Meeting of the Board of Directors
10.00am on Thursday 27 February 2014
Boardroom, Worthing Hospital, Lyndhurst Road,
Worthing, West Sussex, BN11 2DH
AGENDA – MEETING IN PUBLIC
1 10.00
Welcome and Apologies for Absence
Chair
2 10.00
Declarations of Interests
All
3 10.00
Minutes of Board Meeting held on 30 January 2014
To approve
Enclosure
Chair
4 10.05
Matters Arising from the Minutes
To note
Enclosure
Chair
5 10.10
Chief Executive’s Report
To receive and agree any necessary action
Enclosure
MG
PATIENT SAFETY/EXPERIENCE ITEMS
6 10.20
Quality Report
To receive and agree any necessary action
Enclosure
CS/RH
7 10.30
Update on the Organisation’s response to the Francis
Inquiry
To receive and agree any necessary action
Enclosure
CS
OPERATIONAL ITEMS
8 10.40
Performance Report
To receive and agree any necessary action
Enclosure
JF
9 10.50
Organisational Development and Workforce
Performance
To receive and agree any necessary action
Enclosure
DF
Financial Performance
To receive and agree any necessary action
Enclosure
MJ
Enclosure
DF
10 11.00
STRATEGIC ITEMS
11 11.20
Equality and Diversity Annual Report
To receive and agree any necessary action
OTHER ITEMS
12 11.30
Other Business
Chair
13 11.30
Resolution into Board Committee
To pass the following resolution:
Verbal
Chair
“That the Board now meets in private due to the
confidential nature of the business to be transacted.”
14 11.30
Date of Next Meeting
Chair
The next meeting in public of the Board of Directors is
scheduled to take place at 10.00 on 27 March 2014 in the
Bateman Room, Chichester Medical Education Centre,
St Richard’s Hospital, Spitalfield Lane,
Chichester, West Sussex, PO19 6SE
11.30
Close of Meeting
Chair
11.30
to
11.45
Questions from the Public
Chair
Following the close of the meeting there will be an
opportunity for members of the public to ask questions
about the business considered by the Board.
Company Secretary
Western Sussex Hospitals
NHS Trust
Minutes
Minutes of the Board meeting held (in public) at 10.00am on 30 January 2014 in the
Bateman Room, Chichester Medical Education Centre, St. Richard’s Hospital,
Spitalfield Lane, Chichester, West Sussex, PO19 6SE
Dr George Findlay
Jon Furmston
Marianne Griffiths
Dr Rob Haigh
Mike Jennings
Martin Phillips
Cathy Stone
Mike Viggers
Non-executive Director
Non-executive Director
Non-executive Director
Director of Performance
Director of Organisational Development and
Leadership
Medical Director
Non- executive Director
Chief Executive
Interim Medical Director
Interim Director of Finance
Non-executive Director
Director of Nursing & Patient Safety
Chairman
In Attendance:
Ann Merricks
Jan Simmons
Interim Company Secretary
PA to Director of Finance (Minutes)
TBP/01/14/1
WELCOME AND APOLOGIES FOR ABSENCE
1.1
The Chairman welcomed all those present to the meeting and extended a
particularly warm welcome to Dr George Findlay, the Trust’s new Medical
Director.
1.2
Apologies for absence were received from Jane Farrell.
TBP/01/14/2
DECLARATIONS OF INTERESTS
2.1
There were no interests to declare.
TBP/01/14/3
MINUTES OF THE BOARD MEETING HELD ON 28 NOVEMBER 2013
3.1
The Board received the minutes of the meeting held on 28 November 2013
and requested the following amendments to be made:
3.2
TBP/11/13/6.11
Amend the first sentence to read: “The Interim Medical Director advised the
Board that a review of the Acute Kidney Audit had determined……”
3.3
TBP/11/13/6.15
The Interim Medical Director to check the accuracy of the first sentence and
correct if necessary.
(post meeting note: the interim Medical Director confirmed that the minute
was accurate.)
Present:
Bill Brown
Tony Clark
Joanna Crane
Adam Creeggan
Denise Farmer
RH
3.4
The Board resolved that the minutes of the meeting held on
28 November 2013 would be approved as an accurate record of the
meeting and signed by the Chairman.
TBP/01/14/4
MATTERS ARISING FROM THE MINUTES
4.1
The Board received and noted the report of matters arising from its meeting
held on 28 November 2013.
4.2
TBP/09/13/6.10 - Follow up the project to redesign the family room at St
Richard’s.
The Board requested Martin Phillips, Non-Executive Director, to ensure that
this project would be presented to the Charitable Funds Committee for
funding within the next two months.
MP
TBP/11/13/6.3 – Follow up the reported ‘red’ whistleblowing report.
The Director of Nursing and Patient Safety advised that the next Insight
Report was due in the next 8 weeks. It was hoped that this would provide
more transparency and would be referred to in the Quality Report.
CS
4.3
TBP/01/14/5
CHIEF EXECUTIVE’S REPORT
5.1
The Chief Executive presented the report, the main points of which were as
follows:
5.2
On behalf of NHS England the Trust had been asked to communicate their
search for independent Chairs for Continuing Healthcare Independent
Review Panels. The role was open to members of an NHS Foundation Trust
and therefore anyone interested could request further information from the
contact details in the report.
5.3
The Winter Friends pledge was a campaign led by NHS Choices and
supported by national media that sought to help the elderly by appealing to
an old-fashioned sense of neighbourliness. The initiative was part of a wider
NHS campaign to encourage people to take care of their health during
winter. Specifically it was seeking 100,000 people to sign an electronic
pledge that stated: “I will take time out this winter to look in on an elderly
friend or neighbour to make sure they are warm and coping well.” Those
who sign the pledge would receive free cold weather alerts and email tips
throughout the winter to help them do their bit. Governors were urged to
support this initiative.
5.4
On 10 December 2013 a team of Care Quality Commission inspectors made
an unannounced visit to Worthing Hospital where they focussed on the
Accident and Emergency Department, the children’s unit and Broadwater
and Becket wards. They were assessing five measures: Respecting and
involving people who use services; Care and welfare of people who use
services; Cleanliness and infection control; Staffing; Assessing and
monitoring the quality of service provision. The inspectors found the Hospital
to be fully compliant with all five measures being assessed and were glowing
in their praise of staff. The Chief Executive asked for a huge thank you to be
extended to the staff of Worthing Hospital who had made this a reality.
5.5
The new Breast Screening unit, with the very latest in digital screening
technology, had opened at Worthing Hospital. The new facility would not
only increase the number of patients that could be screened and cared for,
but also allowed for a radical improvement in terms of the standard of
Page 2 of 14
diagnostics. Currently around 43,000 people a year were called for
screening and with the extra screening capacity and age extension this was
likely to rise to an annual total of 46,000.
5.6
The Chief Executive informed the Board that Cheryl Edwards, a Senior Staff
Nurse on Eartham Ward at Worthing Hospital, had been the first recipient of
the Employee of the Month award for 2014. The award had been made in
recognition of her efforts to promote a Christmas Hamper raffle in aid of the
Worthing Heart Fund and her empathy and interest in her patients, her
dedication to her work and her concern for their wellbeing, all of which were
exemplary.
5.7
The Board’s attention was drawn to two events being held in the Mickerson
Hall, Chichester Medical Education Centre at St Richard’s Hospital. The first
event on 11 February 2014 was a stakeholder Forum which was open to all
and in addition to news from the Trust would include items on maternity, an
update on the new technology used in outpatients and an update on
dementia care. The second event on 11 March 2014 would be an
information, education and support focusing on Crohn’s Disease and
Ulcerative Colitiis.
5.8
Following the Francis Report, an independent review had recommended an
increase in the number of nursing staff on wards at night to ensure sufficient
staffing levels to deliver quality care. Subsequently the Trust had reviewed
its staffing levels and had secured additional staff. It had also been
suggested that staffing levels should be published on wards and, pending a
bid to the Technology fund to install white boards, laminated posters would
be displayed on each ward to record staffing levels. These would record
each day, by shift, the required staffing level against the day’s level and
whether they were registered or student nurses. It was also considered
important that this information should also be displayed in bays.
5.9
The Board resolved to note the report.
TBP/01/14/6
PRODUCTIVE WARD CERTIFICATES
6.1
The Productive Ward programme was a Government scheme designed to
help staff improve efficiency and ultimately increase the amount of time they
spend with their patients. Jackie Lipsham, had developed and facilitated the
programme across the organisation and was thanked by the Board for all the
support she had given to the process.
6.2
Those being presented with their certificates today for achieving the
initiative’s gold standard, by completing all 11 NHS Institute modules in the
Productive Ward programme, were Nadia Chuter from the Acute Coronary
unit at St Richard’s Hospital, Wendy Holmes from Downlands Ward and
Pam Everiss from Courtlands Ward both at Worthing Hospital.
6.3
Following the successful introduction of the Productive Ward programme the
Board were keen to know what percentage of the day nurses now spent
caring for patients when compared to 30% of the day at the start of the
programme. It was agreed that Jackie Lipsham should be invited annually to
give a presentation at the Board Seminar.
CS/AG
Page 3 of 14
TBP/01/14/7
QUALITY REPORT
7.1
The Director of Nursing and Patient Safety and the Interim Medical Director
presented the report the key issues of which to note were as follows:
7.2
Infection Control
The Board was advised that during December the Trust had reported zero
cases of Methicillin-resistant Staphylococcus Aureus (MRSA) bacteraemia.
There had been 2 MRSA attributed to the Trust for November, both of which
had been unavoidable. For the year to date the Trust had reported 4 cases
of MRSA, one of which had been a contaminated sample rather than an
infection and had been deemed avoidable, but with the actions put in place
following this, no repeat occurrences had been reported.
7.3
The Trust had reported 8 Methicillin-sensitive Staphyloccus aureus (MSSA),
however, all had been reported pre-48 hours and therefore had not been
attributed to the Trust.
7.4
During December the Trust had reported 2 cases of Clostridium difficile post
72 hours on the Worthing site. One case had been deemed avoidable as a
result of antibiotic management and the second case was noted to be
unavoidable. However, the Board noted that with this case the patient had
been experiencing diarrhoea on admission, the specimen had not been
correctly labelled and had therefore been discarded. Had the specimen been
correctly labelled the case would not have been attributed to the Trust.
Processes have since been instigated to remedy this.
7.5
The Trust had reported 7 cases of Clostridium difficile during Quarter 3 which
reflected the continued trend of improvement. The Board was advised that
the Director of Nursing and Patient Safety and Medical Director would be
undertaking an in-depth review to determine any improvements that could be
made and a letter had also been sent to medical staff to reinforce the
antibiotic policy.
7.6
NHS Patient Safety Thermometer
The Director of Nursing and Patient Safety advised the Board that the NHS
Patient Safety Thermometer was now used across all relevant wards in the
Trust. The harm-free care score for the Trust in December was 95.2%. This
included harms suffered by the patient in health care settings prior to
admission. The actual number of patients with no new harms during their
inpatient stay was 98.4% and had been maintained against very increased
activity in the Trust.
7.7
The number of pressure ulcers in the Trust had fallen over the last two years
from 283 in 2010/11 to 124 in 2012/13. In December the Trust reported 8
patients with grade 2 pressure damage which was below the in-month
trajectory and no hospital acquired grade 3 or 4 pressure ulcers. The Trust
had been free of new grade 3 or 4 ulcers for 11 months. A 365 club had
been created to award those wards who had achieved this number of days
without any pressure damage.
7.8
Care Quality Commission
The Trust had received two unannounced visits from the Care Quality
Commission (CQC) during the last two weeks. The Board noted that of the
three ‘arms’ of the CQC (Social Care, Compliance and Mental Health Act
Commissioner) the Trust had been visited by the Compliance and Mental
Health Act.
Page 4 of 14
7.9
The CQC team made an unannounced themed visit to St Richard’s Hospital
last week where the focus had been on dementia. The team visited
