% 97.42% 95.97% 97.07% 97.66% 96.79%
96.83%
NHS Fylde & Wyre CCG
95.00% 100.00% 100.00% 100.00% 100.00% 88.24% 97.06%
100.00%
NHS Fylde & Wyre CCG
95.00% 97.02% 96.78% 96.56% 96.61% 97.26% 97.32%
96.78%
NHS Greater Preston CCG
95.00% 100.00% 100.00% 91.67% 100.00% 97.22% 100.00%
97.37%
NHS Greater Preston CCG
95.00% 97.14% 98.72% 97.36% 98.05% 96.69% 98.37%
97.74%
NHS Lancashire North CCG
95.00% 100.00% 100.00% 90.00% 60.00% 86.96% 96.77%
97.06%
NHS Lancashire North CCG
95.00% 96.05% 96.49% 97.72% 96.72% 96.37% 96.43%
96.81%
NHS West Lancashire CCG
95.00% 100.00% 100.00% 100.00% 100.00% 90.48% 94.44%
100.00%
NHS West Lancashire CCG
95.00% 95.96% 95.81% 97.83% 95.44% 96.04% 96.59%
96.56%
Total Figure - 8 CCGs
95.00% 98.20% 99.15% 97.78% 97.47% 95.71% 96.30%
98.35%
Total Figure - 8 CCGs
95.00% 96.83% 96.92% 96.83% 96.78% 96.65% 96.59%
96.86%
Trust position for Lancashire CCGs:
- In Month 12, the Trust has achieved a Performance
of 98.20% against a Target of 95.00% across 8 CCGs.
Trust position for Lancashire CCGs:
- In Month 12, the Trust has achieved a Performance of
96.83% against a Target of 95.00% across 8 CCGs.
CCG Position:
- In Month 12, the Trust has under-performed in 2
CCGs: Blackburn with Darwen and Chorley and South
Ribble. This equates to 2 patients within the Adult
Mental Health Network.
CCG Position:
- In Month 12, the Trust has performed to Target
within all 8 CCGs.
Note: The total figures in the tables above differ from page 4 as they are representative of only 8 contracted CCGs
Performance Management
10
1.1 Performance Activity
Monitor Indicators reported by CCG
Delayed Transfers of Care (DToC)
% DToC
IP Access to Crisis Resolution Home Treatment
Target Mar-16
Feb-16
Jan-16
Q1
Q2
Q3
Q4
NHS Blackburn with Darwen CCG
≤ 7.50% 0.15%
1.95%
4.02%
2.32%
5.97%
8.22%
1.98%
NHS Blackburn with Darwen CCG
% IP Acces to CRHTT
95.00% 95.83% 100.00% 95.45%
Target Mar-16
Feb-16
NHS Blackpool CCG
≤ 7.50% 10.24%
7.81%
7.46%
3.05%
6.35%
8.02%
8.50%
NHS Blackpool CCG
95.00% 100.00% 95.24% 100.00% 100.00% 98.46%
88.46%
98.36%
NHS Chorley and South Ribble CCG
≤ 7.50% 11.30%
17.16%
14.99%
17.53%
23.65%
14.52%
14.33%
NHS Chorley and South Ribble CCG
95.00% 88.24%
90.91%
88.89% 100.00% 100.00% 96.97%
89.19%
NHS East Lancashire CCG
≤ 7.50% 7.24%
8.24%
7.16%
0.00%
7.26%
8.75%
7.54%
NHS East Lancashire CCG
95.00% 97.56%
90.91%
92.50%
98.11%
97.33%
93.60%
NHS Fylde & Wyre CCG
≤ 7.50% 15.81%
12.82%
9.64%
15.72%
21.79%
6.59%
12.63%
NHS Fylde & Wyre CCG
95.00% 93.33%
94.44% 100.00% 100.00% 96.97%
97.44%
95.74%
NHS Greater Preston CCG
≤ 7.50% 2.88%
2.91%
3.86%
7.58%
11.81%
5.74%
3.23%
NHS Greater Preston CCG
95.00% 100.00% 95.24%
94.74% 100.00% 100.00% 97.62%
96.77%
NHS Lancashire North CCG
≤ 7.50% 9.39%
12.48%
9.49%
10.52%
14.54%
8.92%
10.36%
NHS Lancashire North CCG
95.00% 100.00% 100.00% 90.91% 100.00% 96.55%
93.94%
97.78%
NHS West Lancashire CCG
≤ 7.50% 23.14%
15.53%
8.31%
7.13%
9.64%
5.33%
15.05%
NHS West Lancashire CCG
95.00% 100.00% 100.00% 100.00% 91.67% 100.00% 85.71%
100.00%
Total Figure - 8 CCGs
≤ 7.50% 7.76%
8.18%
7.21%
7.94%
10.84%
8.01%
7.70%
Total Figure - 8 CCGs
95.00% 96.89%
95.74%
95.06%
Jan-16
95.24%
Q1
Q2
Q3
88.00% 100.00% 98.04%
94.59%
95.86%
98.68%
95.09%
Q4
97.14%
Trust position for Lancashire CCGs:
- In Month 12, the Trust has failed to achieved a Target of ≤
7.50% with a Performance of 7.76% across 8 CCGs.
Trust position for Lancashire CCGs:
- In Month 12, the Trust has achieved a Performance of 96.89%
against a Target of 95.00% across 8 CCGs.
CCG Position:
- In Month 12, the Trust has under-performed in 5 CCGs:
Blackpool, Chorley and South Ribble, Flyde & Wyre,
Lancashire North, West Lancashire. The Adult Community
Network continues to be the largest contributor to the
number of Bed Days lost across all 8 CCGs. The Adult Mental
Health Network largest issue in Month 12 was in Blackpool,
Flyde & Wyre, Lancashire North, West Lancashire.
CCG Position:
- In Month 12, the Trust has under-performed in 2 CCGs: Chorley
and South Ribble and Flyde & Wyre. This equates to 5 patients all
within the Adult Mental Health Network.
Note: The total figures in the tables above differ from page 4 as they are representative of only 8 contracted CCGs
Performance Management
11
1.1 Performance Activity
Monitor Indicators reported by CCG
RTT – Consultant Led (Completed Pathway)
% RTT Complete Pathways
RTT – Consultant Led (Incomplete Pathway)
Target Mar-16 Feb-16 Jan-16
Q1
NHS Blackburn with Darwen CCG
95.00% 100.00% 100.00% 100.00%
-
NHS Blackpool CCG
95.00% 100.00% 100.00%
-
NHS Chorley and South Ribble CCG
95.00% 100.00% 100.00% 97.06% 100.00% 97.80% 99.09%
NHS East Lancashire CCG
95.00% 100.00% 100.00% 100.00%
-
NHS Fylde & Wyre CCG
95.00% 100.00% 100.00% 100.00%
-
NHS Greater Preston CCG
95.00% 100.00% 97.44% 97.70% 100.00% 99.38% 98.75%
NHS Lancashire North CCG
95.00% 100.00% 100.00% 100.00%
NHS West Lancashire CCG
95.00% 100.00%
Total Figure - 8 CCGs
95.00% 100.00% 98.80% 97.53% 100.00% 98.85% 99.63%
-
Q2
Q3
Q4
Target Mar-16 Feb-16 Jan-16
Q1
Q2
Q3
Q4
NHS Blackburn with Darwen CCG
92.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%
NHS Blackpool CCG
92.00% 100.00% 100.00% 100.00%
NHS Chorley and South Ribble CCG
92.00% 100.00% 100.00% 99.35% 100.00% 100.00% 99.73%
NHS East Lancashire CCG
92.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%
NHS Fylde & Wyre CCG
92.00% 100.00% 100.00% 100.00%
98.40%
NHS Greater Preston CCG
92.00% 100.00% 100.00% 99.05% 99.31% 99.58% 99.44%
100.00% 100.00% 100.00%
NHS Lancashire North CCG
92.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%
100.00% 100.00% 100.00% 100.00% 100.00%
NHS West Lancashire CCG
92.00% 100.00% 100.00%
Total Figure - 8 CCGs
92.00% 100.00% 100.00% 99.31% 99.58% 99.76% 99.63%
-
-
100.00% 100.00% 100.00%
% RTT Incomplete Pathways
-
100.00% 100.00%
98.92%
100.00% 100.00% 100.00%
-
100.00% 100.00%
99.02%
-
-
-
100.00% 100.00% 100.00%
99.77%
100.00% 100.00% 100.00%
99.68%
100.00% 100.00% 100.00% 100.00%
99.76%
Trust position for Lancashire CCGs:
- In Month 12, the Trust has achieved a Performance
of 100.00% against a Target of 95.00% across 8
CCGs.
Trust position for Lancashire CCGs:
- In Month 12, the Trust has achieved a
Performance of 100.00% against a Target of 92.00%
across 8 CCGs.
CCG Position:
- In Month 12, the Trust has performed to Target
within all 8 CCGs.
CCG Position:
- In Month 12, the Trust has performed to Target
within all 8 CCGs.
Note: The total figures in the tables above differ from page 4 as they are representative of only 8 contracted CCGs.
The symbol “–” denotes zero patients
Performance Management
12
1.1 Performance Activity
Monitor Indicators reported by CCG
IAPT – 6 Weeks
% IAPT - 6 Weeks
IAPT – 18 Weeks
Target Mar-16 Feb-16 Jan-16
Q1
Q2
Q3
Q4
% IAPT - 18 Weeks
Target Mar-16 Feb-16 Jan-16
Q1
Q2
Q3
Q4
NHS Blackburn with Darwen CCG
75.00% 96.15% 99.21% 94.29%
-
-
94.59%
97.00%
NHS Blackburn with Darwen CCG
95.00% 100.00% 100.00% 98.57%
-
-
98.20%
99.67%
NHS Blackpool CCG
75.00%
-
-
-
-
NHS Blackpool CCG
95.00%
-
-
-
-
NHS Chorley and South Ribble CCG
75.00% 97.92% 99.26% 93.75%
-
-
91.90%
96.94%
NHS Chorley and South Ribble CCG
95.00% 100.00% 100.00% 98.44%
-
-
95.40%
99.44%
NHS East Lancashire CCG
75.00% 87.98% 88.24% 87.38%
-
-
81.38%
87.90%
NHS East Lancashire CCG
95.00% 99.04% 99.65% 99.07%
-
-
97.79%
99.30%
NHS Fylde & Wyre CCG
75.00% 83.33% 88.30% 89.39%
-
-
78.95%
87.07%
NHS Fylde & Wyre CCG
95.00% 95.83% 95.74% 96.97%
-
-
90.40%
96.12%
NHS Greater Preston CCG
75.00% 78.06% 81.37% 84.09%
-
-
83.30%
81.06%
NHS Greater Preston CCG
95.00% 96.13% 96.08% 94.96%
-
-
96.89%
95.78%
NHS Lancashire North CCG
75.00% 75.81% 78.40% 80.49%
-
-
72.99%
77.95%
NHS Lancashire North CCG
95.00% 95.97% 95.20% 96.34%
-
-
92.94%
95.77%
NHS West Lancashire CCG
75.00% 94.59% 94.87% 92.31%
-
-
93.45%
94.01%
NHS West Lancashire CCG
95.00% 100.00% 98.72% 96.92%
-
-
98.28%
98.62%
Total Figure - 8 CCGs
75.00% 86.67% 88.96% 88.38%
-
-
84.48%
88.07%
Total Figure - 8 CCGs
95.00% 98.08% 98.10% 97.51%
-
-
96.20%
97.92%
-
-
-
-
-
-
Trust position for Lancashire CCGs:
- In Month 12, the Trust has achieved a Performance of
86.67% against a Target of 75.00% across 8 CCGs.
Trust position for Lancashire CCGs:
- In Month 12, the Trust has achieved a Performance of 98.08%
against a Target of 95.00% across 8 CCGs.
CCG Position:
- In Month 12, the Trust has performed to Target within all 8
CCGs.
- In Month 12, 1 CCG had 0 patients: Blackpool.
CCG Position:
.- In Month 12, the Trust has performed to Target within all 8
CCGs.
- In Month 12, 1 CCG had 0 patients: Blackpool.
Note: The total figures in the tables above differ from page 4 as they are representative of only 8 contracted CCGs.