Fishbourne ward, a ward that had been used for escalation since last July,
and had spent the day talking to staff and patients, and although assurance
had been given that the care they observed had been good and kind a failing
in the completion of documentation had been noted. Whilst the Trust had
been able to demonstrate that all suitable patients were receiving dementia
screening and were receiving the appropriate care if diagnosed, this had not
always been documented correctly. It was uncertain if this would impact on
the Trust’s compliance. It was anticipated that the CQC report would be
received within the next 6 weeks when it would be presented to the Trust CS
Board.
7.10
Worthing Hospital had also recently received a visit from the CQC’s Mental
Health team. Overall the team had witnessed kind and compassionate care
and that all patients had been treated properly. Although a few areas around
documentation were noted as requiring improvement, there were no areas
for concern and it had been acknowledged that the organisation had been
one of the best they had worked with. It was recognised that, although not a
Mental Health Trust, access to a team of experts was available if needed.
7.11
Noting that difficulties had been encountered in the past, due to the Trust’s
relationship with Sussex Partnership Trust, the Board questioned whether it
was confident that this was now robust. The Director of Nursing and Patient
Safety believed there remained issues around assessment and out of hours
support as well as access to beds, although there were other wider issues in
respect of CAMHS services and mental health support for dementia patients.
These were significant risk areas for the Trust and would be addressed
further at the Emergency Care Board for safety.
7.12
Theatres review
The Board was advised that the Trust had received an unannounced peer
review visit at St Richard’s Hospital theatres from the team from Queen
Victoria Hospital NHS Foundation Trust. The full report would be presented
to the Trust shortly but initial feedback had been positive and that the Trust CS
had shown evidence of positive practice and sustained and embedded
change in culture.
7.13
Crude Trust Mortality
The Interim Medical Director reminded the Board that due to the low level of
mortality experienced in elective care, the Trust measured mortality in
relation to non-elective activity. Crude non-elective mortality rose from
2.81% in November to 3.46% in December in line with seasonal variation in
previous years. This related to 175 deaths out of a total of 5065 non-elective
admissions and was marginally lower than the level for the same month last
year (3.49%). The 12 month rolling average also fell to 3.31%, although
remained above the 2012/13 financial year level of 3.24%.
7.14
Hospital Standardised Mortality Ratio (HSMR)
The Board was reminded that there was a two month delay with Dr Foster
data to allow for coding and processing of data and therefore the most recent
data available was for October 2013. For the twelve months to October 2013
the HSMR for the Trust was 94.8 (100 being the national average) making
the Trust’s performance significantly better than predicted by the Dr Foster
model.
Page 5 of 14
7.15
Summary Hospital-Level Mortality Indicator (SHMI)
The Board was advised that the data for this indicator for July 2012 to June
2013 was not yet available.
7.16
Performance in three of the four areas, set out in the Trust’s Quality Account
as amenable to a reduction in mortality, were within trajectory for the year to
date. There had been an increase in crude mortality relating to acute renal
failure as a primary admitting diagnosis in December and this would be
reviewed to ensure these patients had been appropriately coded before any CS/GF
conclusions would be drawn.
7.17
C-section rate
The C-section rate for December 2013 had remained above the indicative
target of 24.7% as a result of 16.8% of women this month requiring
unplanned C-sections. Root cause analysis was carried out following all Csections to ensure decisions taken had been in the best interest of mother
and infant.
7.18
Dementia screening
As a CQUIN target, the Trust is required to screen all emergency patients
aged 75+ with the national screening question (‘have you been more
forgetful in the last twelve months?’) during the first 72 hours after admission.
The Trust achieved the 90% target for all three measures for the first time in
December 2013 and again in January 2014. This performance would need
to be maintained for three consecutive months to be judged to have achieved
the CQUIN goal for the year.
7.19
With regard to the change and increase in medication errors the Board was
advised by the Director of Nursing and Patient Safety that an increase in
reporting had been noticed and the reasons for this were being investigated.
However, currently there were no wards or areas giving cause for concern.
More information would be available for the Board next month.
CS
7.20
The Chief Executive advised the Board that a Medicines Improvement Forum
was being formed to include the Chief of Service for Core Division, the Head
of Medicines Management, the Chief Executive and the Medical Director.
The initial meeting would take place on 6 February 2014. With the
introduction of the e-prescribing system, all variables would be reviewed and
any necessary actions put in place. Junior doctors, with a history of different
practices from different hospitals, were now required to undertake a
prescribing test before being allowed on the wards. The Interim Medical
Director assured the Board that the Trust had a very robust system of
feedback to junior doctors across Divisions when errors had been made.
The terms of reference for the Medicines Improvement Forum and a report MG/GF
would be presented to the Board in April.
7.21
With regard to the PAS score of 68.9 for the month of December the Board
queried the value of an aggregate score without any narrative in the report to
indicate the reason for improvements. It was agreed that a narrative would CS
be included in future reports.
7.22
The Director of Nursing and Patient Safety drew attention to the
recommendation in the Francis Report that the Board should receive the
Nursing report on an annual basis. However it was suggested, and agreed, CS
that this should be bi-annually.
Page 6 of 14
7.23
In response to a question from the Board relating to a comment in the press
about stroke care, the Interim Medical Director said it had been identified that
the current scanning of patients within 24 hours was not now considered
good enough and from April 2014 this would change to within 12 hours and
will apply to wherever thrombolysis takes place. Discussions were taking
place to determine how this requirement could be delivered in a timely
fashion. It had been recognised that there was a need to think differently
about hyper-acute stroke units and this would feature increasingly in
discussions and strategies going forward. It was proposed that stroke care RH/GF/
should be reviewed in a Board seminar, included in the Quality report and AG
reported back to Trust Board.
7.24
Attention was drawn to data relating to the number of patients seen by a
consultant prior to a fractured neck of femur operation had not been included CS/RH/
in the report. The Board requested that this be clarified.
GF
7.25
Evaluation of the Cost Improvement Programme (CIP) Quality Impact
Monitoring Process
In 2013/14 the Trust implemented a strengthened governance process to
provide assurance that no elements of its Cost Improvement Programme
would lead to adverse impacts on quality, safety or experience. The report
detailed how the process had been embedded and was operating correctly.
It had, however, been noted that the process for the current year was overly
complex and the Trust was currently refining the process as part of the
2014/15 CIP planning round. Subsequently approved and submitted to
Monitor.
7.26
The Board resolved to note the report
TBP/01/14/8
PERFORMANCE REPORT
8.1
The Director of Performance presented the report and highlighted the salient
points as follows:
8.2
The Trust generated a Monitor Risk Assessment Framework score of 1 point
in Quarter 3, with C.difficile variance to trajectory being the only noncompliant metric. The Trust had 2 cases of C.difficile in December
generating a cumulative volume of 44 cases against the cumulative target for
the end of Quarter 3 of 34.5 cases.
8.3
Due to demand pressures within the Trust the Board noted the immense
challenge it had been to deliver all of the performance metrics for month 9.
8.4
Cancer
The Trust had achieved compliance against all seven cancer metrics in
December 2013, and for Quarter 3 in aggregation against which Monitor
compliance is determined. Sustained compliance was set against a
significant rise in demand, which continued to increase the challenge of
maintaining compliance, with an increase in weekly referrals over the
preceding two years of some 30% and a significant element of this growth
occurring in 2013/14.
8.5
There had been a significant increase in pathways with 18% (600) more
patients seen following 2 week referrals, 17% (72) more patients being
treated within 62 days of referral and 8% (62) more patients 31 days from
decision to treat.
Page 7 of 14
8.6
The Board was asked to note that compliance had been achieved through
the incredible diligence and hard work of members of staff.
8.7
Referral to Treatment (RTT) (18 Weeks)
The Director of Performance reported that the Trust remained fully compliant
against the maximum waiting time for diagnostic tests in December with only
0.18% (10 of 5,497) of those patients waiting more than 6 weeks.
8.8
Although RTT had been compliant for Quarter 3 it had represented the
lowest compliant positions reported in the Trust’s history. Compliance in
January would be significantly challenged, and if compliance was achieved
this would also be by the narrowest of margins.
8.9
The Board’s attention was drawn to the changing demand profile as set out
in the report, and the effect it had on elective waiting. During the first half of
2012/13 the Trust saw a return to higher referral levels and the waiting list
grew as a result. The waiting list reduction prior to that had been supported
by reduced demand via the PCT led GP referral peer review programme.
However the referral levels in 2013/14 had consistently exceeded the agreed
referral plan. The Trust’s 2013/14 contract embedded a referral plan aligned
to the peer review volumes which were sustainable, but this plan had not
been achieved and a range of 10-25% above planned levels had been
observed in key specialties. In addition the increase in volume had been
exacerbated by the increase in urgency.
8.10
In itself a change to the waiting list profile would compromise RTT but with
the addition of a volume increase would make sustaining compliance
extremely challenging. A solution would be to increase the Trust’s efficiency
particularly in respect of Trauma and Orthopaedics and Ophthalmology and
to ensure that contract discussions with Commissioners for 2014/15 reflected
a decrease in demand or an acknowledgment of the demand and an
increase the local health economy capacity.
8.11
A&E
The Director of Performance reported that the Trust had narrowly missed the
A&E compliance target in December with 94.89% of patients waiting less
than four hours from arrival at A&E to admission, transfer, or discharge
against a national target of 95%. However the Trust had achieved
compliance for Quarter 3, the basis for compliance for Monitor assessment,
with an aggregate of 95.43%.
8.12
An analysis of the December non-compliance had highlighted a number of
key issues, both internally and externally, including the inability to access
social care, very erratic peaks of demand, staffing availability, a higher
volume of patients brought in by ambulance and the loss of patient transport
service vehicles resulting in failed discharges during Christmas week.
8.13
A number of actions had been implemented since to address the situation
with increased access to community beds, increased cover including A&E
doctors, therapies, pharmacy, access to private ambulance for each hospital
and spot purchasing of nursing home capacity.
8.14
Although January remained very challenging the Director of Performance
reported that, with only two days of the month remaining, the Trust was
compliant at 95.35%.
Page 8 of 14
8.15
The Board noted that this area of compliance was receiving the very highest
level of management focus and support.
8.16
Non-elective Activity
At the November Trust Board Committee meeting the interim Medical
Director had led a discussion on the changes in the 2013/14 profile of nonelectives admissions in the Trust, reflecting the increasing age, complexity
and length of stay of patients being treated in acute medical and surgical
wards. This discussion had focussed on the ‘reverse concentration’ of