Performance Management
13
1.1 Performance Activity
Summary - Adult Mental Health
Performance Management
14
1.1 Performance Activity
Summary - Adult Community
Performance Management
15
1.1 Performance Activity
Summary – Children and Families
Indicators achieved
Actual
Target
Performance
Exception
Reports
Additional comments
Monitor
CPA 7 Day Follow Up
100.00% 95.00%
Achieved
No
CPA 12 Month Review
98.62%
95.00%
Achieved
No
EIS in place for New Psychosis Cases
133.45% 95.00%
Achieved
No
MH Data Completeness - Identifiers
99.76%
97.00%
Achieved
No
MH Data Completeness - Outcomes
65.81%
50.00%
Achieved
No
2 Week wait for Treatment for EIP Programme
66.67%
50.00%
Achieved
Yes
Other Indicators
Sexual Health
No
AQ Psychosis
100.00% 73.90%
Clustering Indicator
93.33%
95.00%
Number of Patients without a Care Co-ordinator Allocated > 2
Weeks
13.00
0.00
Achieved
No
No
Underperforming
System changes are affected Data Accuracy and Report currently
unavailable
Yes
Performance Management
16
1.1 Performance Activity
Summary – Specialist Services
Actual
Target
Performance
Exception
Reports
CPA 12 Month Review
98.77%
95.00%
Achieved
No
Delayed Transfers of Care (DToCs)
0.69%
≤ 7.50%
Achieved
No
MH Data Completeness - Identifiers
97.61%
97.00%
Achieved
No
MH Data Completeness - Outcomes
87.74%
50.00%
Achieved
No
88.55%
93.00%
Underperforming
Yes
171.00 > 2.00
Weeks
≤ 2.00
Weeks
Underperforming
Yes
25Hrs Meaningful Activity - Offered
100.00%
100.00%
Achieved
25Hrs Meaningful Activity - Uptake
76.06%
75.00%
Achieved
Indicators achieved
Additional comments
Monitor
Gross Occupancy
Overall Gross Occupancy
Waiting times
GP Waits over 2 Weeks
Other indicators
Referrals to Forensic Outreach
Prone Restraint
No
5.00 Prisons >
10.00%
10.00%
Underperforming
Yes
0.00
0.00
Achieved
No
100.00%
100.00%
83.00%
100.00%
99.00%
100.00%
Use of Physical Intervention
New Referrals - Assessments & Reports
CPA Reviews within 6 Months - SMHBU
Yes
Underperforming
Prison CPA Review within 6 Months
Number of Patients without a Care Co-ordinator
Allocated > 2 Weeks
Internal Target for Uptake
No
Bowel Screening
GP DNAs
No
No
These measures are reported the Month
following Quarter End
No
No narrative required
No
162.00
0.00
Underperforming
Yes
Performance Management
17
1.1 Performance Activity
Network Indicators Exception Reports
A number of indicators are below internal and contractual targets within specific networks (even though we may have achieved this as a Trust for Monitor
targets) and these are summarised below.
Also included are exception reports on measures where a breach has occurred previously and where 3 months of compliance is required before it is no longer
considered an exception. Networks are asked to revise plans to achieve the set trajectories where performance has remained generally static or under target.
Adult Mental Health Network
Children & Families Network
-
-
OATs Beds
ADHD
A&E Compliance
Unallocated AMH Patients (See Data Quality
Section)
Adult Community Network
-
EIS 2 Week wait
Unallocated C&F Patients (See Data Quality Section)
Specialist Services Network
-
Overall Gross Occupancy
GP Waits over 2 Weeks
GP DNAs
Unallocated SS Patients (See Data Quality Section)
AC DToC
Prison Dental
Community Dental
MAS 6 Week wait
Unallocated AC Patients (See Data Quality Section)
Performance Management
18
1.1 Performance Activity
Adult Mental Health – Out of Area Treatment (OAT) Beds
Out of Area Treatment (OAT) Beds:
OAT occupied bed days in March were 1051, higher than February though
with a longer month. February progress in addressing the OATs pressures
was maintained in March, which included the Easter Bank Holiday period.
Bronze command arrangements have moved to business as usual with 3
times per day conference calls between service managers to address any
actual or potential discharge blocks.
Actions:
1. Opening of additional 2 female assessment beds in April (Pauline Cullen,
Service Manager)
2. Development of Chorley Crisis Support Unit in April (Lorraine McDonaldJohnson, Service Manager)
3. Relocation of 6 female assessment beds to dedicated ward, releasing
further 4 female treatment beds end April/early May (Pauline Cullen, service
manager)
North Lancs Acute Therapy Service is now operational.
Performance Management
19
1.1 Performance Activity
Adult Mental Health – ADHD
ADHD:
Actions:
ADHD Transition: The ADHD Service is 100% compliant with the 18 week Referral to Treatment Target for cases transferring from CAMHS.
100% of transferred cases have been waiting under 18 weeks.
The service has transferred to the
Clinical Treatment Team
management, enabling further review
ADHD New: The service received the highest volume of 'New' referrals in M12, 42, compared to any other month throughout the year, placing of the service model to identify
increased pressure on waiting times for new cases.
capacity to be re-focussed on new
presentations.
Overview of Activity: In March the service accepted 61 referrals (42 New and 19 Transitions). 24 people were taken off the waiting list and
122 follow ups took place. 34 people were discharged from the service leaving 526 active caseloads.
As at the end of March there were 197 New and 56 Transitions on the waiting list.
Team review of capacity indicated limited scope for transfer of activity from transitions to new referrals. A further Band 6 Practitioner is
currently being recruited to address the increasing waiting list, and the service await confirmation of the revised business case from
commissioners
Performance Management
20
1.1 Performance Activity
Adult Mental Health – A&E Compliance
A&E Compliance:
The demand within the MHLT is the root cause for this target not being
met. This is due to multiple referrals being made at the same time and
only one Mental health Liaison Practitioner being on duty.
Actions:
1. Business cases to be discussed with CCGs, jointly by LCFT and ELTH
managers.
Performance Management
21
1.1 Performance Activity
Adult Community – DToC
AC DToC:
Actions:
The current position at the end M12 is 20.7%, significantly above target.
This reflects 23 DToCs in March, a slight reduction on the position of
previous months. The majority of delays continues to be patients
awaiting challenging behaviour beds- with packages of care which are
agreed- but placements remain unavailable. The placements within
Bellsfield/Rossall have been delayed and became available during the end
of March with all but one discharge now affected. The current position is
8 patients who are delayed discharges..
The weekly teleconference continues to be productive for all
stakeholders.
Work continues via the recovery plan to improve the processes around
reporting and the role of the nerve centre in this is being explored with
AMH colleagues.
Senior OAMH colleagues are joining the internal teleconference daily to
progress actions around all patient flow including OATS and DTOC.
The CSU are facilitating the development of closer team working between
local authority care navigators and LCFT discharge coordinators.
Performance Management
22
1.1 Performance Activity
Adult Community – Prison Dental
Prison Dental:
Actions:
M12 performance for Prison Dental shows an improving position and is
88.51% against a target of 95% (10 patients seen over 18 weeks). All of the
breaches were due to cancellation or DNA by patients/prison.
All breaches occurred at Wymott & Garth where we have historic problems
with gaining consistent and adequate access to prisoners which puts constant
pressure on our waiting times. The pressure at Wymott increased following a
period of sickness and annual leaved from our Wymott Dentist. We have 1
sessional dentist who can work in prisons but the capacity available is limited
by the cover that is also required for Calderstones and GA sessions at Burnley
General. Recruitment to a vacant dental post in Liverpool will increase our
ability to flex resources across our prisons.
Meeting taken place with dentist at Wymott to look at more robust plan to
reduce breaches and provide proactive/improved cover for leave and sickness
across prison dental.
Improved waiting list management and breach forecasting system has been
implemented across prisons.
More robust scrutiny prior to any clinics being cancelled has been put in place,
with a cancellation policy being drafted (to be ratified at Network Performance
in April).
Dialogue will continue with prison staff and prison management to avoid
future DNA's and minimise cancelled appointments where possible.
Performance Management
23
1.1 Performance Activity
Adult Community – Community Dental
Community Dental:
Actions:
M12 performance for community dental shows a deteriorating position and is
86.67% against a target of 95%. This equates to 24 patients who waited over
18 weeks for treatment who were treated in month. Long waits are due to
continued vacancies, ( 1 post now filled but start date of July 16) unplanned
sickness and patients who cancelled appointments. Two maternity leaves, a
number of medium & short term absences and delayed recruitment continue
to challenge capacity.
Return from sickness will start to improve the available capacity and therefore
reduce the waiting list through month 1. Very high referral rates in March
increased the overall waiting list by 23% to 850 patients waiting, with 44
patients over 18 weeks. Annual increase in referrals has been discussed with
NHS England who are supporting LCFT in addressing high referring surgeries.
A recovery plan is in place with weekly monitoring and reporting (see actions).
A recovery plan is in place to address the waiting list and achieve 95% RTT
compliance using every available resource and approach.
The PTL is being used to target the longest waiting patients with continued
focus on long waiters; 35 of the 44 18 week waiters have appointments
booked in April.
Additional capacity is being created through established dental staff
performing extra weekly clinic sessions and recruitment to a CDS sessional
post (start 13/4/16) and new substantive appointments are now in post.
Ongoing management of the waiting list is in place via a monthly meeting with
dental team coordinators. Work is under way to increase triage scrutiny and
work with surgeries to reduce referral rates.
Performance Management
24
1.1 Performance Activity
Adult Community – MAS 6 Week Wait
MAS 6 Week Wait:
As forecasted since the additional staffing resource has been
withdrawn the waiting times continue to increase accordingly.
LCFT has formally requested that annual medication reviews are
undertaken by Primary Care in order to release capacity for new
assessments.
CCG representatives have agreed to provide update within 4
weeks as to their position re the following options - inaction,
further investment, incorporation of reviews into Primary Care.
Actions:
Details of patients requiring reviews will be issued to respective CCG members in order to
assist in their appreciation of the impact within Primary Care.
Greater Preston, CSR and West Lancs have indicated that they are not in a position to
invest or accept reviews. West Lancs will work with LCFT to identify where reviews are
already undertaken.
Fylde have invested further resource and have included reviews as a KPI in their GP
contracts. East have also accepted reviews.
Lancaster have been issued with patient level detail as have West Lancs in order to
determine their next steps.
The waiting list continues to be managed and scrutinised through fortnightly Team
Manager Meetings.
Performance Management
25
1.1 Performance Activity
Children and Families – Early Intervention for Psychosis
Early Intervention for Psychosis :
Quality standard one – RTT within 14 days
The Performance for M12 was 66.6% against a threshold of 50%. This equates to 33 service users in month receiving treatment of which 22 received treatment within 2 weeks of
referral and 11 outside of the target timescales.
This improved position is understood to be due to the weekly PTL meetings, ensuring robust and prospective monitoring of patient pathways by the EIS operational management team,
and clear escalation protocols to team leaders should assessments not be possible by working day 10.
To continually drive further pathway and performance management process improvements, the management team are classifying breaches as ‘accepted’ or ‘unacceptable.’ Acceptable
breaches note where there is clear clinical reasoning to evidence why the service user has had a prolonged assessment over two weeks. Unacceptable breaches are due to avoidable
delays in referral, assessment or decision to treat. There are 7 acceptable and 4 unacceptable breaches. A summary of the reasons for the unacceptable breaches are as follows:
• 1 breached due to delays in a medical appointment in EIS
• 1 breached due to delays within EIS in assessment appointments
• 1 breached due to delay in allocation to a Care Coordinator
• 1 breached due to delayed referral from AMH related to Bluelight 71
From the 1st of April 16, the Trust must achieve the RTT standard of 50% within two weeks, as this is now a Monitor standard. To mitigate the risk of non-achievement of the RTT target
for April, the management team are reviewing the RTT weekly, using the live report. A clear escalation process has been put in place to ensure all pathways greater than 10 days are
flagged to the management team who will support in ensuring an assessment slot is offered within the timescales when appropriate. A meeting is also to be set up to review Blue light
71 protocol, to ensure there are no delays in referrals being received into EIS when a service user is also under crisis teams.
The new technical guidance released on the 1st March 16 confirms that a service user coming into treatment must be allocated and engaged with an EIP Care co-ordinator. This
validates the need to change the age criteria for EIS to become ageless, which requires an increase in caseload management capacity of c20%. Additional funding has now been
confirmed to the value of £400k for 16/17. The workforce modelling undertaken identified the requirement for £881k and therefore work is ongoing to ensure the monies available in
year are utilised to mitigate the greatest risks to performance, which are considered to be making the service ageless in line with the guidance.
There is still a challenge identifying service users over 35 within other service areas, whilst we await the workforce increasing and the ability to accept referrals. The risk of under
reporting this cohort will therefore continue throughout Q1 whilst recruitment takes place.
As outlined previously, now that EIS is delivering services in line with NICE standards, any over 35s that are identified will be classed as fails, which could impact on RTT performance.
Quality Standards two - eight
In order to meet NICE compliance, a new clinical model is being designed and tailored to individual service user needs. Clinical colleagues within the service are working on the model
that will be launched with the operational teams in M12, prior to 1 April 2016. An innovative approach has been adopted, which is the creation of a visual pathway within SharePoint
that contains: what we do, why we do this, showing we make a difference, where to record, templates and how we are doing, rather than using standards operating procedures.
Performance Management
26
1.1 Performance Activity
Children and Families – Early Intervention for Psychosis
Performance Management
27
1.1 Performance Activity
Specialist Services – Overall Gross Occupancy
Overall Gross Occupancy:
Across the Secure Mental Health Business Unit in March, occupancy has been above the 93%
target with the exception of capacity remaining within the Female Medium Secure Service, the
Male Transitional Normal Business (MI) Service, the ABI Low Secure and ABI Step Down Services.
Actions:
We continue to await the availability of a bed at the Therapeutically Enhanced Medium Secure
Service offered by The Edenfield to enable the transfer of one of our Medium Secure female
Service Users currently being nursed in seclusion. The bed is expected to become available
towards the end of April.