emergency admissions and the impact that this effect had on bed occupancy,
and working with the information team, the interim Medical Director, in his
role as Chief of Medicine, had compared the age profile, length of stay and
co-morbidity of patients admitted during the first 6 months of 2013 and the
same period of 2012.
8.17
The Board noted that the report had explored three questions - had more
elderly patients been admitted, had they required care for longer and were
emergency admissions in 2013 sicker than in 2012.
8.18
The research had highlighted that emergency admissions had reduced by
7.9% overall. However, 75% of the reduction was in patients staying less
than 24 hours, reflecting the evolving role of ambulatory care in the
emergency care pathway, as well as continuous improvements in turnover
and flow within the acute assessment areas.
8.19
The greatest reduction in emergency admission volume had occurred
amongst patients under 65, but the overall proportion of emergency
admissions over 65 years had actually increased by about 2%.
8.20
Whilst the overall number of emergency admissions had fallen, the average
bed occupancy for emergency admissions had increased by the equivalent of
50 beds, reflecting an increased average length of stay, but bed occupancy
for patients aged 65 - 94 years had increased by 12%, the equivalent of 56
beds, with those aged 85-94 having increase by 20% (36 beds).
8.21
The report concluded that in 2013 there had been a subtle, but important
change in the emergency admission profile, with the greater proportion of
elderly and very elderly patients, requiring more prolonged acute hospital
care, because of more severe illness, and generating the need for an
increased number of acute beds. It was believed, therefore, that these
changes may help to explain why, in the context of a reduced number of
admissions overall, there had been a sustained requirement for escalation
capacity throughout much of the last year.
8.22
The Board thanked the interim Medical Director for a very helpful report.
8.23
The Board discussed the findings of the report and highlighted the need for
more proactive care to take place in the community in order to reduce the
number of sicker patients being admitted to hospital and the subsequent
impact on the Trust’s RTT target.
8.24
The Board resolved to note the report
Page 9 of 14
TBP/01/14/9
ORGANISATIONAL DEVELOPMENT AND WORKFORCE
PERFORMANCE
9.1
The Director of Organisational Development and Leadership presented the
report, the main points of discussion were as follows:
9.2
The Board was advised that despite an improvement in the number of
substantive staff during the month, the reliance on temporary staffing
remained high at 9.5%.
9.3
Sickness absence in November had increased over the previous month to
4.1%. A detailed Health and Wellbeing report would be presented to the
Board as a separate item.
9.4
The Board noted that the national staff survey for 2013 closed on 2
December 2013 with the Trust’s final response rate being 55% compared to
47% in 2012, however the national results had not yet been published.
Overall results would be shared with Divisions to develop appropriate action
plans. A more detailed report would be provided to the Board when the
results were available.
9.5
The Director of Organisational Development and Leadership informed the
Board of the development of a mentorship role for senior Consultants to
provide mentorship to junior Consultants.
9.6
The Board was advised that time to hire data remained difficult to obtain, but
it was anticipated that, with the implementation of NHS Jobs2, the data would
be easier to access. It would be provided to the Board as soon as possible.
However, the Board noted that this data would only apply to non-medical
recruitment.
9.7
With regard to statutory and mandatory training, the Director of
Organisational Development and Leadership advised the Board that the
number of staff who had never undertaken this training had reduced from 79
to 68 of which 50 were medical staff and 38 of those junior doctors. Actions
were being taken to improve the situation.
9.8
The Board resolved to note the report.
TBP/01/14/10
FINANCIAL PERFORMANCE
10.1
The interim Director of Finance presented the report, the main points to note
being as follows:
10.2
The Board was advised that the Trust’s financial position for December was
a surplus of £128k against the budgeted in-month deficit of £167k, providing
a surplus of £294k against plan.
10.3
With an increase in the number of bed days escalation costs were increasing
with the necessity to pay agency staff to ensure safety levels were
maintained and therefore pay costs had remained high.
10.4
Consistent with past months, the greatest adverse variance by staff group
remained with medical staff where there was still a number of vacancies that
were proving to difficult to fill. Agency costs remained higher than at the
equivalent point in the past two years but continued to decline compared to
the last few months, with lower medical staff and nursing costs.
DF
DF
Page 10 of 14
10.5
The Board noted that the Trust had secured reinvestment of some winter
costs and these had been reflected in the reported income lines. Winter
plans had also been funded.
10.6
In respect of non-pay, much of the adverse variance on drugs fell within the
Medicine Division and a review to determine the cause was on-going.
10.7
The forecasted outturn for capital expenditure was £28m against £38m, but
some plans, particularly in respect of Endoscopy and the Emergency floor
had been delayed with expenditure reassigned to next year.
10.8
The Trust’s cash position had been significantly down at the end of
December but this was expected to improve in February 2014.
10.9
Overall it was still anticipated that the Trust would achieve a surplus at year
end, but this would still be a challenge and would be closely monitored.
10.10
Responding to a question from the Board on payment terms for creditors, the
interim Director of Finance advised that good performance was being
maintained and although, due to the Trust’s cash situation, payments had
slipped slightly over the past month or so, 30 day payments were still being
achieved.
10.11
The Board expressed their thanks to the interim Director of Finance for the
successful contract discussions with the Coastal West Sussex Clinical
Commissioning Group. This had been an excellent achievement by the
Finance and Performance management teams.
10.12
The Board resolved to note the report.
TBP/01/14/11
ANNUAL PLAN PROGRESS REPORT AND REVIEW OF BAF
11.1
The Director of Organisational Development and Leadership presented the
report which reviewed the progress, at the end of Quarter 3, of the Annual
Plan against delivery of the corporate objectives and the BAF which
assessed the risks to the achievement of those objectives.
11.2
Good progress had been made across the range of objectives. However,
one corporate objective had received a red rating; this related to a reported
C.difficile rate at the end of Quarter 3 of 46 cases. The upper limit for the
2013/14 year end was 46 and this had been exceeded. A number of actions
and improvements had been put into place during Quarter 3 to improve
performance and the trend in reduced numbers being reported continued into
Quarter 3.
11.3
Executive Directors had reviewed the risks assigned to them in a review of
the Board Assurance Framework, with no changes having been made to the
net and gross ratings for this Quarter. Alongside the review of the Board
Assurance Framework, three risks had been subjected to in-depth reviews
and had shown good progress.
11.4
The Board resolved to note the report.
Page 11 of 14
TBP/01/14/12
HEALTH AND WELLBEING UPDATE
12.1
The Director of Organisational Development and Leadership presented the
report with the main points to note being as follows:
12.2
A Staff Health and Wellbeing steering group had been formed to monitor the
progress of the work and identify an on-going programme to deliver the aims
of the Health and Wellbeing strategy over the longer term. There were two
main areas of focus – absence and wellbeing.
12.3
Sickness absence rates in the Trust had continued to rise with the level at
the end of the 2012/13 financial year standing at 3.62%, an increase of
0.07% over the previous year’s figure and significantly higher than the Trust
sickness absence ceiling level of 3.3%. The year to date figure at the end of
November 2013 was 3.7% compared to 3.5% for the same period last year.
12.4
The Board noted that on average just over 50% of the Trust’s sickness
absence was due to long term sickness absence and had been the trend for
the last few years. Detailed discussions had been held with the Trust’s
Occupational Health provider to gain an insight on how this absence could be
improved. The Fit2Work programme, being developed as part of the Health
and Wellbeing strategy, would provide access to additional support to staff to
ensure they received appropriate support to enable them to return to work.
12.5
Musculoskeletal and back problems remained the most significant reason for
absence, with anxiety, stress, depression and other psychiatric illnesses the
second most common reason for absence. These areas would be the focus
for additional physiotherapy support and a return to work programme.
12.6
The Board discussed the disappointing uptake of the flu vaccine and the
impact this may have had on sickness absence, as well as the robustness of
return to work interviews. Noting that 50% of sickness was long-term the
Director of Organisational Development and Leadership reassured the Board
that the Trust had a sickness policy with very clear steps and consequences.
12.7
With growing concern around sickness absence the Board requested a
review to be presented to the Board in March/April and the subject for a
future Board seminar.
12.8
The Board resolved to note the report.
TBP/01/14/13
CLINICAL STRATEGY
13.1
The Director of Organisational Development and Leadership presented the
paper which outlined the key proposed strands of a refreshed Clinical
strategy.
13.2
The updated strategy reflected a combination of input from the Board, the
Council of Governors and clinical colleagues.
A number of service
developments had already taken place; these included the second catheter
lab at Worthing which had been completed, the Breast Screening centre at
Worthing, the two paediatric inpatient wards at Worthing which had been
amalgamated and the additional CT scanner at Worthing had been secured.
In addition, Endoscopy services were being developed with a Full Business
Case to the Board due in the spring, Pathology services being redesigned
with St Richard’s as the hub, work on the Emergency Floor at Worthing had
begun, the Harness Block had been declared surplus to requirements, the
DF/AG
Page 12 of 14
preadmission area at Worthing had been refurbished and a market
assessment for the shift of Ophthalmology services had been undertaken
and would inform a future business case on the development of Southlands
Hospital.
13.3
Following a discussion the Board requested that the key enablers of the
strategy be extended to include seven day working and Telemedicine and
recommended a twice-yearly review.
13.4
The Board resolved to approve the 2014 Clinical Services Strategy
subject to the above caveats.
TBP/01/14/14
STANDARDS FOR MEMBERS OF NHS BOARDS AND CLINICAL
COMMISSIONING GROUP GOVERNING BODIES IN ENGLAND
14.1
The interim Company Secretary presented the paper, advising that The
Professional Standards Authority had revised and republished the standards
for members of NHS boards and Clinical Commissioning Group (CCG)
governing bodies to reflect the findings of the Francis report and other
subsequent reviews. The Government, in its response to the Francis report,
said that the standards would form ‘the basis for assessing the fitness of
senior board-level leaders and managers’ in the proposed fit and proper
person test. The standards were first published in 2012 by the Professional
Standards Authority.
14.2
The Board resolved to agree the adoption of the standards.
TBP/01/14/15
OTHER BUSINESS
DF
There being no other business to discuss the Board opened the meeting to
receive questions from the public.
TBP/01/14/16
RESOLUTION INTO BOARD COMMITTEE
The Board resolved to meet in private due to the confidential nature of
the business to be transacted.
TBP/01/14/17
DATE OF NEXT MEETING
The next meeting in public of the Board of Directors would take place at
10.00am on 27 February 2014 in the Boardroom, Worthing Hospital,
Lyndhurst Road, Worthing, West Sussex, BN11 2DH.
Jan Simmons
PA to Company Secretary
January 2014
Signed as an accurate record of the meeting
………………………………………………….
Chair
…………………………………………………
Date
Page 13 of 14
WESTERN SUSSEX HOSPITALS NHS TRUST
BOARD MEETING HELD ON 30 JANUARY 2014
QUESTIONS ASKED/COMMENTS MADE BY MEMBERS OF THE PUBLIC ATTENDING THE MEETING
No.
1
Question/Comment
John Gooderham (Elected Public Governor for Horsham)
asked if the Board had anything further to add with regard to
the siting of Radiotherapy services at either Worthing or St
Richard’s hospitals.
Response
Action
The Chief Executive advised that the siting of the LINACs
would be discussed further in part II of the Board meeting with
the recommendation that it should be sited at St Richard’s
Hospital in Chichester.
2
Crystal Golder referred to a neighbour being treated for
Lymphoma who could call a cancer nurse specialist if she had
any concerns. The Board was asked if all patients were
provided with this.
The Board confirmed that all cancer patients had access to a
cancer nurse specialist and those receiving chemotherapy
were given a card and contact number which enabled them to
return directly to the ward, via ambulance if necessary.
3
Margaret Bamford (Elected Public Governor, Arun) asked if The Chief Executive confirmed that this would be an agenda
staff and Consultants were being involved in the Francis item for next month’s Board meeting.
workstreams.
It was noted that the Better Care Fund had not been included The Board agreed that the Better Care Fund should be
included as a driver for change in the Clinical Strategy.
in the Clinical Strategy
Barbara Porter (Elected Public Governor, Adur) asked the The Board also recognised the excellent care given to patients
Board to note that feedback received from the care of the in these areas.
elderly wards in Worthing had been very complimentary and
relatives had asked for their thanks to be recorded.
Tribute was also paid to the staff who had worked so hard on
the Productive Ward programme.
MATTERS ARISING FROM BOARD MEETINGS HELD IN PUBLIC
MATTERS ARISING FROM THE MEETING HELD ON 28 NOVEMBER 2013
Minute Ref
Description of Action
Responsible Deadline
Person
Report
TBP/09/13/6.10
Follow up the project to redesign the
family room at St Richard’s
Martin Phillips, Non-Executive Director to
ensure on Charitable Funds Committee
agenda in the next couple of months.
TBP11/13/6.3
Follow up the reported ‘red’
whistleblowing report
CS
February
Hoped more transparency would be seen in
the next Insight report due in the next 8
weeks. Insight report part of Quality Report.
A
TBP10/13/6.7
Review crude mortality figures in depth
WR
December
Covered in the Committee agenda in
December.
G
TBP10/13/10.3
Report back on progress with
implementation of Outpatients Booking
System
JF
February
KG/MP
March
Went live on 6th December in the Outpatient
Booking Office based on the Southlands site
following staff training.
Call volume has been monitored, and this
month the ‘Queuebuster’ application will be
deployed (when there are delays this allows
patients to request a call back).
A meeting with the system provider (Netcall)
took place on 13th February to discuss the
technical requirements.
An upgrade to Sema was carried out in
January to facilitate the partial booking
application - currently being tested by IT.
Self-check in kiosks are being piloted in
outpatients
at
both
Worthing
and
Chichester. This allows the collection of
additional
information
from
patients,
including mobile telephone numbers which in
turn facilitates text reminders for outpatient
appointments. An internal working group
RAG
Status
A
G
Page 1 of 4
MATTERS ARISING FROM THE MEETING HELD ON 28 NOVEMBER 2013
Minute Ref
Description of Action
Responsible Deadline
Person
Report
RAG
Status
project managed by Simon Steeles has been
implemented to ensure that the internal
processes, new technology and internal
Information Systems are all aligned to
ensure the maximum benefit.
TBP/11/13/6.7
A review of nursing staffing levels to be
presented to the Board
CS
February
MATTERS ARISING FROM THE MEETING HELD ON 30 JANUARY 2014
Minute Ref
Description of Action
Responsible Deadline
Person
TBP/01/14/6.3
Productive Ward – presentation to be
given twice yearly at Board Seminar.
CS
TBP/01/14/7.8
CQC report to be presented to the
Trust Board when received
CS
March
TBP/01/14/7.16
Quality Report – an increase in crude
mortality relating to acute renal failure
as a primary admitting diagnosis was
noted in December. A review will be
conducted to ensure correct coding
before drawing conclusions.
GF
February
Provide an update on the increase in
medication errors.
CS
TBP/01/14/7.19
July
In line with Francis Inquiry. Noted as part of
Francis update presentation.
Report
Presented at January Board – next
presentation July.
A
RAG
Status
G
Review of coding underway for acute renal
failure.
A
Dr Foster mortality outlier alert received for
fluid and electrolyte disorders.
February
Verbal update at meeting
A
Page 2 of 4
MATTERS ARISING FROM THE MEETING HELD ON 28 NOVEMBER 2013
Minute Ref
Description of Action
Responsible Deadline
Person
Report
RAG
Status
MATTERS ARISING FROM THE MEETING HELD ON 30 JANUARY 2014
Minute Ref
Description of Action
Responsible Deadline
Person
Report
RAG
Status
TBP/01/14/7.20
Terms of Reference and report from
the Medicines Improvement Forum to
be presented to the Board.
MG/GF
February
In hand
A
TBP/01/14/7.21
PAS aggregate score - Include a
narrative in future reports to indicate
the reason for improvements.
CS
February
Quality Board updated
G
TBP/01/14/7.22
The Board to receive the Nursing
report on a bi-annual basis instead of
annually.
CS
April
On April Agenda
G
TBP/01/14/7.23
Stroke care to be included in a future
Board Seminar.
AG/RH
March
TBP/01/14/7.24
#NoF – clarify if data on the number of
patients seen by a consultant prior to
surgery should be included in the
#NOF dashboard
RH/GF
February
To be clarified at the next Board
A
TBP/01/14/9.4
National Staff Survey – provide a more
detailed Board report when national
results were available.
DF
March
TBP/01/14/9.6
Provide time to hire data once NHS
Jobs2 was implemented.
DF
March
TBP/01/14/12.7
Sickness absence – include in a Board
seminar and provide a review for the
DF/AG
March/April
Page 3 of 4
MATTERS ARISING FROM THE MEETING HELD ON 28 NOVEMBER 2013
Minute Ref
Description of Action
Responsible Deadline
Person
Board in March/April.
Clinical strategy – extend the key
TBP/01/14/13.3
enablers to include 7-day working and
DF
February
Telemedicine.
Key
R
A
G
Report
Noted in Strategy. Complete.
RAG
Status
G
No action has been taken to address the action
The action is partially complete or has been added to the agenda plan for a future meeting
The action has been completed
Page 4 of 4
To:
Trust Board
Date: 27 February 2014
From: Marianne Griffiths, Chief Executive
Agenda Item: 5
FOR INFORMATION
CHIEF EXECUTIVE’S BOARD PAPER
1. External factors
NHS Change Day 'A Game Changer'
The first NHS Change Day last year served to harness the passion, drive, commitment and
innovation that we see every single day from staff. It used the power of shared purpose to give
us the boost to challenge the status quo and try something simple but different to improve
patient care.
Last year a single message on Twitter sparked a staff-inspired social movement that saw
people take collective action and in doing so make 189,000 pledges. This year the goal is for
500,000 pledges and we are promoting and encouraging our staff to take part.
Change Day is not just about a single day of action. It is about making the changes that matter
in every day practice and reminding ourselves of why we do what we do. No matter how big or
small the pledges were - from a clinician trying a child’s medicine to understand how it tasted
to a receptionist promising to smile more it gave us all a focus and reinforced our belief in the
values of the NHS.
Anyone can make a pledge today. It is personal to you.
•Those who use the NHS, we ask you to join us
•Those who see a better way but do not feel they have the power or permission to make it
happen, we ask you to join with like-minded people and ignite the spirit of collective action
•Those who are leaders, we are asking you to use your authority to support us by being an
inspiration to others and empowering them to change
We ask everyone to embrace the energy of Change Day on 3 March 2014 and to pledge,
share, do and inspire to make the NHS the best it can be.
Health and Care Innovation Expo
On March 3 and 4 NHS England will host one of the most important events in the health
calendar. The Health and Care Innovation Expo, being staged at Manchester Central, will
bring together more than 10,000 people who want to work to change and improve the NHS and
care services for all.
Dr Mike Bewick, GP and Deputy Medical Director for NHS England, explains why local
government colleagues are not just a ‘nice to have’ but are central to achieving long-term,
sustainable change for the benefit of the communities we serve. As a GP who has worked in
both acute and primary care in Cumbria for over 20 years, he knows only too well the
pressures facing colleagues across the country.
GPs see over one million people every working day, the average patient visits their doctor just
over five times a year, and the demand for services across the system, including general
practice and wider primary care, continues to rise. The number of people aged 65 or older is
expected to be around 16 million in 2030, and those likely to require care is predicted to rise by
over 60 per cent by 2030.
He says the NHS must take advantage of the depth and breadth of expertise that spans local
government: public health, health protection, social care, transport, housing, education and
regeneration and the environment to grasp the problems and develop new innovative
solutions. He says we must work together as one system for the benefit of the patient to tackle
problems where they surface – pharmacists, carers, social care and housing colleagues often
spot first when health is deteriorating.
Changing the model for long-term conditions is a key theme at this year’s Innovation Expo. In
the pop-up university a whole theme is devoted to the House of Care, and delegates will learn
about how to ensure care for long term conditions is integrated across health and social care.
Expo will bring together experts from across the health, care and wider public and private
organisations to change the model for long-term conditions. Dr Martin McShane, NHS
England’s Director for Improving the Quality of Life for People with Long Term Conditions, said
in an interview a few weeks ago, long term conditions are the biggest problem facing the health
and care system. They are the health care equivalent to climate change. Anyone can follow the
latest updates as they happen on Twitter @NHSExpo .
Page 2 of 4
2. BBC News 24 coverage of A&E
The BBC News Channel spent two days at the Trust in February, filming in the A&E
department at St Richard’s. The result was a combination of pre-recorded and live interviews
which were broadcast throughout 7 February on the BBC’s 24-hour rolling news channel, and
as part of news bulletins elsewhere on the network. The filming was part of the BBC’s NHS
Winter project.
Trust staff explained why they work in A&E, and why the Trust has been able to perform so
well in terms of hitting national waiting time targets, generating strong feedback from the
Friends and Family Test, and how they work with local partners – through the One Call One
Team initiative – to ensure that patients get the best possible unplanned care.
The BBC has created a Facebook page for the NHS Winter project, including many of the prerecorded interviews they conducted with our colleagues, and we have also put many of their
posts onto our own page, at www.facebook.com/WesternSussexHospitals.
On behalf of the Board I would like to extend a big thank you and congratulations to the team
in A&E, to our partners who took part and to Dr Amanda Wellesley, A&E Consultant and
Clinical Director for Emergency Medicine, for making it such a success.
3. New appointments
We extend a warm welcome to Dr Nicholson who joined us this month:
Dr James Nicholson, Consultant Anaesthetist (Critical Care) at Worthing (GMC No: 4441005)
4. Employee of the Month
Lead Chaplain Rachel Bennett and her team were successfully nominated by Katrina Rankin,
Waste Manager at Worthing Hospital for the February award. Katrina explained that December
had been a particularly difficult month for Rachel and her team because of the number of
distraught parents, family members and staff they had supported. Katrina wanted to highlight
the fact that the team were always there – for anyone, regardless of faith or the time of day or
Page 3 of 4
night – to offer comfort and support. She felt the service quietly worked behind the scenes but
was relied on enormously in times of greatest personal distress.
Katrina’s nomination was endorsed by Denise Matthams, Head of Children’s Nursing and
Services and Carole Garrick Associate Director/Head of Midwifery. Carole added that the team
not only offers pastoral and religious support but now co-ordinates any administration for the
bereaved families too.
5. Events