Gross Occupancy for the Secure Mental Health Business Unit as at 31 March 2016 was 88.53%
A Service User from HMP Styal was admitted into the Female Medium Secure Service at the end
of March and another Service User is due to transfer from the Female Step down Service in early
April, therefore occupancy will be above 93% for April.
We continue to await availability of a bed at Ashworth High Secure Hospital to enable the
transfer of one of our Medium Secure ABI Service Users currently being managed in seclusion.
Ashworth High Secure Hospital are unable to give a time scale for the availability of a bed.
Weekly contact is maintained with the bed Manager at Ashworth Hospital for updates on the
situation.
Capacity remains within the Transitional Male normal business (MI) Unit as this is required to
allow for the Women’s LSU to become operational. Capacity will remain within the Transitional
Male normal business (MI) Service until the Women’s LSU is operational.
Four Service Users in the ABI Medium Secure Service have been identified as being suitable for
transfer to the ABI Low Secure Service, one of the transfers has taken place in March and two are
scheduled for early April. MOJ permission is required for the remaining transfer, this has been
requested. The ABI Transitional Service has now been opened up to admit normal business (MI)
Service Users. Occupancy has increased from 60.00% in February to 66.45% in March.
The service attended the quarterly contract meeting as planned with NHSE in February during
which commissioners expressed that that did not have any concerns with the current occupancy
level of the service
Performance Management
28
1.1 Performance Activity
Specialist Services – GP Waits over 2 Weeks
GP Waits over 2 Weeks:
Actions:
HMP Garth - At the end of March 36 patients were waiting longer than 2 weeks which is an
increase from 5 in February. The service has not experienced any GP clinic cancellations or
operational issues during the month of March that would usually contribute to the extended
waiting list. There are 26 non compliant medication patients that have required reviews which is
taking up additional GP time. The Nurse Prescriber is continuing with his Nurse Practitioner
training to expand his portfolio as the variety of patients he could review was limited.
HMP Garth have allocated GP time at the weekend for admin, tasks and referrals to be
completed. This will take pressure off sessions during the week allowing for more patients to be
seen. A request has been made to the GP provider to facilitate additional sessions where
possible to assist in reducing the current waits. There are two staff who have recently
completed 'Same Day Consultation' and can now provide triage for minor complaints.
HMP Wymott - At the end of March 14 patients were waiting longer than 2 weeks which is an
increase from 12 in February. The service is working hard to maintain waits under 2 weeks. In
March the waiting times have been impacted by the bank holidays and a total of six GP sessions
being missed. Management of the waiting times during this period has been effective for the
increase to be small.
HMP Wymott will continue to monitor the GP waiting list and work towards maintaining the
waiting list below 2 weeks. The healthcare manager will negotiate recovery of the six sessions
missed.
HMP Liverpool will continue to review the processes in place and will be monitoring the waiting
lists on a weekly basis. A new healthcare link governor is in place and regular meetings are
taking place to manage the escalation of issues with the prison.
HMP Liverpool - At the end of March 89 patients were waiting longer than 2 weeks which has
decreased from 110 in February. The new processes in place for the admin and HCA staff, for
managing waiting lists and the re-booking of patients, is reflecting in the reduction of waits. The
Nurse Practioners have started triage clinics and the referrals from the mental health team are
also being reviewed to ensure the team take responsibility for prescribing for their patients in
turn helping to reduce the waiting list.
Performance Management
29
1.1 Performance Activity
Specialist Services – GP DNA’s
GP DNA’s:
HMP Preston - DNA rates have reduced to 15.33% for the month of March from 18.41% in February.
HMP Preston has continued to monitor their DNA rates with Enablement and Patient Declined
continuing to be the two main reasons for DNA’s.
HMP Garth - DNA rates have increased to 16.07% for the month of March from 14.01% in February.
There is a process in place so that if a patient does not attend for their appointment the receptionist
will ring the wing or workplace to remind the patient of the appointment and give them an
opportunity to attend or confirm the reason for non-attendance.
HMP Lancaster Farms - DNA rates have increased to 15.74% for the month of March from 9.32% in
February. The same approach has been followed for March as was implemented in February, which
reduced the DNA rate. The appointment slips go out to patients two days prior to the appointment.
The administration team ring for patients to come over to the clinic on the day and document reasons
for them not attending but unfortunately there has been an increase this month. Clinics have also
been impacted by the restriction of movement due to the current problem with the prison alarm
system and patients have experienced difficulty accessing healthcare at the appropriate time.
HMP Liverpool - DNA rates have increased to 31.65% for the month of March from 25.40% in
February. The healthcare team continue to look at ways to improve attendance at clinics and reduce
the DNA’s. A new process is being trialled utilising 2 GPs at one of the sessions per day, allowing
additional patients to be invited over to counteract possible DNA's and this will help reduce the
waiting list. The receptionist will be providing further information on why patients are not attending.
HMP Kennet - DNA rates have increased to 31.0% for the month of March from 29.57% in February.
The prison receive 2 GP sessions a week and it has been identified that clinic sessions have recently
been booked a little further in advance than usual impacting on DNA's. The DNA monitoring in place
at HMP Liverpool needs to be replicated in HMP Kennet to provide a clearer understanding of the
DNA reasons. A small number of DNA's can impact the figures dramatically due to the GP sessions
available.
Actions:
HMP Preston are continuing to work with the prison to find a solution that works
operationally for managing the enablement issues being experienced. The whole
Enablers’ role is to be reviewed with the prisons Head of Safer Custody Officer.
Healthcare have met with the Enablers to understand what is an achievable runners
list as the one that was in place was getting quite large, in the interim, the runners
lists has been revised to ensure that it is more achievable.
HMP Garth are continuing to review the DNA's and identify ways to reduce them to
improve clinic attendance.
HMP Lancaster Farms will continue to follow this process and monitor its future
effectiveness. The service plans to send out letters to patients who DNA GP clinics
to advise them of the impact of them not attending and that if they inform
Healthcare of appointments that they no longer require, in advance, that they will
receive positive feedback on their prison record. This may encourage patients to
cancel in advance.
HMP Liverpool will be trialling the new appointment system and utilising the
Receptionist to pro-actively monitor its effectiveness. The new Governor linked to
Healthcare is working with the Managers to manage the escalation of issue to the
prison. HMP Liverpool has undertaken regular detailed analysis of DNAs which has
been shared with Governors and NHSE. This level of reporting is not sustainable as
it requires a member of staff to visit each and every DNA. All recommendations
which Healthcare can meet have been done and these will continue to be monitored
by the Admin Manager. The DNA report will continue to be shared with the Prison
however the enablement is crucial.
At HMP Kennet a new Healthcare Manager is now in post and will be managing the
allocation of appointments, reviewing processes and working with the prison to
ensure that the patients are aware of their appointments in a timely manner and
follow up of any DNAs.
Performance Management
30
1.1 Performance Activity
Specialist Services – GP DNA’s
Performance Management
31
Section 1.2
Data Quality
Performance Management
32
1.2 Data Quality
PBR Clustering
The recent Monitor consultation document made clear that whilst they will not mandate movement off bock contract this year but they will do
so next financial year. To form a valid tariff for next years contract the trust will require full clustering data for as much of 206-17 as possible.
Current clustering summary shows cluster rate as 55.5% Target is 95%
Clustering percentage has been falling and continues to fall, this is due to a combination of un-clustered and un-closed or un-transferred cases
including 371 (reduced from 377 last month) cases in Preston primary mental health team which is no longer operating, a large scale data
cleanse will be required to clear these cases.
Memory assessment services continue to carry the largest total number of un-clustered patients from lack of follow up cluster, this can in part
be attributed to the model of annual review not fitting with the cluster 19 six month review period. The issue of what should happen for service
users in Memory Assessment Services assessed above cluster 18 requires further discussion, however for costing they will remain on the
previously assigned cluster to align with the methodology adopted by other trusts.
The remaining un-clustered cases are distributed across services.
Automated email summaries continue to be non-functional, this is due to staff team mapping and requires resolution. To achieve 95% a return
to automated summaries will be necessary.
February 2016
March 2016
Indicator
Statistic
% clustered
55.50%
No. patients clustered
Number of patients approaching a
review
Number of patients overdue a first
assessment
Number of patients overdue a
follow up assessment
Average no. of assessments per
day in the past month
9,576
731
2,415
5,290
71
Performance Management
33
1.2 Data Quality
Unallocated Patients
LCFT Trust:
Cases have fallen by 94% since the start of the project and what remains are complex cases and difficult to resolve, hence the slower pace. The Networks have argued
that sustaining zero unallocated over 2 weeks in unachievable in the long term due to the complex nature of some cases.
Actions - Performance manager has developed a new measure based upon unallocated as a percentage of caseload and is progressing to gain ratification.
Performance Management
34
1.2 Data Quality
Unallocated Patients (cont’d)
The AMH Network reports that overall numbers have risen slightly even though average numbers per team have fallen. Teams with higher incidence than others remain
the high turnover teams such as A+E Liaison and Crisis teams.
Actions - Weekly monitoring and oversight by Deputy Director. Weekly update to all services. Performance Manager to highlight and visit teams with higher incidence.
The ACS Network have now operationally achieved zero unallocated beyond 2 weeks of cases that are within their control. At lock down 2 patients were showing which
are not under the operational control of Adult community, but are currently being resolved internally.
Actions - Continue to monitor and maintain low levels.
The C&F Network have achieved zero unallocated beyond 2 weeks of their own cases. The numbers fluctuate for cases that aren't theirs but with whom they have
fleeting contact and so show up on unallocated reports as they had the last contact.
Actions - Outreach teams are allocating or liaising with the host service to get the case allocated quickly.
The SS Network has had questions about the best method of dealing with unallocated cases where they aren't the host service. Agreement has now been reached,
though the cases that remain are non straightforward.
Actions - Continue to work through unallocated lists to reduce numbers of unallocated records.
Feb-16
Mar-16
Total
< 2 Wks
> 2 Wks
Total
AMH
375
209
236
445
ACS
40
25
2
27
C&F
23
4
13
17
SS
169
58
162
220
Trust
696
301
496
797
Performance Management
35
1.2 Data Quality
Unallocated Patients (cont’d)
Performance Management
36
Section 2
Finance and Contracting
Performance Management
37
Section 2:- Finance and Contracting
Section 2.1:- Financial Activity
• FSRR CIN Full
• Summary I+E position
• Summary of Clinical Services
• CIPS
• Capital Expenditure
Section 2.2:- Community Contract Activity - Variance to Plan
• Network Planned Detailed Activity - Summary
• Network Planned Detailed Activity – Adult Community
• Network Planned Detailed Activity – Children and Families
• CQUIN Executive Summary
• 2015/16 CQUIN Schemes
• 2015/16 CQUIN Schemes Quarter 4 position
To Be Included
• Debtors
• Surplus Margin
• Monitor and Compliance Sustainability
• Income Expenditure – at Trust and Network Level
• Cash Flow
Performance Management
38
Section 2.1
Financial Activity
Performance Management
39
2.1 Financial Activity
Financial Sustainability Risk Rating (FSRR)
Financial Sustainability Risk Rating (FSRR)
Overall the draft FSRR is rated at 2 against plan of 3 - the rating is constrained by Debt Service rating which is
rated at 1 - any score of 1 limits score to 2.
The draft position will have to improve by c£0.2m to achieve a 3.
A rating of 2 could trigger a regulatory review of the Trust's position, although Monitor have confirmed that it is
not their intention to investigate the position further at this time.
It should be noted that information is still being received from third parties (including solicitors and advisors)
which could impact on the draft position.
Performance Management
2.1 Financial Activity
Summary I&E Position
FUNDED
WTE
EST.
ACTUAL
BUDGET DETAIL
Healthcare Income
5,953.6
782.6
5,972.6 Clinical Services
775.0 Corporate Services
Reserves and Capital Charges
6,736.2
6,747.5
BUDGET
ACTUAL
£
ANNUAL
PROJECTED
£
TO DATE
TO DATE
VARIANCE
BUDGET
ACTUAL
VARIANCE
£'000
£'000
£'000
£'000
£'000
£'000
301,234
302,411
1,177
301,233.7
302,411
1,177
-235,483
-239,552
-4,070
-235,482.6
-239,552
-4,070
-53,906
-54,313
-408
-53,905.6
-54,313
-408
-11,845
-11,558
287
-11,845.5
-11,558
287
-3,013
-3,013
-3,013
-3,013
Sustainability
The Draft position indicates plan has been achieved and delivers an operating deficit of -£3.0m against a plan
of £3.0 (Month 11 -£3.3m). The operating deficit after technical adjustments for impairments is -£3.7m.
It should be noted that information is still being received from third parties (including solicitors and advisors)
which could impact on the draft position.
Performance Management
2.1 Financial Activity
Summary of Clinical Services
FUNDED
WTE
EST.