A Stakeholder Forum meeting was held this month with a high number of attendees on
what was one of the wettest days of the month. Thank you to everyone who braved the
weather to hear our news and dementia update, information about our inpatient survey,
the new technology used outpatients and to take part in the very useful breakout
session about our Sit and See project.

Event reminder: Do you – or someone you know – suffer with Crohn’s Disease or
Ulcerative Colitis?
Many people may feel that they are isolated or alone as they face their condition, but
there is a chance to meet other people in the same situation, learn more about the
illness, and get support. Clinical nurse specialist Carla Hookway is running an event on
Tuesday, 11 March, in Mickerson Hall, CMEC, at St Richard’s. The information,
education and support evening will take place between 6-8pm. Places are limited. If
you would like to attend, email [email protected] or leave a message on
01243 831812 to book a place.

Our next Medicine for Members event is on the topic of Stroke - treatment, care and
support - and is being presented by Consultant Physician, Dr Rajen Patel on Tuesday
18 March, 2pm - 4pm in the board room at Worthing Hospital. The event will be videoed
and available on our website. To book a place please email [email protected] or
call 01903-205 x85140.

We are enormously fortunate to be unveiling identical sculptures, created by Rodney
Munday called The Gift in our main receptions at Worthing and St Richard’s next month
to celebrate and raise the profile of Organ Donation and Transplant. The unveiling is a
culmination of many years of planning by our Organ Donation and Transplant
Committee, led by Chairman and Non-Clinical Lead Angela Fisher, and I hope the
beauty and location of the sculptures will potentially spark conversations and
discussions which may not have happened before the sculptures were present.
Page 4 of 4
To: Trust Board
Date of Meeting: 27 February 2014
Agenda Item: 6
Title
Month 10, 2013/14 Quality Report
Responsible Executive Director
Dr George Findlay (Medical Director) and Cathy Stone (Director of Nursing and Patient Safety)
Prepared by
Jamie Cochrane (Planning and Performance Manager), Mark Dennis (Head of Information Services), Sandie
Ellard (Deputy Director of Nursing).
Status
Disclosable
Summary of Proposal
Not applicable
Implications for Quality of Care
Describes performance against quality outcome KPIs, including safety, infection control, experience,
effectiveness and mortality.
Link to Strategic Objectives/Board Assurance Framework
The WSHT Quality Strategy 2011-2013 set out the strategic objectives for the Trust in relation to quality.
This report pulls together key national, regional and local quality indicators relating to quality and safety
providing assurance for the board and (if necessary) highlighting issues.
Financial Implications
Describes KPIs that have potential financial impact (e.g. CQUIN)
Human Resource Implications
Describes KPIs linked to workforce
Recommendation
The Board is asked to: Note the contents of this report.
Communication and Consultation
Not applicable
Appendices
Appendix I: Quality Scorecard
Appendix II: Infection Control Dashboard
Appendix III: Fracture Neck of Femur Dashboard
1
INTRODUCTION
1.1
This report brings together key national, regional and local quality indicators relating to quality and
safety. The purpose of the report is to bring to the attention of the Trust Board quality performance within
Western Sussex Hospitals Foundation Trust (WSHFT).
1.2
The paper describes performance on an exceptional basis determined by RAG (red/amber/green)
ratings based on national, regional or local targets. Further quality items are shown as dashboards in the
appendices.
2.
KEY QUALITY OBJECTIVES
2.1
Dashboard Definitions
2.1.1
The full Clinical Quality Dashboard is presented as Appendix II. This includes measures identified in the
Trust Quality Strategy. Figures are in month figures (e.g. the number of falls reported in January) unless
otherwise stated. The dashboard shows 13 months to allow trends to be identified, although some data
items are reported retrospectively. Year to date actuals/targets are based on financial years unless
otherwise stated (e.g. standardised mortality ratios are recorded as 12 month positions). A subset of the
key measures from the report is presented at 2.2.
2.1.2
Exception reports are included under the relevant section of this report (i.e. under the broad headings
Effectiveness, Safety and Experience).
2.1.3
Targets are based on national or regional benchmarks where available. In the absence of established
benchmarks, locally agreed targets or levels have been defined. Where there has been no specific
agreement on a target, an improvement on 2012/13 baseline has been used. The list of the targets and
whether benchmarks are national, regional or local is available on the Trust’s public website:
http://www.westernsussexhospitals.nhs.uk/about-us/trust-board/trust-board-meetings/boardpapers/quality-scorecard-targets/
2
Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board
2.2
Overview of Key Quality Objectives
2.2.1
The following table shows performance against key, top level quality objectives.
Indicator
Nov
Dec 2013
Jan 2014
2013
2013/14
2013/14
to date
Target /
limit
E01 Trust crude mortality rate (non-elective)
2.81%
E02 Hospital Standardised Mortality Ratio for top
3.46%
3.79%
93.9
3.16%
3.24%
-
<100
56 diagnoses (Dr Foster, based on rolling 12
months)
S01 Patient Aggregate Safety Score (PASS)
98.3
68.9
85.7
87.8
<100
2
1
2
22
26
96.4%
96.5%
96.1%
96.0%
95%
S14 Numbers of hospital attributable MRSA
2
0
0
4
0
S15 Numbers of hospital attributable C. diff
2
2
7
51
46
78
74
74
76
TbC
X02 The Friends and Family Test Score: A&E
76
75
78
76
TbC
X15 Mixed Sex Accommodation breaches (for
0
0
0
0
0
40
37
53
428
562
S05 Number of Serious Incidents Requiring
Investigation (number reported in month)
S09
VTE:
Compliance
with
the
DoH
risk
assessment tool
X01
The
Friends
and
Family
Test
Score:
Inpatients
clarity the number of breaches is reported here,
but in the scorecard, in line with the reporting of
this metrics in other Trust scorecards this is
expressed
as
a
proportion
of
Consultant
Episodes)
X20 Number of complaints
3
Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board
3.
EFFECTIVENESS
3.1
Crude Trust Mortality
3.1.1
Due to the low level of mortality experienced in elective care, the Trust measures mortality in relation to
non-elective activity. The Trust Quality Strategy set out an objective to reduce its mortality rate by 10%
(relative to the year 2010/11) by the end of 2012. The Trust achieved this objective and for 2012/13 nonelective mortality was 3.24% compared to 3.30% in 2012/13. The trust continues to seek to demonstrate
an improvement against the 2012/13 level (see the graph below) and to reduce the 12 month rolling
average.
3.1.2
Crude non-elective mortality rose from 3.46% in December to 3.79% in January, in line with seasonal
variation in previous years. This is lower than the level for the same month last year (January 2013 =
4.13%). The 12 month rolling average also fell to 3.29%, although it remains above the 2012/13 financial
year level of 3.24%. The 3.79% mortality related to 189 deaths out of a total of 4990 non-elective
admissions.
4
Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board
3.2
Hospital Standardised Mortality Ratio (HSMR)
3.2.1
There is a two month delay with Dr Foster data (to allow for coding and processing of data). As such
November 2013 is the most recent data available. WSHFT HSMR for the twelve months to November
2013 was 93.9 (where 100 is the national average), i.e. the Trust performance is significantly better than
predicted by the Dr Foster model.
3.2.2
The twelve month HSMR to November 2013 split by site is lower for St Richards (92.9) than for Worthing
/ Southlands Hospitals (94.6), however both are lower than 100.
3.2.3
A further report is available to the Trust Quality Board showing the clinical diagnostic areas with high
actual versus expected mortality and any mortality CuSum alerts.
3.3
Summary Hospital-Level Mortality Indicator (SMHI)
3.3.1
The Summary Hospital Level Mortality Indicator for July 2012 to June 2013 was published on 29th
January. The Trust remains at 1.02 (where 1.00) is the national average and is banded as ‘as expected’.
3.4
Exception Reports Relating to Effectiveness
3.4.1
Exception Report - Indicators E05 to E08 Mortality in Specific Conditions: These measures reflect the
pledge set out in the 2011/12 Trust Quality Account to reduce mortality in four key areas amenable to
mortality by 10% against 2011/12 levels. Performance against the agreed trajectories is shown below.
5
Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board
3.4.2
Performance for three of the four areas continues to be within trajectory for the year to date. Mortality for
acute renal failure (as a primary diagnosis in the admitting episode) fell in January to beneath trajectory,
but the year to date figure remains higher than trajectory.
3.4.3
Exception Report – E11: Emergency readmissions within 30 days: The level of readmissions within 30
days increased for January 2014. This data will be reviewed with the divisions to identify trends or
particular areas that have increased.
3.4.4
Exception Report – E12: Emergency admissions not usually requiring admission:
This measure is
based on the basket of measures identified by the National Quality Dashboard as not usually requiring
admission. Data is reported in arrears to allow for coding. December is the second consecutive month
that has been above target, however the Trust remains on trajectory for the year to date.
3.4.5
Exception Report – E15: % Deliveries complicated by post-partum haemorrhage: The rate of deliveries
complicated by blood loss of greater than 2500mls was 1.2% for January against a limit of 1.0%. This
related to 5 cases, 2 at St Richards Hospital and 3 at Worthing. The Trust has guidelines relating to
post-partum haemorrhage to ensure appropriate and timely care and to limit the bleeding as much as
possible. These cases have been reviewed under the clinical governance and safety arrangements to
ensure any learning has been shared. The Trust remains below the 1.0% limit for the year to date.
3.4.6
Exception Report – E18 to E20: Dementia screening is a key CQUIN target for Western Sussex
Hospitals Foundation Trust in 2013/14. The Trust is required to screen all emergency patients aged 75
or over with the national screening question (‘have you been more forgetful in the last twelve months?’)
during the first 72 hours. The Trust has now achieved the 90% target for all three of these measures for
the second consecutive month. The Trust needs to maintain this performance for three consecutive
months to be judged to have achieved the CQUIN goal for the year.
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Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board
4.
SAFETY
4.1
Patient Aggregate Safety Score (PASS): Background and Methodology
4.1.1
The PASS is an aggregate score comparing performance against a baseline for a total of 15 measures.
These vary in polarity (i.e. whether a high score indicates a safer environment or not). The methodology
was presented to the board in full with worked examples in August 2011:
Group
Measure
Polarity
Weighting
VTE
VTE Prophylaxis given (syringe packs prescribed)
Positive
0.50
Baseline
(2012/13)
1943
VTE risk assessments done
Positive
1.00
93%
MRSA
Negative
1.00
0.1
C. diff
Negative
1.00
6.0
SIRIs
SIRIs
Negative
2.00
2.2
Patient safety
Total incidents
Positive
1.00
674
incidents
Moderate, severe and death
Negative
1.00
7.1
Complaints
Complaints about nursing care
Negative
0.67
3.4
Complaints about communications
Negative
0.67
6.3
Complaints about staff attitude
Negative
0.67
4.7
Tissue viability
Total grade 2 or higher pressure ulcer incidents
Negative
1.50
10.3
Falls
Falls resulting in harm
Negative
1.50
40.1
Prescribing
Total incidents involving prescribing and drug
Positive
0.50
91.3
Negative
1.50
0.33
Positive
1.00
85.8%
HCIA
errors
Moderate, severe and death errors involving
prescribing / drug errors
Nutrition
4.1.1
Nutritional Assessments in 24 hours
The measures are unchanged for 2013/14, but all baselines have been updated to 2012/13 figures so
that the PASS score for 2013/14 is an indication of whether the Trust in the current month is more or
less safe (based on these measures) than 2012/13. All individual elements of the PASS score are also
reported in the Quality Scorecard.
4.1.2
Scores can range from 0 to 200, with a lower score indicating a safer Trust and 100 being the equivalent
of the Trust last year.
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Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board
4.2
PASS Performance 2012/13 to Date
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Year
to
date
PASS
4.2.1
89.9
88.9
85.0
96.8
98.3
81.8
84.3
98.3
68.9
85.7
87.8
The PASS score for the year as a whole is calculated based on the averages of each of the individual
months.
4.2.2
For January the following PASS measures showed adverse performance compared to the average for
2012/13: C. difficile; moderate incidents; pressure ulcers and falls. The remaining 11 metrics were the
same or better than last year.
4.3
Central Alert System (CAS) Safety Alerts
4.3.1
There are no outstanding alerts for the Trust relating to January 2014 or earlier.
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Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board
4.4
Infection control
4.4.1
In January the Trust reported zero cases of Methicillin-resistant Staphylococcus Aureus (MRSA)
bacteraemia.
4.4.2
In January 6 cases of Meticillin Sensitive Staphylococcus Aureus (MSSA) were reported.
4.4.3
The Trust disappointingly reported 7 cases of Clostridium Difficile, 5 on the Worthing site and 2 on the
St. Richards site. 5 were reported as avoidable, following the Root Cause Analysis (RCA) issues
relating to compliance with the antibiotic formulary. The Medical Director has written to all Consultants
reinforcing the importance of adherence to the Policy. There was a delay in specimens in patients who
were positive on admission to hospital in 2 cases. The Director of Nursing has met with the Matrons and
ward Sisters of the clinical area. A programme of increased education has been introduced.
4.4.4
A full Bioquell cleaning of the Worthing Critical Care Unit was undertaken in January.
4.4.5
To date in February the Trust has reported 3 cases.
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Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board
4.5
Falls
4.5.1
Following the completion of the SHA Safer Smarter Nursing Programme, the Trust has continued to aim
to reduce the number of falls resulting in harm. The target for 2013/14 seeks a further improvement
against the 2012/13 level. As such the limits for 2013/14 are 481 or less falls resulting in harm and 2 falls
resulting in severe harm or death.

In January there were 44 falls resulting in harm. Although this was above the in-month trajectory
of 40, the trust remains on course to deliver the 10% improvement for the year as a whole (note
that January 2014 was lower than the peak for January 2013).