ACTUAL
BUDGET DETAIL
2,064.3
PAY
2,184.3 ADULT
2,064.3
BUDGET
ACTUAL
£
%
ANNUAL
PROJECTED
£
TO DATE
TO DATE
VARIANCE
VARIANCE
BUDGET
ACTUAL
VARIANCE
£'000
£'000
£'000
£'000
£'000
£'000
PAY
NON PAY
PATIENT RELATED INCOME
NON PATIENT RELATED INCOME
79,517.0
10,174.6
-8,566.5
-764.7
80,827.5
15,387.4
-8,401.9
-719.0
-1,310.5
-5,212.8
-164.6
-45.7
-1.6
-51.2
1.9
-6.0
79,517.0
10,174.8
-8,566.7
-764.7
80,827.5
15,387.4
-8,401.9
-719.0
-1,310.5
-5,212.6
-164.8
-45.7
2,184.3
TOTAL
80,360.4
87,094.0
-6,733.6
-8.4
80,360.4
87,094.0
-6,733.6
1,701.0
1,664.8 ADULT COMMUNITY
PAY
NON PAY
PATIENT RELATED INCOME
NON PATIENT RELATED INCOME
61,003.8
17,169.6
-9,338.1
-2,358.6
60,741.0
16,558.2
-9,344.6
-2,483.0
262.8
611.4
6.5
124.3
0.4
3.6
-0.1
5.3
61,003.8
17,169.6
-9,338.1
-2,358.6
60,741.0
16,558.2
-9,344.6
-2,483.0
262.8
611.4
6.5
124.3
1,701.0
1,664.8
TOTAL
66,476.7
65,471.6
1,005.1
1.5
66,476.7
65,471.6
1,005.1
1,207.0
1,144.4 CHILDREN AND FAMILY
PAY
NON PAY
PATIENT RELATED INCOME
NON PATIENT RELATED INCOME
45,187.1
5,404.4
-1,096.7
-1,855.0
44,326.5
5,268.2
-1,349.0
-1,871.3
860.5
136.2
252.2
16.3
1.9
2.5
-23.0
0.9
45,187.1
5,404.4
-1,096.7
-1,855.0
44,326.5
5,268.2
-1,349.0
-1,871.3
860.5
136.2
252.2
16.3
1,207.0
1,144.4
TOTAL
47,639.7
46,374.4
1,265.3
2.7
47,639.7
46,374.4
1,265.3
50.6
48.7 PHARMACY
PAY
NON PAY
NON PATIENT RELATED INCOME
2,409.6
454.2
0.0
2,164.7
420.5
-5.2
244.8
33.7
5.2
10.2
7.4
No Budget
2,409.6
454.2
0.0
2,164.7
420.5
-5.2
244.8
33.7
5.2
50.6
48.7
TOTAL
2,863.8
2,580.1
283.7
9.9
2,863.8
2,580.1
283.7
930.6
930.4 SECURE SERVICES
PAY
NON PAY
PATIENT RELATED INCOME
NON PATIENT RELATED INCOME
33,742.0
4,407.1
-262.0
-528.2
34,115.1
4,991.0
-825.9
-926.5
-373.1
-583.8
563.9
398.3
-1.1
13.2
215.2
75.4
33,742.0
4,407.1
-262.0
-528.2
34,115.1
4,991.0
-825.9
-926.5
-373.1
-583.8
563.9
398.3
930.6
930.4
TOTAL
37,358.9
37,353.6
5.3
0.0
37,358.9
37,353.6
5.3
0.0
0.0 CLINICAL MANAGEMENT
PAY
NON PAY
0.0
783.2
0.0
678.4
0.0
104.7
No Budget
13.4
0.0
783.2
0.0
678.4
0.0
104.7
0.0
0.0
TOTAL
783.2
678.4
104.7
13.4
783.2
678.4
104.7
235,482.6
239,552.1
-4,069.5
-1.7
235,482.6
239,552.1
-4,069.5
5,953.6
5,972.6 TOTAL
Performance Management
2.1 Financial Activity
CIPs
Delivering the Strategy - 2015/16
Program
Programmes
me No.
1
Specialist Mental Health Rehab
2
Unscheduled Care
3
Community MH Redesign
4
Excellence in In-patient Care
5
Out of Hospital
6
CYP Emotional Health and Wellbeing
7
Estates
8
Workforce clinical
9
Workforce technical
10
Health Informatics
11
Administration
12
Corporate
13
Pharmacy
14
Procurement
15
Networks
16
Commissioning and Contracts
PROGRAMMES
Projects
Moss Vew
Gateway
Service Redesign
CRHT and liaison redesign
Management on-call
Structural Redesign
Substitute CIPs
Productivity
Burnley reconfiguration
ECT single site
CAMHs Tier 3 and 4 redesign
Single Inpatient Site CAMHS tier 4
Increase annual leave purchase
Workforce Business Plans
Bank and Agency
Medical Productivity
Governance and Quality Business Plans
Workforce Business Plans
Workforce review Group
Transformation and Innovation Business Plans
Working differently
IM&T Business Plans
Trust Wide Admin
Petty Cash
Leadership Development
Consultancy Control
Mileage Claim Forms
Medical Workforce Business Plans
Pharmacy Business Plans
ePMA benefits realisation
Procurement
Invoice Discrepancies
Finance Business Plans
Adult Comm Business Plans
Adult MH Business Plans
C & F Business Plans
SS Business Plans
Comms & engagement Business Plans
Successful Bids and Tenders
Gov & Compliance Business Plans
Contract gains
Actual YTD
Performance
44,161
30,350
1,261,091
1,640,597
508,636
22,400
381,071
201,884
1,091,000
153,399
303,002
217,299
178,437
321,465
376,095
51,074
140,000
300,000
145,009
1,663,777
2,145,386
790,056
31,000
47,279
200,000
12,244,467
Plan YTD
106,141
30,350
1,261,091
885,000
1,159,550
22,400
500,000
269,884
1,091,000
153,399
49,000
303,002
168,299
178,437
291,465
242,595
184,574
140,000
300,000
145,009
1,697,018
1,988,351
790,056
31,000
47,279
200,000
12,234,899
Var
-
-
-
-
-
-
61,980
755,597
650,914
118,929
68,000
49,000
49,000
30,000
133,500
133,500
33,240
157,035
9,569
Annual Performance
44,161
30,350
1,261,091
1,640,597
508,636
22,400
381,071
201,884
1,091,000
153,399
303,002
217,299
178,437
321,465
376,095
51,074
140,000
300,000
145,009
1,663,777
2,145,386
790,056
31,000
47,279
200,000
12,244,467
Reserves
Annual Plan
106,141
30,350
1,261,091
885,000
1,159,550
22,400
500,000
269,884
1,091,000
153,399
49,000
303,002
168,299
178,437
291,465
242,595
184,574
140,000
300,000
145,009
1,697,018
1,988,351
790,056
31,000
47,279
200,000
12,234,899
-
Forecast Outturn
Performance Management
12,244,467
Var
-
-
-
-
-
-
61,980
755,597
650,914
118,929
68,000
49,000
49,000
30,000
133,500
133,500
33,240
157,035
9,569
442,899
442,899
11,792,000
452,467
It should be
noted that
the Trust
exceeded
the plan
submitted
to Monitor
by £0.45m
2.1 Financial Activity
Capital Expenditure
Category
Inpatients
IT
Minor
Subtotal
Actual
858
2,670
5,011
8,539
Plan Variance
1,090
232
3,400
730
5,163
152
9,653
1,114
Forecast
858
2,670
5,011
8,539
Plan Variance
1,090
232
3,400
730
5,163
152
9,653
1,114
Capital Expenditure
Draft figures capital expenditure out-turn is below plan though within tolerance and in line with the position
expected by Monitor. The net position is underspent by c£1.1m. The primary reason for this is slippage on the
PAS replacement scheme of c£1m.
CQC, Backlog and OATs based pressures have been funded up.
It should be noted that information is still being received from third parties (including solicitors and advisors)
which could impact on the draft position.
Performance Management
Section 2.2
Community Contract Activity
Performance Management
45
2.2 Community Contract Activity – Variance to Plan
Network Planned Detailed Activity
Community Activity Variance to Plan
Monthly
Plan
Adult Community Total Against Plan
87,840
Children & Families Total Against Plan 1,587
Trust Total Against Plan
89,427
Network
YTD
YTD
Variance Variance %
82,931 80,021 83,925 90,653 80,610 83,432 92,887 89,419 86,912 87,722 90,000 89,432 1,037,944 16,1362%1,359 1,326 1,612 1,572 1,222 1,675 1,571 1,772 1,412 1,780 1,638 1,585 18,524
5203%84,290 81,347 85,537 92,225 81,832 85,107 94,458 91,191 88,324 89,502 91,638 91,017 1,056,468 16,6562%Apr May Jun
Jul
Aug
Sep
Oct
Nov Dec
Jan
Feb Mar YearToDate
Planned
YearToDate
1,054,080
19,044
1,073,124
Schedule 6 M12
Activity
At Quarter 4, prior to the year-end refresh the overall trust variance is at -2% against a plan of 1,073,124 contacts for the 2015/16. Adult
Community has a variance of -2% against a plan of 1,054,080 contacts whilst C&F has a variance of -3% against a plan of 19,044 contacts.
Baselines
Working with the Community Networks the Performance and Information team has prepared the 2016/17 Community Baselines by reviewing the
2015/16 Plans against the forecasted outturn and whilst factoring in Contract Variations to determine whether the 2015/16 Plans remain
appropriate for 2016/17.
A review within the Network of the Older Adult MH Baselines has been completed whilst the Adult MH Network met with Commissioners and
have agreed in the most part to roll over the 2015/16 baselines for 2016/17.
Performance Management
46
Network
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community
Adult Community Total Against Plan
Service
Adult Learning Disability Service Total
Adult Speech and Language Therapy Total
CHESS Total
Chronic Fatigue Service Total
Community IV Service BwD Total
Community Matrons Total
Community Neuro Team Total
Community Respiratory Service Total
Community Stroke Service Total
Continence Service Total
Dermatology Service Total
DESMOND Total
Diabetes Specialist Nursing Total
District Nursing Total
Domiciliary Physiotherapy Total
Falls Team Total
Healthy Legs Total
Heart Failure Service Total
Intermediate Care Total
Nutrition & Dietetics Total
Oxygen Service Total
Phlebotomy Total
Podiatry Total
Pulmonary Rehabilitation Total
Rapid Assessment Team Total
Rheumatology Total
Specialist Nurse TB Total
Tissue Viability Service Total
Treatment Room Total
Viral Hepatitis Service Total
Monthly
Plan
1,073
246
324
45
152
2,607
1,053
738
505
354
436
75
1,245
37,640
463
364
92
238
3,104
248
321
15,413
5,453
583
1,491
1,458
424
200
11,088
407
87,840
Apr
May
Jun
997
308
189
128
0
2,710
1,094
919
242
325
483
97
1,072
33,084
573
171
73
233
3,398
180
313
17,784
5,088
500
1,671
1,656
640
146
8,775
82
82,931
1,156
239
194
106
0
2,561
1,116
832
246
179
425
93
1,054
34,524
639
268
84
207
3,432
183
249
13,820
4,973
655
1,624
1,336
454
149
9,212
11
80,021
1,427
338
303
125
0
2,707
1,165
1,004
357
391
463
100
1,068
34,703
765
273
102
277
3,796
211
216
14,659
5,275
675
1,833
1,624
411
197
9,437
23
83,925
YTD
YTD
Planned
Variance Variance % YearToDate
1,520 1,518 1,519 1,511 1,593 1,708 2,170 1,979 2,055
19,153
6,277+
49%+
12,876
398 382 327 384 417 363 338 292 230
4,016
1,064+
36%+
2,952
437 310 473 358 427 402 258 157 217
3,725
1634%3,888
155 118 137 144 133 110 111 109 111
1,487
947+
175%+
540
0
16
19
69
30
41
59
40
91
365
1,45980%1,824
2,864 2,225 2,068 2,225 2,192 1,721 1,610 1,125 1,065
25,073
6,21120%31,284
1,307 990 1,259 1,260 1,241 1,072 1,167 1,164 1,071
13,906
1,270+
10%+
12,636
1,035 915 1,044 1,270 1,380 1,198 1,362 1,268 1,316
13,543
4,687+
53%+
8,856
508 457 518 437 535 432 660 635 652
5,679
3816%6,060
293 216 333 332 317 225 342 288 312
3,553
69516%4,248
521 477 208 251 226 236 438 470 471
4,669
56311%5,232
43
43 105
92
84
59 124 104
93
1,037
137+
15%+
900
1,013 804 803 859 826 807 926 1,014 953
11,199
3,74125%14,940
37,231 35,326 35,268 37,379 37,746 37,002 36,512 39,304 40,848 438,927 12,7533%451,680
925 712 946 868 1,129 1,043 1,025 929 857
10,411
4,855+
87%+
5,556
391 333 388 475 559 475 455 498 511
4,797
429+
10%+
4,368
98
81
90
90
53
47
60
66
77
921
18317%1,104
226 154 301 282 292 235 256 248 321
3,032
176+
6%+
2,856
3,827 3,182 3,614 3,940 3,769 3,470 3,579 3,588 3,016
42,611
5,363+
14%+
37,248
264 295 172 266 310 277 306 398 488
3,350
374+
13%+
2,976
357 231 214 411 236 468 387 453 544
4,079
227+
6%+
3,852
17,747 14,018 14,688 19,994 16,211 16,981 16,512 16,361 15,558 194,333
9,377+
5%+
184,956
4,918 4,787 5,356 4,897 5,349 4,897 4,855 4,957 4,488
59,840
5,5969%65,436
628 561 557 599 682 548 755 798 639
7,597
601+
9%+
6,996
1,632 1,350 1,669 2,126 1,933 1,543 1,428 1,293 1,332
19,434
1,542+
9%+
17,892
1,863 1,615 1,713 1,914 1,819 1,643 1,825 1,778 1,837
20,623
3,127+
18%+
17,496
363 270 271 374 267 313 299 449 256
4,367
72114%5,088
187 115 174 145 126 181 267 289 215
2,191
2099%2,400
9,871 9,089 9,123 9,904 9,488 9,390 9,553 9,909 9,777 113,528 19,52815%133,056
31
20
75
31
49
25
83
37
31
498
4,38690%4,884
90,653 80,610 83,432 92,887 89,419 86,912 87,722 90,000 89,432 1,037,944 16,1362%1,054,080
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar YearToDate
Performance Management
47
Adult Community Planned Contract Activity M12
The Adult Community Network has provided the following explanations as to why certain services are underperforming by more than 10%
against the baseline.
Community IV Service -80%
BwD – IV therapy service is reporting a significant underperformance of 84% year
to date.
This is a slight improvement on last month’s position of 85% below baseline .
The position reflects the delay in recruiting the appropriate skilled practitioner to
lead the service across Q1 & Q2 and the very low referral rate from ELHT inpatients
during August and September. October saw a rise to 56 contacts from a total of 5
referrals . In November only 2 referrals were received which generated 30 contacts
whilst in December 41 contacts were made and 2 referrals were received.
Contacts continue to rise in January to 59. Data has been cleansed to remove any
joint visits and this is reflected by a small reduction in contacts each month.
Community Matron s All CCGs -20%
C&SR – At month 11 the service is reporting an under performance of 11% against
plan, this shows a drop in performance over the last quarter. This is due to reduced
capacity issues due to sickness. This skill set is challenging to replace on both a
temporary and permanent basis. Active recruitment to temporary posts is in
progress.
.
Continence Service All CCGs -16%
C&SR – In M11 the team activity was 145 which is a shortfall of 25 contacts against
the monthly trajectory and forecasted target. Staff sickness in the early part of the
year, and annual leave in the summer has led to the service having to perform
ahead of trajectory to recover the year end trajectory position. The team have also
corrected a definition error in the previous years contact recording which we aim to
adjust when setting 2016/17 baselines.
Diabetes Specialist Nursing All CCGs -25%
C&SR – Maternity leave, staff sickness and delays in recruitment to vacancy
contributing to loss of capacity. Staff working additional hours where possible
however still not meeting expected activity levels. Trained DSNs are not available to
recruit to bank and any recruitment requires a significant period of training and
mentorship until competent to work independently, this has contributed further to
loss of capacity.
DSNs support LTH as part of their service specification, although this activity
continues to be captured against LCFT some of this activity is associated activity and
therefore is not captured against CSR CCG. Total associate activity for the year to
date is 321 (35 in month). Equally there has been an additional 277 (21 in month)
YTD contacts which are non contracted activity, again these will be patients seen in
LTH but will not be captured against CSR and GP CCG; this suggests a shift in activity
that is out of scope due to inpatient contacts. General activity levels carried out at
LTH are dependent on demand at the time and cannot be predicted.
There are areas which historically were in CSR which are now regarded as GP, the
baselines made from historic data may therefore result in over estimating the
planned activity expected for CSR (however, this in turn would mean an under
estimating of expected activity for GP)
Performance Management
48
Healthy legs -17%
BwD – In M11 the service is showing that it is underperforming by 19%.
The Healthy legs service show a drop in activity due to cyclical variation in
attendance. The recent prolonged wet weather has impacted significantly
on activity figures.
Specialist Nurse TB All CCGs -14%
GP– M11 shows a shortfall of 77 contacts against the monthly trajectory of
238.
The number of active TB cases has reduced over the past 3 months which
in turn reduces the number of referrals into the team and subsequently
the level of activity that the service generates.
Combined Treatment Rooms All CCGs -15%
GP & C&SR – The service is currently under performing against activity
plan.
This is due a number of issues:
1) Baseline data plans for both GPCCG and CSRCCG are identical
2) Historically all Treatment Room activity was carried out by DN Teams.
The activity is now delivered by staff working across both CBS and
Community Teams. There have been data capture issues linked to the
activity for treatment rooms carried out by DNs which has led to an under
reporting against Treatment Room activity.
3) There is current long term sickness within the team and this is likely to
continue into March
4) Interventions with longer treatment times e.g. complex wound care are
taking precedence over those with shorter intervention times e.g. Ear Care
this reducing the number of contacts although face to face time remains
the same.
TR - Ulcer & Vascular -66%
BwD – This service is under-performing against plan by 66% at Month 11.
Ulcer and Vascular activity is carried out as part of the treatment room activity and
specification. Numbers of referrals for this intervention vary but all patients
currently referred with a wound can be offered an appointment within 1 week,
which demonstrates that the shortfall against baseline is not due to a waiting list
backlog being held.
Overall combined treatment room activity is performing above plan, and the under
performance relates to an inaccurate split of activity
TR - Ear Care -84%
BwD – The service is underperforming against plan by 84% at Month 11.
Ear Care Contacts are captured as part of Treatment Room Activity. The service has
historically offered approx. 5 sessions of specialist ear care per week which will
provide approx. 80 appointment slots per month.
Ear syringing is also carried out as part of the core treatment room service and it
would appear that historical coding anomalies have led to ear syringing being
included in the specialist ear care baseline inappropriately, which has led to an
inflated baseline figure for this specific activity.
Viral Hepatitis Service All CCGs -90%
GP & C&SR – Change in our contract means we will not achieve the level of activity
set in the agreed baseline. We are now only commissioned to support the LTH
service following TUPE of a staff member to LTH. Baseline for 2016/17 needs to be
adjusted to recognise amended contract position
Performance Management
49
2.2 Community Contract Activity – Variance to Plan
Network Planned Detailed Activity – Children and Families
Monthly
Plan
Children & Families
Children's Learning Disability Service Total
1,184
Children & Families
Paediatric Continuing Care Service (CPOC) Total 194
Children & Families
Paediatric Liaison Total
209
Children & Families Total Against Plan
1,587
Network
Service
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YearToDate
946
239
174
1,359
938
236
152
1,326
1,179
220
213
1,612
1,105
247
220
1,572
886
168
168
1,222
1,254
222
199
1,675
1,127
230
214
1,571
1,302
238
232
1,772
971
224
217
1,412
1,401
208
171
1,780
1,255
203
180
1,638
1,226 13,590
184 2,619
175 2,315
1,585 18,524
YTD YTD Planned
Variance Variance % YearToDate
6184%14,208
291+ 13%+
2,328
1938%2,508
5203%19,044
Children and Families continue to achieve activity which is within the agreed tolerance levels in Month and YTD.
Performance Management
50
2.2 Community Contract Activity
CQUIN Executive Summary
2015/16 CQUIn Schemes
Executive Summary
Qtr 1
Qtr 2
Mental Health
Confirmed Position
100.00% Confirmed Position
Community
Confirmed Position
100.00% Confirmed Position
NHS England - Spec Comm
Confirmed Position
100.00% Confirmed Position
NHS England - Public Health No Submission required Qtr1
Confirmed Position
NHS England - Health Visiting No Submission required Qtr1
Confirmed Position
Expected Positionconfirmation due at the
NHS England - Offender Health Confirmed Position
100.00% end of the Financial year
Total
Confirmed Position
100.00% Expected Position
Feb Balanced Scorecard
Qtr 3
Expected Position - awaiting
100.00% confirmation of achievement
Expected Position - awaiting
100.00% confirmation of achievement
Expected Position - awaiting
100.00% confirmation of achievement
100.00% No Submission required Qtr3
100.00% No Submission required Qtr3
Qtr 4
Narrative
Schizophrenia audit for AMH
Inpatients is expected to fail
Expected Position - Submisison not
based on internal analysis of
100.00% due until April 2016
91.35% audit. Funding at risk is £77k
Expected Position - Submisison not
100.00% due until April 2016
100.00%
HIV Scheme is not expected to
Expected Position - Submisison not
achive the requirement.
100.00% due until April 2016
97.21% Funding at risk is £12k
No Submission required Qtr4
No Submission required Qtr4
Expected Position - awaiting
Expected Position - Submisison not
100.00% confirmation of achievement 100.00% due until April 2016
100.00%
100.00% Expected Position
100.00% Expected Position
95.54%
Quarter 3 CQUIN submissions have been completed and there are not expected to be any concerns.
Quarter 4 submissions are due to take place on the 21st April. We know that the Schizophrenia audit for AMH
in-patients is expected to fail based on an internal audit that has been carried out. This could equate to £77k
loss in income to the Trust. We are now also not expecting the HIV scheme to achieve which would be a loss
of income of £12k.
Performance Management
51
2.2 Community Contract Activity
2015/16 CQUIN Schemes
2015/16 CQUIn Schemes
Funding allocation
CQUIn Scheme - Funding per scheme (£'000s)
2.5% CQUIN
Services
CQUIn Scheme - %'s per scheme
Physical health - 1 (Scizophrenia) - National
Physical health 2 - Communication with GP
Quality Improvement Framework - Local
Harm reduction - local
Unscheduled Care - Local
Health & Wellbeing - Local
COPD - Local
Collaborative Risk Management
Supporting Carer Involvement
Supporting SU in Secure Service to stop smoking
Improving Care Pathways
Review of un-planned admissions
HIV reducing unnecessary CD4 monitoring
Health Inequalities Asessment & Action Plan
Delivery of Chronic Disease Care
Suicide Prevention
CPA Audit
LCFT Proposed %'s
Mental Health & Secure & CAMHs T4
Mental Health
Mental Health/Community
Mental Health
Mental Health
Community
Community
Secure
Secure
Secure
CAMHS Tier 4
CAMHS Tier 4
HIV
Health Visiting & Imm & Vacc services
Prison Services
Prison Services
Prison Services
Mental Health
£3,429,682
0.25%
0.25%
0.67%
0.67%
0.67%
NHS England Community Spec Comm
£1,369,264
£781,642
NHS England Public Health
£18,062
NHS England - NHS England Health Visiting Offender Health
Total
£448,132
£222,801 £6,269,583
0.50%
0.83%
0.83%
0.83%
0.39%
0.39%
0.39%
0.39%
0.39%
0.04%
2.50%
2.50%
2.50%
2.50%
2.50%
2.50%
2.50%
0.83%
0.83%
0.83%
2.50%
0.75%
0.25%
1.50%
0.67%
0.67%
0.83%
0.83%
0.39%
0.39%
0.39%
0.39%
0.39%
0.04%
5.00%
0.83%
0.83%
0.83%
Q1
Q2
Q3
Q4
Total
£1,176,661 £1,796,607 £1,290,766 £2,005,549 £6,269,583
Qtr1
20%
0%
25%
25%
25%
25%
10%
0%
0%
0%
25%
25%
0%
0%
25%
25%
25%
Qtr2
0%
100%
25%
25%
25%
25%
20%
25%
25%
30%
25%
25%
0%
50%
25%
25%
25%
Qtr3
20%
0%
25%
25%
25%
25%
35%
0%
0%
0%
25%
25%
0%
0%
25%
25%
25%
Qtr4
60%
0%
25%
25%
25%
25%
35%
75%
75%
70%
25%
25%
100%
50%
25%
25%
25%
Total
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
Performance Management
52
2.2 Community Contract Activity
2015/16 CQUIN Schemes (cont’d)
2015/16 CQUIn Schemes
Funding allocation
CQUIn Scheme - Funding per scheme (£'000s)
2.5% CQUIN
Physical health - 1 (Scizophrenia) - National
Physical health 2 - Communication with GP
Quality Improvement Framework - Local
Harm reduction - local
Unscheduled Care - Local
Health & Wellbeing - Local
COPD - Local
Collaborative Risk Management
Supporting Carer Involvement
Supporting SU in Secure Service to stop smoking
Improving Care Pathways
Review of un-planned admissions
HIV reducing unnecessary CD4 monitoring
Health Inequalities Asessment & Action Plan
Delivery of Chronic Disease Care
Suicide Prevention
CPA Audit
Services
Mental Health & Secure & CAMHs T4
Mental Health
Mental Health/Community
Mental Health
Mental Health
Community
Community
Secure
Secure
Secure
CAMHS Tier 4
CAMHS Tier 4
HIV
Health Visiting & Imm & Vacc services
Prison Services
Prison Services
0 Prison Services