4.5.2
There were no falls resulting in serious harm or death.
The 44 falls equate to 1.55 falls resulting in harm per 1000 occupied bed days compared to the national
benchmark of 2.5 (Royal College of Physicians Report of the 2011 Inpatient Falls Pilot Audit).
4.5.3
As part of our CQUIN goal for 2013/14 the Trust is undertaking an analysis of all the patients who are
identified as fallers on the NHS Patient Safety Thermometer (see indicator S24). A trajectory for the
reduction in preventable falls has been agreed with commissioners. The Trust achieved this trajectory
for January. Note: the agreed improvement period for this measure was from June 2013 onwards (April
and May formed part of the baseline), and as such the year to date figure in the scorecard reflects June
onwards.
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Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board
4.6
Tissue Viability
4.6.1
The number of pressure ulcers in the Trust has fallen over the last two years from 283 in 2010/11 to 226
in 2011/12 and further to 124 in 2012/13. The Trust has set a stretch target for 2013/14 of a further 5%
reduction against the 2013/14 value. This gives a limit for grade 2 pressure ulcers of 114 (see trajectory
below). The Trust will also try to maintain or reduce the number of grade 3 or 4 ulcers (i.e. a limit of 4).
4.6.2
During January the Trust reported 15 cases of hospital acquired pressure sores (Grade 2). This was
against an in-month trajectory of 10 and sadly this was an increase on a consistently decreasing trend.
The frailty and acuity of the inpatient admitted to the Trust in January combined with the increased
activity has been reflected in the tissue damage. However all patients had been assessed and 1 was
deemed to be avoidable.
4.6.3
A breakdown of the individual cases did not reflect concerns regarding specific wards, availability of
equipment or escalation wards and the use of agency staff. 6 patients due to their clinical condition were
unable to be compliant with repositioning and 4 patients were admitted to the Trust with impaired
cognition and nutritionally compromised. There was no deterioration in the month in any previously
reported tissue viability damage. To date in February at the time of this report the Trust had reported 5
pressure ulcers.
4.6.4
There were no hospital acquired grade 3 or 4 pressure ulcers in January. The Trust has been free of
new grade 3 or grade 4 pressure ulcers for 12 months.
4.6.5
The incidence of pressure ulcers (developing 72 hours after admission) per 1000 bed days in January
was 0.53.
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Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board
4.6.6
There were 110 patients were admitted to the Trust from the Community with pressure damage during
January.
4.7 NHS Patient Safety Thermometer
4.7.1
The NHS Patient Safety Thermometer is now used across all relevant wards. This tool looks at point
prevalence of four key harms (falls, pressure ulcers, urinary tract infections and deep vein thrombosis
(DVT) and pulmonary embolism (PE)) in all patients on a specific day in the month. A dashboard
showing Trust-wide and ward-level data for each individual harm as well as the harm-free care score is
available to each ward.
4.7.2
The harm-free care score for the Trust in January was 93.3% (indicator S02), compared to a national
average for the month of 93.5%. The Trust value is lower than previous months as a result of an
increase in the number of patients identified in by the survey with community acquired pressure ulcers.
4.7.3
The Safety Thermometer includes harms suffered by the patient in health care settings prior to
admission. The actual number of patients with no new harms during their inpatient stay at WSHFT
(indicator S03) 97.7% (national average 97.3%).
4.8
Exception Reports Relating to Safety:
4.8.1
Exception Report: Indicator S04: Total Incidents: Unfortunately there was a data error for this indicator
recorded in the scorecard last month. The total number of patient safety incidents reported in December
2013 was 799 (January was 780). The scorecard has been amended retrospectively and the RAG rating
changed accordingly.
4.8.2
Exception Report: Indicator S05: Total moderate, severe or death incidents: There were 9 incidents that
caused moderate harm to patients. Of these incidents, 5 involved falls resulting in fracture. There were
no common themes identified in terms of ward area and all were subject to scrutiny through Root Cause
Analysis (RCA). There were two incidents involving delayed diagnosis and failure to follow up. Both are
being investigated and the former is the subject of a SIRI investigation. There was one post 48 hours
MSSA bacteraemia - RCA was undertaken and the care of the patient was found to be appropriate and
the infection unavoidable. Moderate harm was also caused to another patient when there was failure by
a nurse to recognise deterioration in condition. Corrective action has been taken in relation to the staff
member involved. There were no incidents resulting in severe harm or death in January.
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Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board
4.8.3
Exception Report: Indicator S08: Total incidents involving drug / prescribing errors: There has been an
increase in reporting of medication errors during December and January. On initial review of the
incidents there are no obvious themes but the patient safety team is undertaking a more in-depth review
of the incident reporting patterns during these two months and will provide feedback to the next Board.
The Medicines Management Task and Finish Group will be meeting in March chaired by the Chief
Executive and with representation from the senior divisional leadership. The group will undertake selfassessment against national guidance frameworks before developing and disseminating an action plan
for improvement across all areas of medicines management.
4.8.4
Exception Report: Indicator S13: Incidence of VTE: The Trust continues to see a slightly greater number
of patients with deep vein thrombosis or pulmonary embolism than in 2012/13. This indicator is based on
the National Quality Dashboard indicator, which does not distinguish between hospital acquired VTE
community acquired VTE. As such, in many cases the VTE will therefore be the cause of the admission,
not a consequence of it. The Trust subjects all hospital acquired VTE to a root cause analysis the results
of which are reported to the Thrombosis Committee.
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Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board
5.
PATIENT EXPERIENCE
5.1
PALS and Complaints
5.1.1
All complaints are responded to by the Trust Office. The process is administered by the Customer
Relations Team. The Quarterly Complaints Report provides an in depth analysis of trends and lessons
learned. This is reviewed by the Patient Experience and Feedback Committee and is presented to the
Trust Board.
5.1.2
During January 2014 the Trust received 53 complaints (of which 4 were graded as high resulting in
further investigation). Although an increase compared to previous months, there is no evidence of a
sustained increase in levels and the Trust is 9% below the 2012/13 level for the year to date.
5.1.3
Worthing
Southlands
Chichester
Total
All complaints
33
1
19
53
High grade complaints
1
0
3
4
The majority of complaints in January related to clinical treatment. These were not attributable to one
clinical site or area.
5.1.4
In January there were 3 complaints received where nursing care was the primary issue. There were not
attributed to one clinical area or site
5.2
Friends and Family Test
5.2.1
Data collection for the Government’s Friends and Family test is currently underway in A&E, the inpatient
wards, and in maternity.
5.2.2
National guidance details how this question will be scored nationally as follows: The proportion of
respondents who would be extremely likely to recommend (response category: ‘extremely likely’) MINUS
the proportion of respondents who would not recommend (response categories: ‘neither likely nor
unlikely’, ‘unlikely’ and ‘extremely unlikely’) (the response ‘likely’ is included in the percentage but does
not have a positive or negative impact). This results in scores with a possible range of -100 to 100.
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Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board
5.2.3
Immediate feedback is provided to wards on a continuous basis to ensure staff can address problems or
get positive feedback as quickly as possible. In addition to this a dashboard has been launched giving
wards access to their individual scores.
5.2.4
National Friends and Family data is published on the NHS England website. December is the most
recent data available nationally. In December WSHFT ranked 16th nationally (of 143) for its A&E score of
75 (national average = 56) and 80th (of 170) for its inpatient score of 74 (national average = 72).
5.2.5
Although national data is not yet available, locally feedback remained positive for January. Although the
response rate fell a little compared to December it remained above the current national target of 20%.
January scores are as follows:
5.2.6

The overall score for the Trust (IP and A&E) was 77 based on 2852 responses.

The inpatient score was 74 based on 707 responses.

The A&E score was 78 based on 2145 responses.
The Friends and Family data collection for maternity services was launched in October 2013 using text
messaging as one potential option to allow women to feedback on the quality of their care. National data
for December has now been published. Women are asked at four separate points whether they would
recommend the Trust. December results are as follows (the response rate is only published in relation to
the second indicator):

Antenatal care: The Trust was 81 based on 17 responses (England 63).

Delivery: The Trust was 75 based on 70 responses: 19% response rate (England 75, 19%
response rate)

Post-delivery ward: 64 based on 61 responses (England 66)

Discharge from community midwifery care: 70 based on 10 responses (England 74).
5.3
Feedback from Hospital Experience Questionnaires
5.3.1
Detailed results from the Real-Time Patient Experience (RTPE) project are routinely fed back to
divisions and wards and aggregate scores are included in the Quality Scorecard within the Experience
section (indicators X03 to X07). Targets for these measures for 2013/14 are based on an improvement
against 2012/13.
5.3.2
All five of these measures (indicators X03 to X07) were above target for January and for the year to date
position.
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Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board
5.3.3
406 inpatients gave their views on the Trust using the RTPE system in January.
5.4
Exception Reports Relating to Experience
5.4.1
Exception Report: Indicator X11: PALS contacts relating to appointment problem: January data will be
reported in arrears next month.
5.4.2
Exception Report: Indicator X12: Patients cancelled on day of surgery for non-clinical reasons: There
were 45 short notice cancellations for non-clinical reasons in January. This was a direct result of
emergency pressures in the Trust. Although an increase on previous months this is in line with the
performance for January last year and overall the Trust remains on course to deliver a reduction in
2013/14. (Note: although dependent on seasonal variation, this target has not been profiled for 2013/14).
5.5
Care Quality Commission 2013 Maternity Survey of Women’s Experience of Maternity Services
5.5.1
In February 2013, all women giving birth in England were sent a detailed questionnaire regarding their
experience of maternity care by the Care Quality Commission (CQC). The review reported on care
during the antenatal, postnatal, labour and birth and was benchmarked against the results from the CQC
maternity in survey in 2010 and the Health Care Commission (HCC) in 2007. The national report was
published mid December 2013 and is available on the CQC website.
5.5.2
Overall the CQC survey for women’s experience of WSHFT was very positive and demonstrated results
similar or better than the survey undertaken in 2010. None of the areas highlighted for the Trust in the
2010 report featured as areas for concern in the 2013 report.
5.5.3
There was only one question within the aggregated score for labour and birth that the WSHFT score was
among the worst performing: gaining access to the hospital in early labour.
5.5.4
Whilst it is well recognised there needs to be an appropriate triage system in place to ensure women are
admitted to labour ward at the right time to concentrate available staff to deliver 1:1 care in labour, it is
clear that our current processes need further development, to support women in the latent phase of
labour. An action plan to address this has been agreed by the Trust Management Board.
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Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board
6
CARE QUALITY COMMISSION (CQC)
6.1
CQC Compliance:
6.1.1
The Trust received an unannounced themed visit from the CQC on the St Richards site 23rd January.
The visit focused on the care and welfare of patients with dementia. The CQC reported that they
witnessed kind and compassionate care and saw overall that patients were treated with privacy and
dignity.
6.1.2
Although areas of excellent care and the management of the patients with dementia were commended,
this level of care focused on the dementia pathway was not consistently observed during the visit and
documentation was noted to be incomplete and there was a consistent failure to complete the ‘knowing
me’ documentation.
6.1.3
The Trust is awaiting the report, however, in the interim a programme of audits of the use of the
‘knowing me’ documentation has already been implemented.
6.1.4
The Trust also received an announced CQC inspection to Worthing Hospital on 28th January to monitor
Section 120 of the Mental Health Act 1983 in Acute Hospitals. The purpose of the visit was to check
compliance with the Mental Health Act and its associated Code of Practice. This included considering
how well the Trust integrates the various parts of the care pathway and how it contributes to outcomes of
care for people who use the service.
6.1.5
The Trust received the draft CQC Feedback Report 13th February. All detentions were found to be in
accordance with the Mental Health Act. The Trust is currently in the process of providing a Trust
Provider Action Statement in response to the findings detailing how improvements are currently being
made and are underway.
6.2
CQC Intelligent Monitoring Reports
6.2.1
These reports are published quarterly. The latest available report bands Western Sussex NHS
Foundation Trust as Band 6 – within the lowest risk band. The full report is available on the CQC
website:
http://www.cqc.org.uk/sites/default/files/media/reports/RYR_101_WV.pdf
6.2.2
An update is due 13th March 2014.
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Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board
7
7.1
NATIONAL AND LOCAL REPORTS
The 365 Club: The 365 Club was launched in 2012 to celebrate best practice in the prevention of
pressure ulcers, recognising the work involved in keeping patients safe from tissue damage. The
number of avoidable pressure ulcer-free days accrued by each ward over a calendar year determines
the level of certificate awarded.
7.1.1
A gold certificate recognises 365 days avoidable pressure ulcer-free days, silver is for 200 days and
bronze for 100 days.
7.1.2
Each hospital-acquired pressure ulcer is reported as a datix incident and assessed by the tissue viability
team. The care delivery is examined to assess whether all elements of the Skin Bundle protocol
(surface, repositioning, incontinence management and nutritional support) have been implemented in a
timely, collective and reliable manner, together with completion of Waterlow and MUST risk
assessments, and evaluations of care.
7.1.3
In conjunction with the Department of Health definition, this assessment is used to determine whether
the pressure ulcer was avoidable or unavoidable, the outcome of which is discussed with the Ward
Manager and Matron. In spite of optimal care, some patients develop pressure damage due to comorbidities, frailty, end-of-life skin changes, and/or non-concordance with preventative care strategies.
7.1.4
In 2013 there were 37 wards achieving the gold certificate of the 365 Club, compared to 31 in 2012.This
standard was maintained for a second year by 26 wards, and overall 12 wards had improved their
standard from the previous year.
7.1.5
The 365 certificates for 2013 were presented to the wards by Cathy Stone, Director of Nursing and
Patient Safety.
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Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board
7.2
Ward nursing staffing establishment
7.2.1
An external review of ward staffing was undertaken and presented to the Finance & Investment
Committee. The outcome was that overall Western Sussex Hospitals Foundation Trust nurse staffing
levels were within nationally recognised levels of staff. (Whilst acknowledging that currently there does
not exist mandated staffing levels for general inpatients wards within an Acute Trust).
7.2.2
The review presented 3 options for ongoing improvement. The key priority was to enhance the night
nurse staffing levels across 7 wards. The increase was implemented and those wards have been fully
established. A set of metrics highlighting patient care has been monitored and improvements in care, in
conjunction with a reduction in the numbers of staff required to undertake specialling care has been
highlighted.
7.2.3
National requirements: The two most recent National Health reviews: Review into the quality of care and
treatment provided by 14 Hospital Trusts in England an overview report (Professor Sir Bruce Keogh July
2013) and Improving the Safety of Patients in England (report chaired by Professor Don Berwick August
2013) reflected that ward nursing establishment within General Medical and Surgical wards with fewer
than one Registered Nurse per eight patients may increase risk substantially.
7.2.4
The Safe Staffing Alliance recommend that ward establishments provide a minimum ratio of 1
Registered nurse per 8 patients during the day. The review of the ward staffing previously presented to
the August Finance & Investment Committee provided a breakdown of wards by staff ratio and shift
patterns.
7.2.5
All Western Sussex Hospitals NHS Foundation Trust inpatient wards provide a baseline establishment of
at least 1 nurse per 7 patients during the day (assessment ward areas provide a greater skill mix ratio in
line with the clinical area)
7.2.6
In line with the recommendations of the Francis Inquiry into the Mid Staffordshire NHS Foundation Trust
a Nursing report detailing staffing levels across the acute inpatient wards will be provided to the April
Trust Board.
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Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board
7.3
Surgical Site Surveillance Scores – 2013/14
7.3.1
The following surgical site infection rates relating to July to September 2013 have been published:

Hip Replacement Surgery: Trust rate 1.0% National rate 0.8%

Knee replacement Surgery: Trust Rate 3.9%, National 0.9%

Large Bowel Surgery: Trust Rate 13.9% National 10.7%

Breast Surgery: Trust Rate 3.5% National 4.5%
7.3.2
The Medical Director and Director of Nursing and Patient Safety have met with the Chief of Surgery and
an action plan is underway. This will be monitored and the Monthly Operational Group and the Trust
Infection Control Committee.
8
8.1.1
COMMISSIONING FOR QUALITY AND INNOVATION (CQUIN)
Since 2009/10 a proportion of the money the Trust receives has been payable on achievement of
agreed quality metrics. A detailed agreement has been reached with commissioners for 2013/14.
8.1.2
In addition to the national CQUINS (Friends and Family, VTE, NHS Safety Thermometer and Dementia)
and the regional Enhancing Quality Programme, goals have been agreed in relation to the redesign of
the musculoskeletal service, the One Call One Team, anti-biotic prescribing, outpatient experience and
assistance with feeding.
8.1.3
9
9.1.1
A separate section has been added to the scorecard, pulling together CQUIN indicators.
RECOMMENDATION
The Board is asked to note the contents of this report.
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Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board
Mark Dennis, Head of Information Services
t: 01903 285273 (ext 5273)
QUALITY SCORECARD
JANUARY 2014
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
JAN
YTD Actual
YTD Target
Target
E01 Trust crude mortality rate (non‐elective)
4.13%
3.69%
4.10%
3.76%
3.18%
2.83%
3.51%
2.66%
2.80%
2.77%
2.81%
3.46%
3.79%
3.16%
3.17%
3.24%
E02 Crude mortality rate (non‐elective): 12 month rolling
3.20%
3.18%
3.24%
3.26%
3.28%
3.29%
3.37%
3.35%
3.35%
3.33%
3.31%
3.31%
3.29%
3.29%
3.24%
3.24%
E03 Trust Hospital Standardised Mortality Ratio (HSMR)
101.4
99.4
100.5
99.2
99.0
97.9
98.3
96.5
95.8
94.8
93.9
#N/A
#N/A
93.9
100
100
1.02
1.00
1.00
Trend
EFFECTIVENESS
1.02
E04 Summary Hospital‐level Mortality Indicator (SHMI) (rolling 12M)
#N/A
1.02
Improve mortality in specific conditions
E05 Crude non‐elective mortality for Pneumonia
18.4%
15.9%
18.1%
15.8%
13.8%
15.3%
17.1%
17.9%
18.6%
16.4%
17.3%
17.8%
12.9%
16.1%
18.7%
18.0%
E06 Crude non‐elective mortality for COPD
8.7%
8.7%
6.3%
6.7%
3.4%
6.2%
11.3%
4.8%
4.4%
4.6%
1.5%
3.1%
3.7%
4.8%
6.6%
6.7%
E07 Crude non‐elective mortality for Renal failure
40.6%
24.2%
40.0%
45.9%
20.0%
30.0%
14.8%
0.0%
17.4%
9.4%
21.4%
34.5%
14.6%
23.2%
18.8%
20.4%
E08 Crude non‐elective mortality for Chronic heart failure
18.9%
11.1%
22.8%
26.5%
16.7%
12.2%
19.1%
19.6%
14.0%
5.8%
9.1%
14.5%
17.9%
15.3%
19.0%
18.7%
E09 SMR for hip fracture (all diagnoses/procedures)
123.9
129.0
125.2
127.3
125.4
121.5
119.1
115.5
113.1
117.0
114.7
#N/A
#N/A
114.7
100
100
Reduce mortality following hip fracture
E09a Worthing SMR for hip fracture (all diagnoses/procedures)
111.8
119.3
113.6
111.0
114.6
113.7
113.1
109.0
108.3
117.2
115.9
#N/A
#N/A
115.9
100
100
E09b St Richard's SMR for hip fracture (all diagnoses/procedures)
143.4
144.4
143.2
152.1
141.4
132.9
128.1
125.1
119.9
116.8
112.9
#N/A
#N/A
112.9
100
100
E10 30 day mortaliy rate following hip fracture
12.5%
14.9%
5.5%
15.5%
8.0%
3.3%
6.9%
4.8%
11.1%
5.5%
7.1%
#N/A
#N/A
8.2%
8.3%
8.3%
12.3%
12.6%
11.9%
11.7%
11.3%
12.4%
12.4%
12.5%
11.6%
12.0%
11.5%
12.2%
13.1%
12.3%
12.2%
12.2%
669
668
686
677
655
652
601
581
649
664
693
709
5,881
5957
7,942
E13 C‐Section Rate
23.0%
26.3%
26.9%
27.9%
24.3%
23.9%
28.6%
23.5%
26.9%
25.0%
25.0%
26.7%
24.7%
25.6%
24.7%
24.7%
E14 % Mothers requiring forceps for delivery
9.0%
11.7%
9.7%
10.5%
10.5%
12.5%
10.8%
13.0%
11.2%
9.3%
13.9%
14.4%
13.8%
12.0%
<15%
<15%
E15 % Deliveries complicated by post‐partum haemorrhage
Reduce the rate of readmission following discharge from the Trust
E11 Emergency readmissions within 30 days %
E12 Emergency admissions not usually requiring admission
To improve maternity care by encouraging natural chilbirth
0.90%
1.10%
1.00%
0.70%
0.90%
0.90%
0.00%
0.20%
0.70%
0.80%
0.00%
1.20%
1.20%
0.70%
1%
1%
E16 Maternal deaths
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
E17 Admission of term babies to neonatal care
‐
‐
‐
2.50%
2.20%
3.30%
3.70%
4.20%
2.40%
2.20%
1.50%
3.80%
2.20%
2.80%
<10%
<10%
E18 % Emergency admissions staying over 72h screened for dementia
‐
‐
‐
10.2%
20.4%
31.0%
37.9%
54.8%
68.7%
77.0%
87.3%
90.9%
92.1%
57.0%
90%
90%
% Patients identified as at risk of dementia for whom further E19
investigations are carried out
‐
‐
‐
61.5%
80.9%
72.7%
77.5%
77.9%
74.6%
76.7%
83.1%
91.5%
96.0%
79.2%
90%
90%
E20 % Patients with identified dementia referred to specialist services
‐
‐
‐
75.0%
95.5%
93.1%
93.8%
91.5%
95.2%
98.0% 100.0% 95.7%
95.9%
93.4%
90%
90%
E21 Patients recruited to interventional studies within CRN portfolio 24
33
45
49
24
27
22
31
30
22
19
21
12
257
n/a
n/a
E22 Patients recruited to observational studies within CRN portfolio 26
25
41
30
35
8
13
12
13
9
22
23
48
213
n/a
n/a
E23 CLRN Score
146
190
266
275
155
143
123
167
163
119
117
128
108
1498
1088
1305
94.9
95.8
95.8
96.6
96.8
97.7
98.0
98.0
96
96
Caring for the elderly patient
Ensure active engagement with research
Data Quality
E24 NHS IC Data validity summary (YTD)
6b Quality scorecard M10 v2.xls (colour).Quality scorecard
Page 1 of 4
Printed 21/02/2014 08:45
Mark Dennis, Head of Information Services
t: 01903 285273 (ext 5273)
QUALITY SCORECARD
JANUARY 2014
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
JAN
YTD Actual
YTD Target
Target
89.9
88.9
85.0
96.8
98.3
81.8
84.3
98.3
68.9
85.7
87.8
<100
<100
5057‐8428
6068 ‐ 10,114
Trend
SAFETY
S01 Patient Aggregate Safety Score (PASS)
General Safety
S02 Safety Thermometer: % of patients harm‐free
93.2%
93.4%
92.0%
93.0%
92.5%
93.9%
93.0%
95.4%
95.2%
95.5%
94.0%
95.2%
93.3%
94.1%
S03 Safety Thermometer: % of patients with no new harms
97.7%
96.9%
97.8%
97.1%
98.1%
98.4%
97.3%
98.3%
98.8%
98.2%
98.0%
98.4%
97.7%
98.0%
693
714
765
711
722
773
744
680
692
812
719
799
780
7432
S05 Total moderate, severe or death incidents
9
3
8
6
8
9
12
6
10
9
9
7
9
85
71
85
S06 Total serious incidents (SIRI)
2
2
3
2
1
0
3
4
4
3
2
1
2
22
22
26
S07 Number of outstanding CAS alerts
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
S08 Total incidents involving drug/prescribing errors
72
95
92
79
80
87
78
79
78
74
91
121
119
886
S09 Moderate/severe incidents involving drug/prescribing errors
1
0
0
0
2
1
0
0
0
0
2
0
0
5
3
4
67%
80%
80%
S04 Total incidents
Improve safety of prescribing
67%
S10 Reduced errors on zero tolerance anti‐microbial prescribing audits
76%
61%
64%
688‐1147 826 ‐1376
Reduce incidence of healthcare associated VTE
S11 95% compliance with the DoH risk assessment tool
95.0%
95.0%
94.0%
94.4%
95.2%
95.6%
97.0%
96.0%
96.5%
96.6%
96.4%
96.5%
96.1%
96.0%
95%
95%
S12 Prescriptions for VTE prophylaxis
1999
2007
2069
1998
2184
1778
1913
2113
2160
2288
2103
2295
2241
21073
19433
23320
25
23
23
33
34
24
31
28
29
29
31
29
30
298
278
334
S14 Number of hospital attributable MRSA cases
0
1
0
0
0
0
1
1
0
0
2
0
0
4
0
0
S15 Number of hospital attributable C.diff cases
5
4
9
13
5
7
2
7
3
3
2
2
7
51
39
46
S16 Number of reportable MSSA bacteraemia cases
6
1
10
6
4
6
7
7
4
3
4
8
6
55
tbc
tbc
S17 Number of reportable E.coli cases
14
12
21
25
30
23
25
30
17
18
15
30
24
237
tbc
tbc
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
S13 Incidence of VTE
Reduce incidence of healthcare acquired infections
Improve theatre safety for patients
100%
S18 Full compliance with WHO Surgical Safety Checklist
S19 NEVER events
0
0
0
0
0
0
1
0
0
0
0
0
0
1
0
0
S20 Theatre related SIRIs
0
0
0
0
0
0
1
0
1
0
0
1
0
3
0
0
S21 Falls resulting in harm
53
36
45
46
29
36
37
26
40
45
31
41
44
375
401
481
S22 Falls resulting in severe harm or death
0
0
1
2
0
0
0
2
1
0
0
0
0
5
2
2
S23 Falls assessment within 24hrs of admission
93.5%
90.0%
91.5%
92.0%
93.5%
94.5%
93.7%
95.5%
90.0%
93.3%
93.6%
91.0%
90.0%
92.7%
80%
80%
S24 Avoidable falls identified on the Safety Thermometer
2.27%
1.49%
1.70%
1.46%
1.42%
0.89%
0.85%
0.64%
0.48%
0.71%
0.24%
0.67%
0.69%
0.65%
1.41%
1.41%
S25 Grade 2 pressure sores
11
6
13
12
9
7
9
9
5
8
6
8
15
88
95
114
S26 Grade 3 & 4 pressure sores
1
0
0
0
0
0
0
0
0
0
0
0
0
0
3
4
Reduce number of falls in hospital
Pressure damage
6b Quality scorecard M10 v2.xls (colour).Quality scorecard
Page 2 of 4
Printed 21/02/2014 08:45
Mark Dennis, Head of Information Services
t: 01903 285273 (ext 5273)