Total CQUIN income (£'000s)
check
Mental Health
£3,429,682
£342,968
£342,968
£914,582
£914,582
£914,582
NHS England Community Spec Comm
£1,369,264
£781,642
NHS England Public Health
£18,062
NHS England - NHS England Health Visiting Offender Health
Total
£448,132
£222,801 £6,269,583
£156,328
£456,421
£456,421
£456,421
£122,624
£122,624
£122,624
£122,624
£122,624
£12,196
£3,429,682
£0
£1,369,264
£0
£781,642
£0
£18,062
£448,132
£18,062
£0
£448,132
£0
£499,297
£342,968
£1,371,003
£914,582
£914,582
£456,421
£456,421
£122,624
£122,624
£122,624
£122,624
£122,624
£12,196
£466,194
£74,267 £74,267
£74,267 £74,267
£74,267 £74,267
£222,801 £6,269,583
£0
£0
Q1
Q2
Q3
Q4
Total
£1,176,661 £1,796,607 £1,290,766 £2,005,549 £6,269,583
£99,859
£0
£342,751
£228,645
£228,645
£114,105
£45,642
£0
£0
£0
£30,656
£30,656
£0
£0
£18,567
£18,567
£18,567
£0
£342,968
£342,751
£228,645
£228,645
£114,105
£91,284
£30,656
£30,656
£36,787
£30,656
£30,656
£0
£233,097
£18,567
£18,567
£18,567
£99,859
£0
£342,751
£228,645
£228,645
£114,105
£159,747
£0
£0
£0
£30,656
£30,656
£0
£0
£18,567
£18,567
£18,567
£299,578
£0
£342,751
£228,645
£228,645
£114,105
£159,747
£91,968
£91,968
£85,836
£30,656
£30,656
£12,196
£233,097
£18,567
£18,567
£18,567
£499,297
£342,968
£1,371,003
£914,582
£914,582
£456,421
£456,421
£122,624
£122,624
£122,624
£122,624
£122,624
£12,196
£466,194
£74,267
£74,267
£74,267
£1,176,661 £1,796,607 £1,290,766 £2,005,549 £6,269,583
£0
Performance Management
53
2.2 Community Contract Activity
2015/16 CQUIN Schemes – Quarter 4 Position
2015/16 CQUIn Schemes
CQUIn Scheme - Funding per scheme (£'000s)
2.5% CQUIN
Quarter 4 position
Services
Income Expected
Colour Key
CQUIn Scheme - Achievement/Excepted Achievement
Physical health - 1 (Scizophrenia) - National
Physical health 2 - Communication with GP
Quality Improvement Framework - Local
Harm reduction - local
Unscheduled Care - Local
Health & Wellbeing - Local
COPD - Local
Collaborative Risk Management
Supporting Carer Involvement
Supporting SU in Secure Service to stop smoking
Improving Care Pathways
Review of un-planned admissions
HIV reducing unnecessary CD4 monitoring
Health Inequalities Asessment & Action Plan
Delivery of Chronic Disease Care
Suicide Prevention
CPA Audit
Mental Health & Secure & CAMHs T4
Mental Health
Mental Health/Community
Mental Health
Mental Health
Community
Community
Secure
Secure
Secure
CAMHS Tier 4
CAMHS Tier 4
HIV
Health Visiting & Imm & Vacc services
Prison Services
Prison Services
Prison Services
Mental Health
£891,717
NHS England Community
Spec Comm
£387,958
£437,077
Anticipated
LCFT Area of
Achievement concern
63%
100%
100%
100%
Information
still required
NHS England Public Health
£9,031
Achieved
NHS England NHS England Health Visiting Offender Health
Total
£224,066
£55,700 £2,005,549
Not fully Achieved
100%
100%
100%
100%
100%
100%
100%
100%
100%
0%
100%
100%
100%
100%
100%
91.35%
100.00%
97.21%
0.00%
0.00%
100.00%
95.54%
Performance Management
54
2.2 Community Contract Activity
2015/16 CQUIN Schemes – Quarter 4 Position (cont’d)
2015/16 CQUIn Schemes
CQUIn Scheme - Funding per scheme (£'000s)
2.5% CQUIN
Quarter 4 position
Services
Income Expected
Colour Key
Funding Expected
Physical health - 1 (Scizophrenia) - National
Physical health 2 - Communication with GP
Quality Improvement Framework - Local
Harm reduction - local
Unscheduled Care - Local
Health & Wellbeing - Local
COPD - Local
Collaborative Risk Management
Supporting Carer Involvement
Supporting SU in Secure Service to stop smoking
Improving Care Pathways
Review of un-planned admissions
HIV reducing unnecessary CD4 monitoring
Health Inequalities Asessment & Action Plan
Delivery of Chronic Disease Care
Suicide Prevention
CPA Audit
Total CQUIN income expected (£'000s)
Mental Health & Secure & CAMHs T4
Mental Health
Mental Health/Community
Mental Health
Mental Health
Community
Community
Secure
Secure
Secure
CAMHS Tier 4
CAMHS Tier 4
HIV
Health Visiting & Imm & Vacc services
Prison Services
Prison Services
Prison Services
Mental Health
£891,717
NHS England Community
Spec Comm
£387,958
£437,077
Anticipated LCFT Area of
Achievement concern
£205,781
£228,645
£228,645
£228,645
Information
still required
NHS England Public Health
£9,031
Achieved
NHS England NHS England Health Visiting Offender Health
Total
£224,066
£55,700 £2,005,549
Not fully Achieved
£93,797
£114,105
£114,105
£159,747
£91,968
£91,968
£85,836
£30,656
£30,656
£12,196
£9,031
£224,066
£18,567
£18,567
£18,567
£891,717
£387,958
£437,077
£9,031
£224,066
£299,578
£0
£342,751
£228,645
£228,645
£114,105
£159,747
£91,968
£91,968
£85,836
£30,656
£30,656
£12,196
£233,097
£18,567
£18,567
£18,567
£55,700 £2,005,549
Performance Management
55
2.2 Community Contract Activity
2015/16 CQUIN Schemes – Quarter 4 Position (cont’d)
2015/16 CQUIn Schemes
CQUIn Scheme - Funding per scheme (£'000s)
2.5% CQUIN
Quarter 4 position
Services
Income Expected
Colour Key
Funding Lost
Physical health - 1 (Scizophrenia) - National
Physical health 2 - Communication with GP
Quality Improvement Framework - Local
Harm reduction - local
Unscheduled Care - Local
Health & Wellbeing - Local
COPD - Local
Collaborative Risk Management
Supporting Carer Involvement
Supporting SU in Secure Service to stop smoking
Improving Care Pathways
Review of un-planned admissions
HIV reducing unnecessary CD4 monitoring
Health Inequalities Asessment & Action Plan
Delivery of Chronic Disease Care
Suicide Prevention
CPA Audit
Total CQUIN income (£'000s)
Mental Health & Secure & CAMHs T4
Mental Health
Mental Health/Community
Mental Health
Mental Health
Community
Community
Secure
Secure
Secure
CAMHS Tier 4
CAMHS Tier 4
HIV
Health Visiting & Imm & Vacc services
Prison Services
Prison Services
Prison Services
Mental Health
£891,717
NHS England Community
Spec Comm
£387,958
£437,077
Anticipated LCFT Area of
Achievement concern
Information
still required
-£77,168
£0
£0
£0
NHS England Public Health
£9,031
Achieved
NHS England NHS England Health Visiting Offender Health
Total
£224,066
£55,700 £2,005,549
Not fully Achieved
£0
£0
£0
£0
-£77,168
£0
£0
£0
£0
£0
£0
£0
£0
£0
£0
£0
-£12,196
£0
£0
£0
£0
£0
-£89,364
£0
£0
£0
£0
£0
£0
£0
£0
-£12,196
£0
-£77,168
£0
-£12,196
£0
£0
£0
Performance Management
56
Section 3
Quality
Performance Management
57
Section 3:- Quality
Quality
• Quality Tile
• Quality Surveillance – Safety
• Quality Surveillance – Experience
• Quality Surveillance – Effectiveness
• Leadership
• Delivering the Strategy
To be included
• Schedule 4 Detail
Performance Management
58
3. Quality
Quality Tile. Year to Date
QUALITY AND SAFETY TILE
SAFETY
EXPERIENCE
Number of serious incidents
113
Number of complaints
898
Number of Never Events
1
Number of upheld complaints
292
Number of RIDDOR incidents
36
F&F Test - Patients
94%
Avoidable C. Diff. incidents
1
Number of compliments
6021
Avoidable MRSA incidents
0
Other serious HCAI incidents
2
Regulation 28 Notices received
2
Physical violence to staff
1642
EFFECTIVENESS
LEADERSHIP
Physical Health Harm Free Care Rate
95%
CQC Overall Trust Rating
Mental Health Harm Free Care Rate
69%
CQC Intelligent Monitoring Risks
Compliance with Core Skills
Requires Improvement
77.73%
Note: Data provided above relate to the overall year to date figure where a number or where a percentage the overall year to date average percentage.
Performance Management
59
3. Quality
Safety
QUALITY SURVEILLANCE - Safety
QUANTITATIVE INDICATORS
Domain
Indicator
Target
A
M
J
J
A
S
O
N
D
J
F
M
Incidents
Number of serious incidents
-
22
10
7
9
14
18
8
10
4
4
4
3
% variation from last year
>10%
22%
-38%
-84%
-47%
-30%
38%
-38%
-41%
-71%
-19%
0%
-37%
Incidents
Number of RIDDOR incidents
n/a
3
2
3
5
2
4
5
8
2
0
1
1
Incidents
Number of Never Events
0
0
0
0
0
0
0
0
1
0
0
0
0
Incidents
Duty of candour breaches
0
0
0
0
0
0
0
0
0
0
0
0
0
IPC
Avoidable C. Diff. incidents
0
0
0
0
0
0
0
0
1
0
0
0
0
IPC
Avoidable MRSA incidents
0
0
0
0
0
0
0
0
0
0
0
0
0
IPC
Other serious HCAI incidents
n/a
0
0
0
0
0
0
0
1
0
0
1
0
Patient safety
Overdue CAS alerts
0
1
0
0
0
0
0
0
0
0
0
0
0
Patient safety
Mixed sex breaches
n/a
0
0
0
0
0
0
0
0
0
0
0
0
Patient safety
Avoidable grade 3 and 4
avoidable pressure ulcers
0
4
0
0
0
5
3
0
0
0
1
0
0
Staff safety
Physical violence to staff
-
120
190
133
135
141
117
158
141
112
113
138
144
% variation from last year
>10%
17%
71%
19%
34%
81%
31%
17%
10%
-9%
-11%
39%
24%
Regulation 28 Notices received
n/a
0
0
0
0
0
0
0
2
0
0
0
0
Legal
Sparkline
Trend
Risk
Narrative
Physical violence to staff: The l evel s of physi cal vi ol ence to staff from pati ents remai ns hi gher than the reported year. The year to date average i s a 27% i ncrease.
Never Event: One Never Event has occurred i nvol vi ng a fal l from a wi ndow where the wi ndow restri ctor was abl e to removed by a pati ent.
C. Diff. Incidents: The C Di ff i nci dent reported i n November has been determi ned as not due to a l apse i n care or treatment by the Trust.
QUALITATIVE INDICATORS
Implementation of Harm Reduction CQUIN
Quarter 3 of the CQUIN was submi tted on ti me.
HSE/Fire Authority/NHS Protect Inspection None.
Visits
Performance Management
60
3. Quality
Experience
QUALITY SURVEILLANCE - Experience
QUANTITATIVE INDICATORS
Domain
Indicator
Target
A
M
J
J
A
S
O
N
D
J
F
M
Complaints
Number of complaints
n/a
64
71
81
85
91
79
85
87
70
91
94
107
Complaints
Number of upheld complaints
n/a
36
37
39
21
21
18
21
23
14
20
24
18
Complaints
Number of MP enquiries
n/a
5
2
6
7
14
9
5
8
12
8
10
7
Friends & Family
F&F Test - Patients
95%
97%
97%
94%
93%
97%
94%
94%
96%
93%
88%
91%
Compliments
Number of compliments
n/a
507
383
491
406
310
272
394
774
408
580
787
Sparkline
Trend
Risk
709
Narrative
QUALITATIVE INDICATORS
Implementation of the Experience Vision
Clinical Directors to continue to report on progress with the completion of the baseline experience and involvement
assessment and development to an aspirational experience vision at clinical team/service line levels. The QI
programme in partnership with the patients association has begun and will focus on further personalising the
complaints process and the launch of the new sharing experiences forum in May 2016
Performance Management
61
3. Quality
Effectiveness
QUALITY SURVEILLANCE - Effectiveness
QUANTITATIVE INDICATORS
Domain
Indicator
Target
A
M
J
J
A
S
O
N
D
J
F
M
Harm Free Care
Physical Health HFC Rate
95%
92%
96%
94%
96%
95%
94%
95%
93%
96%
94%
95%
94%
Harm Free Care
Mental Health HFC Rate
90%
42%
68%
63%
42%
58%
83%
80%
77%
78%
80%
80%
79%
Sparkline
Trend
Risk
Narrative
QUALITATIVE INDICATORS
NICE Guidelines (published and baseline
completed / underway)
NICE Quality Standards (published and
baseline completed / underway)
Implementation of the Vision for Quality
Baseline complete / underway:
NG26 Children's attachment
NG28 Type 2 Diabetes
NG32 Care of dying adults in the last days of life
NG33 Tuberculosis
NG43 Transition from childrens to adults services
CG72 (updated) Attention Deficit Hyperactivity
Disorder
Baseline complete / underway:
QS111 Obesity in adults: lifestyle & weight
management programmes
QS107 Preventing unintentional injuries in <16s
QS110 Pneumonia in adults
QS113 Healthcare Associated Infections
QS114 IBS in adults
QS115 Antenatal and postnatal mental health
QS116 Domestic Violence and abuse
Newly published:
NG44 Community engagement: improving health and
wellbeing and reducing health inequalities
NG13 Updated Workplace health: management practices
CG62 Updated Antenatal care for uncomplicated pregnancies
Newly published:
QS117 Preventing excess winter deaths
QS118 Anaphylaxis
QS119 Food allergy
QS120 Medicines optimisation
Final draft of the Quality Vision was presented to the Quality and Safety Subcommittee in September 2015 and
approved in principle with further work underway to ensure that the goals are reflective of the quality led philosophy
across all support service portfolio areas.
Implementation of Quality Improvement
CQUIN
The QIF programme is on track with 40 teams now engaged in progressing quality improvement initiatives having
access to the AQUA supported quality improvement methodologies learning programme and improvement. The initial
show case event is taking place on 9 November 2015. There is a change to the MH Harm Free Care local target in line
Performance Management
with the additional reporting now underway encompassing 4 PICUs, 9 inpatient wards and HMP Liverpool; a revised
organisational aim has been set from the baseline: 100% of mental health inpatient wards will identify a local quality
improvement aim basied on their own safety.
62
3. Quality
Leadership
QUALITY SURVEILLANCE - Leadership
QUANTITATIVE INDICATORS
Domain
Indicator
Target
A
M
J
J
A
S
O
N
D
J
F
M
CQC
Overall Trust Rating
n/a
n/a
n/a
n/a
n/a
n/a
n/a
RI
RI
RI
CQC
Intelligent Monitoring Risks
n/a
-
-
-
6
-
-
-
-
-
RI
RI
RI
-
12
-
CQC
Number of overdue CQC actions
0
n/a
1
4
5
7
26
53
98
142
159
Core Skills
Compliance with Core Skills
85%
77.09%
78.20%
77.91%
77.77%
77.28%
77.20%
77.05%
76.84%
77.12%
77.81%
107
158
Sparkline
Trend
Risk
Requires Improvement
78.58% 79.87%
Narrative
CQC Overall Trust Rating: Requi rements Improvement.
CQC Intelligent Monitoring: Latest report publ i shed February 2016 showi ng 10 ri sks and 2 el evated ri sks (an i ncrease from June 2015, 4 ri sks, 2 el evated ri sks).
CQC Overdue Actions: The system for moni tori ng acti ons i s now ful l y l i ve wi th responsi bl e acti on owners updati ng the system di rect wi th thei r evi dence. Thi s i s then subject to
Cl i ni cal Di rector approval and Cl i ni cal Governance Team veri fi cati on. The data has been retrospecti vel y updated to Apri l 2015. The data shows a cumul ati ve total .
QUALITATIVE INDICATORS
CQC Inspection Visits (year to date):
Total 3 - HMP Li verpool (Jul y 2015 and fol l ow-up September 2015), Trust Wi de i nspecti on Apri l 2015.
CQC Mental Health Act Monitoring Visits
(year to date):
Total 28 (RBH) Cal der, Darwen, Ri bbl e.
(Gui l d Lodge) Fel l si de, Langden, Forest Beck, Greensi de, Mal l owdal e,Bl easdal e, Hermi tage
(RPH) Pl atform.
The Juncti on.
(The Harbour) Byron, Austen, Keat, Bronte, Orwel l , Shakespeare, Churchi l l , Di ckens, Stevenson, Wordsworth
The Orchard.
(BH) Ward 20, Edi sford Ward.
Scari sbri ck Ward (Ormski rk Hospi tal ).
Ki ngfi sher Ward (Moss Vi ew).
Commissioner Quality Visits (year to date): Communi ty: Total 6 - Longri dge INT, Chorl ey and Adl i ngton INT, Intensi ve Home Treatment team, BwD ILT, Longri dge Hospi tal , Ward 22
- vi si t by BwD i n Nov 2015 no report recei ved to date.
Healthwatch Enter and View Visits (year to Total 1
date):
Scari sbri ck Ward, Ormski rk Hospi tal
Internal Quality Assurance visits (year to
Total 2
date):
Longri dge Hospi tal (QAV) response to CQC vi si t
Townel ey and Ri bbl e Ward (Responsi ve vi si t)
Ward 22 - ACS
St. Peters Heal thcare Centre Burnl ey (Vacc and Imm)
St. Marys Penwortham Centre (Vacc and Imm)
Performance Management
63
3. Quality
Delivering the Strategy
In 2015/16 the PMG (Programme Management Group) met twice monthly to manage the overall achievement of DTS programmes from a financial, quality and operational perspective, as well as receiving cases
for change and to receive reports from other Transformational Programmes that sit out with DTS.
The DTS programme Assurance Dashboard is attached for Month 12 - March. There is an exception report attached that explains any critical goals reporting red.
The savings target for 2015/16 was £16.2m. The forecast end year delivery is £12.2m with an in month deterioration of £40k. DTS programmes will unfortunately not deliver the original savings plan of £16.2m,
but will exceed the Monitor target of £11.8m. The savings achieved to date though are supporting the Trust's overall plan to achieve a maximum deficit between £3 - £3.5m, by year end.
The scheme that transacted further savings in M12 was administration (£21k).
The additional headline figures for M12 were no change in the value of non-recurrent CIPs (£2,789k total), an improvement in YTD slippage (£10k) and a reduction in mitigation savings.
Monthly updates in response to the actions highlighted in the MIAA audit are reported through to PMG.
PMG did not receive a report for the HR Transformation Programme in March.
The scope and function of DTS for 2016/17 has been reviewed and agreed by EMT on 7th March 2016. The scope of DTS has significantly increased and will provide assurance, give support and report on the
delivery of the Monitor Operational Plan. The DTS plan for 2016/17 was presented to PMG on 16th March 2016. Work is now underway to align resources to support the newly formed 4 programmes.
The scope of the four DTS programmes for 2016/17 are summarised as follows:
•
Prevention and Community Well Being – Deliver integrated physical and mental health care to patients, closer to home, to prevent hospital admissions.
•
Excellence in Inpatient Care – Provide acute mental health services in the most appropriate setting through transforming models of care that deliver effective treatment and flow
•
Specialist Services – Work with partners in developing the range and geographical spread of sustainable models of Specialist services
•
Corporate Services –Develop the most effective and efficient corporate services models
DTS programmes consist of projects that can be classified into the following categories:
•
Transformational project (-/+ savings in year)
•
Savings project
•
Business Development Opportunity (tender)
•
Reporting
The savings target for the Trust in 2016/17 is £16m. As a result of ongoing due diligence, there are currently DTS CIP/transformation projects identifying a total of £15m savings with £6.9m already on the CIP
tracker and a further £8.1m to be registered on the tracker. To achieve the £16m target a further £1m is yet to be identified but will increase if the amounts identified as above, cannot be achieved as full year
effect, or mitigated with non-recurrent savings.
Performance Management
64
3. Quality
Delivering the Strategy - Dashboard
Performance Management
65
3. Quality
Delivering the Strategy - Dashboard (cont’d)
Performance Management
66
3. Quality
Delivering the Strategy - Exceptions
Performance Management
67
3. Quality
Delivering the Strategy - Exceptions (cont’d)
DTS Assurance - Exceptions Report
Programme
SRO
03
Lisa
Community
Moorhouse
MH Redesign
Goal
(£000)
Slippage YTD Balance To
Month
Against Plan Target (£000) Narative
(£000)
2015/16
Jan(10)
-103
282
This programme continued to mitigate slippage against plans with non-recurrent savings with an
Feb (11)
32
282
improvement in month YTD but was unable to achieve the remaining balance of £282k.
Mar (12)
105
282
3,418
The quality goal of a quantifiable reduction in LOS for CMHT hads not been achieved due to slippage and
inconsistencies in recording across teams.
The CMHT SOP has been signed of and implemented.
Lisa
04 Excellence
Moorhouse
in Inpatient
/ Emma
Care
Foster
05 Out Of
Hospital
Emma
Foster
The red quality goal relates to being unable to provide evidence of achievement by end Jan due to task
allocation rollout being delayed by 5 weeks. The benefit realisation of this goal will not be achieved until
April.
22
Jan (10)
Feb (11)
Mar (12)
-58
-89
-119
119
111
119
Jan (10)
Feb (11)
Mar (12)
-57
-62
-68
68
68
68
500
This programme is showing 5 reds against financial, quality and operational goals. Financially the
programme continues to forecast an end of year deficit of £119k. Regarding the evaluation of the pilot
service mobilisation project, a paper was completed and sent to EMT and new arrangements are now in
place. Resources have now been identified for the evaluation of Beechwood, unfortunately due to sickness
absence and annual leave the completion date has now slipped to end March. Out of Hospital Strategy has
been completed and will now be incorporated into the annual report.
06 CYP
Emotional
Health &
Wellbeing
Lynne
Braley
270
The £68k shortfall relates to the Wesham move not having taken place. The shortfall is being made up from
surpluses elsewhere in the network.
In order to meet NICE compliance, a new clinical model is being designed that will meet all standards and is
tailed to service user needs. Clinical colleagues within the service are working on the model that will be
launched with the operational teams in M12, prior to the 1st April 2016. An innovative approach has been
adopted, which is the creation of a visual pathway within SharePoint that contains: what we do, why we do
this, showing we make a difference, where to record, templates (such as letters and care plans).
Further commissioning guidance has not been published so we are currently 6 weeks behind predictive
milestones for launching the model; however, the model is still on track to be in place from the 1st April.
07 Estates
Alistair
Rose
1,091
The quality critical goal of a measurable reduction in carbon emissions and utilisation of renewable energy
is now being achieved and hence is reporting green this month.
Performance Management
68
3. Quality
Delivering the Strategy - Exceptions (cont’d)
DTS Assurance - Exceptions Report
Programme
SRO
Goal
(£000)
Month
Jan (10)
Feb (11)
Mar (12)
08 Workforce Damian
- Clinical
Gallagher
1,652
Slippage YTD Balance To
Against Plan Target (£000) Narative
(£000)
2015/16
0
1,152
This programme had 3 key projects within it for delivery which were i) annual leave purchase and has £153k
-45
1,147
savings detail yet to outline ii) travel savings of £49k which delivered as at M10 and iii) Bank and Agency
-49
1,147
spending reduction of £1m. The B&A spending reduction has not occured and is in fact ~£1.2m over target.
This is due to significant agency spending required to support the newly acquired Liverpool and Kennett
prisons which fulkl year effect is ~£1.5m. The programme is being reviewed within the overall DTS
restructure for 2016/17 as there is a significant target of £1.8m expected to be achieved, to support the
Monitor agency ceiling of £7.7m for 2016/17.
Year 2 savings not at feasibility stage and hence reporting red but are being worked up.
10 Health
Informatics
11 Admin
Damian
Parkinson
Tanya
Hibbert
Jan (10)
Feb (11)
Mar (12)
25
28
30
100
100
This programme has rolled out the use of skype throughout the Trust to support staff skyping into meetings
100
rather than always attending in person. This increases staff productivity and saves on travel claims and
reduces the carbon footprint as staff are not needing to be in their cars as frequently. The programme has
been able to evidence over the past 9 months that travel claims have reduced, therefore Finance have
agreed to withdraw these savings from budgets from April 2016.
Jan (10)
Feb (11)
Mar (12)
0
120
0
78
This programme's red financial critical goal is due to ongoing challenges for C&F network to achieve their
78
contribution towards this programme. Estate issues have caused a delay to implementation of the C&F CIP
57
plan but this saving will be achieved in 2016/17.
The quality goal for standardised job descriptions shows as red but the majority of JDs are signed off and
currently with HR.
Voice Recognition Business Case is on hold until further notice due lack of capital funding available.
421
200
Performance Management
69
3. Quality
Delivering the Strategy - Exceptions (cont’d)
DTS Assurance - Exceptions Report
Programme
SRO
Goal
(£000)
Slippage YTD Balance To
Month Against Plan Target (£000) Narative
(£000)
2015/16
Jan (10)
0
525 There remains a balance of £525k yet to be detailed at cost centre level around the 3 projects of i)
Feb (11)
0
525 consultancy control (although there is limited CIP to be achieved here as only 2 budgets have a consultancy
Mar (12)
0
525 line identified and will therefore be about spend reduction across the Trust, ii) leadership development
savings of £100k were transacted at M10 iii) mileage claim forms.
Work is ongoing to control and evidence a reduction in expenditure on consultancy. Most consultancy has
been funded on an ad hoc basis, so it is not possible to CIP budgets. Howevere, analysis of expenditure on
Consultancy up to the end of quarter 3 indicates a reduction of £348k year to date compared to the previous
year.
12 Corporate
Dom
McKenna
Agreement has been reached with Finance to implement savings from travel from April 2016 now that the
cost of travel has evidenced to be reducing sustainably. To support ongoing savings around travel, the staff
travel policy continues to be unapproved and a timescale is urgently required.
809
Year 2 savings have been agreed in principle. A further £50k has been badged against the renegotiated
leadership contract. It has been agreed that as there is no budget against consultancy from which savings
can be taken, and a reduction in spending can be evidenced, the £400k target has been badged against
travel.
Within the new programme structure of DTS for Yr 2, a Corporate programme has been established with a
much wider remit. The total savings identified for this programme in 2016/17 are £9.2m, of which £2.6m is
at feasibilty stage currently.
13 Pharmacy
14
Procurement
The operational goal of identifying year 2 savings is red due to the expected savings around ePMA
implementation. Originally the implementation of ePMA was approved as a non cash releasing quality
improvement scheme but work is being undertaken to understand if the savings in time being achieved by
staff as a result of ePMA can be aggregated to determine if there is an opportunity for any cash savings to
be achieved.
Cath
Fewster
Dom
McKenna
Jan (10)
Feb (11)
Mar (12)
445
0
0
0
55
0
This programme has achieved its full year savings target in M11.
0
Work has started to identify Y2 savings, but progress has been delayed due to the workstream lead's
involvement in work relating to the agency cap. There will be an additional target monitored by this
programmme for Y2 in relation to the procurement nurse post, and this will be built into plans.
Performance Management
70
Section 4
Workforce
Performance Management
71
4. Workforce
Section 4:•
•
•
•
•
•
Actual Workforce Costs Compared to Budget
Sickness Absence Rates
Appraisals and Mandatory Training Compliance
Vacancy Management and Active Recruitment
Core Workforce Headcount
Workforce Turnover
To be included:• Personal Development Reviews
• Salary Bill
• Professional Registration
• DBS checks
Performance Management
72
Actual Workforce Costs Compared to Budget - Quarterly Trend
Peripheral Workforce Spend and Usage
2016 03
Business Area
Core
Workforce
Spend £
Bank
Agency
Locum
Spend £
%
Spend £
%
Spend £
%
Total Spend
£
Flexible
Labour
Reliance %
Trust
21,284,387
1,263,981
5.3%
1,009,708
4.3%
189,404
0.8%
23,747,481
10.37%
Adult Community Services
5,143,535
219,578
3.9%
274,196
4.8%
33,681
0.6%
5,670,991
9.30%
Adult Mental Health
6,738,588
615,225
7.9%
352,732
4.6%
41,369
0.5%
7,747,913
13.03%
Children & Families
3,520,112
50,161
1.4%
-15,009
-0.4%
30,083
0.8%
3,585,348
1.82%
Specialist Services
3,020,639
321,984
8.8%
223,602
6.1%
84,271
2.3%
3,650,496
17.25%
Corporate Services
2,861,513
57,033
1.8%
174,187
5.6%
0
0.0%
3,092,733
7.48%
Performance Management
Hot Spot Analysis:
Specialist Services: Network report acuity of Service Users and
Vacancy Rate as key contributors to the level of spend on
Bank and Agency.
Board Assurance:
 Vacancies are being managed effectively – please
refer to Vacancy Rate slide for further information.
Adult Mental Health: Network report Acuity of Service Users,
Vacancy Rate and Sickness Absence as key contributors to the
level of spend on Bank and Agency.
Board Assurance:
 Vacancies are being managed effectively – please
refer to Vacancy Rate slide for further information.
 Network Action Plan in place to Improve Sickness
Absence and the closing position for Q4
demonstrates an improvement in attendance for the
Network.
Adult Community Services: Spend on peripheral workforce has
slightly increased toward the end of Q4 and reports a March Labour
Reliance Rate of 9.30%. The Network report vacancies and Sickness
Absence as contributors to the spend on Peripheral Workforce.
Board Assurance:
 Network deep dives into Sickness Absence and Established
Vacancies is expected to have a positive and sustainable
impact on the Networks spend on peripheral workforce.
 Spending on Bank & Agency is jointly reviewed with the
AMH Network on a monthly basis and consideration given
to how a reduction can be achieved.
73
4. Workforce
Sickness Absence Rates
Trust 12 Month, Year on Year Trend
Children & Families: The Sickness Absence rate has continued to reduce through the Q4 period, from an unusually high absence rate for the
Network, reported in December 2015 and January 2016 to 5.17% for March.
Board Assurance:
 The focussed management of Long Term Sickness cases has resulted in the facilitated return of number of individuals to the workplace
and the termination of those cases appropriate to this action.
 The Network continue to be proactive in the management of Sickness and managers are engaging well with the implanted Network HR
Advisor and actively developing, reviewing and improving action plans to manage sickness cases.
Adult Community Services: Sickness Absence has remained stable through Q4 with a rate of around 6.5%. the March closing rate is reported at
6.42%.
Board Assurance:
 The Network have set up a focus group to undertake a deep dive review into Sickness hot spot areas across the Network. The review
will be completed over a 6 month period and will provide improved understanding of sickness and sickness triggers in the key areas
affected.
Adult Mental Health: Following a four month, sustained, high sickness absence rate, Q4 has shown a steady improvement in attendance, with
Sickness Absence Breakdown
the month of March reporting a significantly improved rate of 6.27%. The main reported reason for Sickness across the Network continues to be
Stress, Anxiety and Depression.
Board Assurance:
 Network continue to work proactively to reduce sickness Absence. A recent initiative, designed to support staff during periods of high
workload pressure, is being trialled at the Harbour.
 The local HR Consultant Support, implanted into the Harbour to provide targeted Sickness Absence Management Support has resulted
in a steady and significant reduction in the absence rate in this area.
Specialist Services: Sickness has decreased considerably in the Q4 period to 6.53% in March.
Board Assurance:
 Network continue to monitor action plans for service lines where sickness is above 4.5% to drive down absence & deliver sustainable
reduction.
 A Health & Wellbeing Group has been established in the Network. Group will focus on delivering the 2016/17 Network and HR
Operating Plan objectives linked to improving employee health and wellbeing at work.
Performance Management
74
Fire Safety Admin
Fire Safety Clinical
Health & Safety
ILS
Infection Control
Admin
Infection Control
Clinical
Manual Handling 1
Manual Handling 2
Manual Handling 3
Resuscitation
Safegurarding
Children 1
Safeguarding Children
2
Safeguarding Adults 1
Information
Governance
Adult
Community
Adult
Mental
Health
Children &
Families
Specialist
Services
Corporate
Services
E&D
Trust
Conflict Resolution
4. Workforce
Appraisals and Mandatory Training Compliance
54.1%
92.4%
91.2%
81.3%
90.6%
42.2%
86.6%
76.6%
82.2%
65.8%
49.4%
70.3%
88.4%
73.9%
86.4%
78.2%
47.8%
93.3%
97.8%
82.1%
91.1%
38.6%
95.1%
77.9%
92.7%
69.0%
53.9%
78.7%
93.3%
76.0%
85.3%
77.0%
54.9%
92.0%
95.0%
79.3%
90.5%
39.7%
90.0%
73.6%
74.2%
67.2%
50.1%
61.2%
85.7%
86.9%
74.2%
70.9%
95.5%
99.6%
86.5%
94.3%
56.0%
98.2%
81.8%
89.7%
68.8%
5.9%
77.0%
95.8%
89.5%
87.5%
46.9%
93.2%
92.2%
85.0%
91.3%
46.7%
84.5%
80.7%
77.8%
58.6%
20.0%
62.3%
92.2%
70.9%
90.3%
77.1%
29.4%
86.5%
82.3%
58.5%
84.1%
33.3%
76.0%
56.1%
79.4%
48.6%
0.0%
59.2%
83.0%
72.2%
79.6%
77.1%
Hot Spot Analysis:
Specialist Services: Network continue to focus on improving Mandatory
and Statutory Training Compliance.
Board Assurance:
 Business Units have specific actions plans in place to address
Compliance Gaps for their workforce. This has resulted in a
marked improvement in compliance across two of the Business
units. Focus is now being placed on the Health & Justice
Business Unit.
Children & Families: Network track their own Mandatory Training
compliance.
Board Assurance:
 Children & Families continue to report compliance locally, in
accordance with their agreement with Quality Academy colleagues,
and are data sharing with the Quality Academy to refine the
accuracy of compliance data records.
Adult Community Services: Network continue to work closely with the
Quality Academy to improve their level or compliance and data quality.
Board Assurance:
 ACS People Meeting continue to centrally track Mandatory and
Statutory Training Compliance and are working closely with the
Quality Academy to find solutions to increase attendance and,
therefore, compliance.
Adult Mental Health: Network continue to work with the Quality Academy
to develop and implement their Network specific compliance improvement
plans.
Board Assurance:
 AMH continue to work closely with the Quality Academy to develop
and deliver a programme of support for the Network to improve
their compliance levels with Mandatory and Statutory Training.
Performance Management
75
4. Workforce
Vacancy Management and Active Recruitment
2016 03
Es ta bl i s hment Va ca nci es
Trust
Ad u l t
Co mmu nity
Se rvi ce s
Ad u l t
Me n ta l
He a lth
Ch i l d ren &
Fa milies
Va ca nci es i n Acti ve Recrui tment
Actua l
Es ta bl i s hment
(FTE)
Budgeted
Es ta bl i s hment
Va ca nci es
(FTE)
BE
Va ca ncy
Ra te
Acti ve
Va ca ncy
Ra te
Acti ve
Va ca ncy
FTE
No.
Pos i ti ons
Avg.
No
Da ys
to
Recrui t
6744.81
6076.64
668.17
9.91%
62.43%
417.13
495
54.31
1702.02
1509.03
192.99
11.34%
45.02%
86.88
109
50.70
2064.32
1839.29
225.03
10.90%
64.70%
145.59
170
60.35
Budgeted
Es ta bl i s hment
(BE)
(FTE)
1207.26
1118.33
88.93
7.37%
107.83%
95.89
117
52.00
Sp e cialist
Se rvi ce s
930.61
817.62
112.99
12.14%
52.48%
59.30
67
65.70
Co rp o ra te
Se rvi ce s
840.60
792.36
48.24
5.74%
61.09%
29.47
32
42.80
Hot Spot Analysis:
Children & Families: The Establishment Vacancy Rate for March remains stable
when compared to the figures reported for January and February. There has
been a significant increase in the number of those vacancies that are being
actively recruited to, reporting 100% in active recruitment. School Nursing
vacancies continue to present attraction challenges and remain high.
Board Assurance:
 School Nursing Vacancies continue to be advertised using an ongoing
‘open ended’ recruitment campaign.
 The Network has initiated an internal action plan to internally develop
their own future qualified workforce and are running a focussed
recruitment campaign on attracting Student Specialist Practitioners into
the service.
Adult Community Services: Establishment vacancy rate has continued to
reduce through the Q4 period and reports a closing rate of 11.34% for
March. The number of those vacancies in active recruitment has
significantly increased to 45.02% in March.
Vacancy clarity and
management continues to be high on the agenda.
Board Assurance:
 Network have established a ‘Vacancy Test Group’ comprising of
key representatives for the network. The Task Group have been
commissioned to undertake a 6 month ‘deep dive’ into vacancies
across the network. This work is linked to CIP Savings planning and
enhancing Workforce Planning activity and will review and take
action on disparities between established and active vacancies,
Performance
Management
explore non recruitment to identified vacancies and assess the
vacancy management processes internal to the Network.
Adult Mental Health: The Establishment Vacancy Rate has remained stable
across the Q4 period and reports a March closing figure of 10.9%. There has
been a gradual, month on month, increase in the number of those vacancies
being actively recruited to. The Network report that this is due to the
ongoing recruitment programme, live within the AMH network
Board Assurance:
 Network are running a large scale, ongoing, recruitment programme
designed to target hard to fill posts within the Network.
 The Network has developed and launched a Recruitment and
Resource management Plan, in conjunction with other Networks,
which has resulted in a streamlined approach to Recruitment
Activity within the Network.
Specialist Services: The establishment vacancy rate for Q4 shows a
continued slow decline through the period. The number of those
vacancies in active recruitment has increased steadily through the
Quarter to rest at around 50%. The vacancy rate is likely to remain high
whilst the network continues to experience challenges in attracting and
retaining Band 5 nurses.
Board Assurance:
 Recruitment & Retention Incentives now in place across 3 service
lines where candidate attraction is a challenge. A review of the
performance of these is due in this next Quarter.
 Controlled over recruitment to RGN positions, continues to
support business delivery stability.
 New Staffing model vacant posts in HMP Liverpool and Kennet
being held for redeployment have now been released for open
recruitment. Recruitment will take placed through February and
March.
76
4. Workforce
Core Workforce Headcount
Feb-16
Network
Mar-16
Headcount
FTE
Headcount
FTE
Trust
6786
6076.88
6801
6103.45
Adult Community
Services
1777
1498.34
1786
1514.60
Adult Mental Health
2008
1862.23
1990
1850.69
Children & Families
1315
1120.43
1319
1123.06
Specialist Services
850
813.60
856
821.24
Corporate Services
836
782.28
850
793.86
Performance Management
77
4. Workforce
Workforce Turnover
Turnover Rate – 12 Month Trend
Performance Management
78