QUALITY SCORECARD
JANUARY 2014
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
JAN
YTD Actual
YTD Target
X01 Trust Friends and Family Score: Inpatient (reported from Q2)
‐
‐
‐
‐
‐
75
79
73
76
75
78
74
74
76
Base‐line Base‐line
X02 Trust Friends and Family Score: A&E (reported from Q2)
‐
‐
‐
‐
‐
79
77
74
74
76
76
75
78
76
Base‐line Base‐line
Target
Trend
EXPERIENCE
Friends and family test
Use of feedback from the real time patient experience project
X03 Realtime feedback on the hospital environment
75
73
76
75
77
76
76
76
77
76
78
75
77
76
75
75
X04 Realtime feedback on assistance
88
86
88
91
90
90
90
92
91
91
93
91
91
91
87
87
X05 Realtime feedback on compassion
87
87
88
89
90
90
89
89
90
90
90
89
90
90
88
88
X06 Realtime feedback on communication
76
79
79
75
79
79
79
76
79
80
78
80
78
78
77
77
X07 Overall experience of the Trust
91
91
92
91
93
93
93
92
93
93
94
93
93
93
92
92
10.9%
10.8%
10.0%
9.9%
8.8%
9.8%
9.0%
8.2%
7.8%
8.3%
8.3%
8.2%
7.5%
8.6%
9.8%
9.8%
47
17
18
19
26
41
16
25
20
25
26
10
26
234
313
376
Reduction in patients suffering a bad experience dealing with the Trust
X08 Percentage of re‐booked outpatient appointments
X09 Clinics cancelled with less than 6 weeks notice
X10 Average number of ward stays per non‐elective admission
1.77
1.82
1.73
1.78
1.78
1.82
1.80
1.75
1.74
1.81
1.74
1.73
1.84
1.78
1.75
1.75
0.10%
0.11%
0.11%
0.12%
0.14%
0.16%
0.16%
0.21%
0.19%
0.14%
0.10%
0.07%
#N/A
0.14%
0.10%
0.10%
46
26
45
31
17
21
16
26
16
27
24
28
45
251
379
455
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0
0 X14 Compliance with MUST tool after 24 hours
86.5%
87.5%
83.0%
84.0%
85.9%
86.7%
86.7%
89.5%
88.4%
86.8%
82.0%
79.5%
85.5%
85.5%
80%
80%
X15 Compliance with MUST tool after 7 days
95.5%
92.0%
93.5%
97.5%
98.0%
98.4%
97.5%
96.5%
98.6%
95.8%
97.0%
96.5%
94.5%
97.0%
95%
95%
X16 Internal PLACE compliance : St Richard's Hospital
96%
97%
96%
97%
94%
95%
96%
98%
99%
97%
97%
99%
98%
97%
85%
85%
X17 Internal PLACE compliance : Worthing Hospital
93%
96%
95%
95%
92%
97%
96%
92%
91%
92%
99%
98%
96%
95%
85%
85%
X18 Number of complaints
46
36
40
39
46
54
37
35
30
57
40
37
53
428
468
562
X19 Complaints where staff attitude or behaviour is an issue
4
5
7
6
6
4
2
2
5
4
3
2
3
37
47
56
X11 PALS contacts relating to appointment problems (% of total appts)
X12 Reduce patients cancelled on the day of surgery for non‐clinical reasons
X13 Breaches of mixed sex accommodation arrangements
Nutritional Assessment
Cleanliness / PEAT Survey
Improve our customer service and become a more caring organisation
X20 Complaints where staff communication is an issue
3
4
5
3
5
2
4
4
2
7
4
6
4
41
63
75
X21 Complaints about nursing
3
3
6
3
1
4
3
3
0
3
0
3
3
23
34
41
X22 Positive care and compassion observations in general care
88%
80%
88%
81%
83%
n/a
n/a
X23 Positive care and compassion observations in patient / visitor interactions
92%
79%
84%
87%
83%
n/a
n/a
6b Quality scorecard M10 v2.xls (colour).Quality scorecard
Page 3 of 4
Printed 21/02/2014 08:45
Mark Dennis, Head of Information Services
t: 01903 285273 (ext 5273)
QUALITY SCORECARD
JANUARY 2014
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
JAN
YTD Actual
YTD Target
Target
E18 % Emergency admissions staying over 72h screened for dementia
10.2%
20.4%
31.0%
37.9%
54.8%
68.7%
77.0%
87.3%
90.9%
92.1%
57.0%
90%
90%
% Patients identified as at risk of dementia for whom further E19
investigations are carried out
61.5%
80.9%
72.7%
77.5%
77.9%
74.6%
76.7%
83.1%
91.5%
96.0%
79.2%
90%
90%
E20 % Patients with identified dementia referred to specialist services
75.0%
95.5%
93.1%
93.8%
91.5%
95.2%
98.0% 100.0% 95.7%
95.9%
93.4%
90%
90%
Jan
Feb
Mar
Trend
CQUIN SCHEMES
National CQUINS
S11 95% compliance with the DoH risk assessment tool
95.0%
95.0%
94.0%
94.4%
95.2%
95.6%
97.0%
96.0%
96.5%
96.6%
96.4%
96.5%
96.1%
96.0%
95%
95%
S24 Avoidable falls identified on the Safety Thermometer
2.27%
1.49%
1.70%
1.46%
1.42%
0.89%
0.85%
0.64%
0.48%
0.71%
0.24%
0.67%
0.69%
0.65%
1.41%
1.41%
X24 Trust Friends and Family Response Rate: Inpatient
7.8%
6.6%
12.3%
13.6%
16.1%
26.0%
17.8%
16.5%
20.6%
22.7%
32.9%
24.0%
20.3%
20%
20%
X25 Trust Friends and Family Response Rate: A&E
0.9%
0.7%
1.4%
1.9%
6.8%
12.0%
9.8%
15.3%
19.4%
30.2%
42.0%
35.0%
17.4%
20%
20%
6b Quality scorecard M10 v2.xls (colour).Quality scorecard
Page 4 of 4
Printed 21/02/2014 08:45
Mark Dennis, Head of Information Services
t: 01903 285273 (ext 5273)
INFECTION CONTROL SCORECARD
JANUARY 2014
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
YTD Actual YTD Target
Target
Trend
Compliance with high impact intervention care bundles (HII)
Renal
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
95%
95%
Central line
100%
100%
100%
100%
96%
100%
100%
99%
100%
100%
99%
100%
100%
99%
95%
95%
Ventilation
97%
100%
100%
100%
100%
99%
83%
100%
100%
98%
97%
100%
98%
98%
95%
95%
Hand hygiene
98%
96%
97%
97%
98%
99%
98%
99%
98%
97%
98%
97%
96%
98%
95%
95%
Peripheral IV Line
98%
98%
97%
99%
96%
97%
97%
97%
97%
97%
97%
98%
96%
97%
95%
95%
Catheter care
100%
99%
100%
100%
100%
100%
100%
100%
100%
100%
100%
99%
100%
100%
95%
95%
Compliance with elective MRSA screening
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Compliance with non‐elective MRSA screening
97%
98%
98%
98%
98%
99%
98%
98%
98%
98%
98%
98%
98%
98%
100%
100%
Screening
Hospital cleanliness
Very high risk
98%
99%
99%
99%
99%
99%
99%
99%
99%
99%
99%
100%
100%
99%
98%
98%
High risk
98%
98%
97%
97%
97%
98%
98%
98%
98%
98%
98%
98%
98%
98%
95%
95%
Significant risk
97%
97%
97%
96%
96%
97%
96%
96%
95%
95%
96%
97%
97%
96%
85%
85%
Low risk
90%
92%
91%
93%
97%
94%
94%
97%
94%
90%
94%
95%
95%
94%
75%
75%
100%
100%
98%
98%
98%
99%
100%
97%
99%
98%
98%
99%
98%
98%
Decontamination of equipment
Decontamination of equipment
6c Infection Control Scorecard M10 (colour).Infection Control
Page 1 of 1
Printed 21/02/2014 08:46
Mark Dennis, Head of Information Services
t: 01903 285273 (ext 5273)
FRACTURED NECK OF FEMUR DASHBOARD
Site: Western Sussex Hospitals
Data for period:
DECEMBER 2013
version 1.5
% Patients operated on within 36 hours of A&E attendance (source: NHFDb)
% op < 36 hrs ‐ All patients
Mortality in hospital and within 30 days of admission (source: NHFDb/Sema Helix)
% op < 36 hrs ‐ Medically fit
% Deaths within 30 days of admission
100%
% Deaths in hospital
95% CI (Overall Nat. 30 day mortality)
35%
90%
30%
80%
70%
25%
60%
20%
50%
40%
15%
30%
10%
20%
5%
10%
% Patients who saw Consultant Physician Pre‐op (source: NHFDb)
% Patients mobilised within 24 hours post‐op
Dec 13
Oct 13
Aug 13
Jun 13
Apr 13
Feb 13
Dec 12
Oct 12
Aug 12
Jun 12
Average LOS
100%
90%
90%
80%
80%
70%
70%
25
60%
20
50%
Apr 12
Total LOS and LOS on post‐op ward (source: NHFDb)
Data between June and December 2012 relates to SRH only. Data collection recommenced at Worthing in December 2012 and is reflected in reported performance from January 2013
100%
60%
Feb 12
Dec 11
Oct 11
Aug 11
Jun 11
Apr 11
Feb 11
Dec 10
Oct 10
Aug 10
Jun 10
Apr 10
Dec 13
Oct 13
Aug 13
Jun 13
Apr 13
Feb 13
Dec 12
Oct 12
Aug 12
Jun 12
Apr 12
Feb 12
Dec 11
Oct 11
Aug 11
Jun 11
Apr 11
Feb 11
Dec 10
Oct 10
Aug 10
Jun 10
0%
Apr 10
0%
Average post‐op LOS
35
30
50%
40%
30%
20%
40%
15
30%
10
20%
5
10%
6d #NOFDashboard_1312_Dec_v2 (colour + all sheets).Western Sussex Hospitals
Page 1 of 4
Oct 13
Printed 21/02/2014 08:46
Dec 13
Aug 13
Jun 13
Apr 13
Feb 13
Dec 12
Oct 12
Jun 12
Aug 12
Apr 12
Feb 12
Dec 11
Oct 11
Jun 11
Aug 11
Apr 11
Feb 11
Dec 10
Oct 10
Jun 10
Aug 10
Dec 13
Oct 13
Jun 13
Aug 13
Apr 13
Feb 13
Dec 12
Oct 12
Aug 12
Jun 12
Apr 12
Feb 12
Oct 11
Dec 11
Aug 11
Jun 11
Apr 11
Feb 11
Oct 10
Dec 10
Aug 10
0
Jun 10
0%
Apr 10
Dec 13
Oct 13
Jun 13
Aug 13
Apr 13
Feb 13
Dec 12
Oct 12
Aug 12
Jun 12
Apr 12
Feb 12
Dec 11
Oct 11
Aug 11
Jun 11
Apr 11
Feb 11
Oct 10
Dec 10
Aug 10
Jun 10
Apr 10
0%
Apr 10
10%
Mark Dennis, Head of Information Services
t: 01903 285273 (ext 5273)
FRACTURED NECK OF FEMUR DASHBOARD
Site: St Richard's Hospital
Data for period:
DECEMBER 2013
version 1.5
% Patients operated on within 36 hours of A&E attendance (source: NHFDb)
% op < 36 hrs ‐ All patients
Mortality in hospital and within 30 days of admission (source: NHFDb/Sema Helix)
% op < 36 hrs ‐ Medically fit
% Deaths within 30 days of admission
100%
% Deaths in hospital
95% CI (Overall Nat. 30 day mortality)
30%
90%
25%
80%
70%
20%
60%
50%
15%
40%
10%
30%
20%
5%
10%
% Patients who saw Consultant Physician Pre‐op (source: NHFDb)
Dec 13
Oct 13
Aug 13
Jun 13
Apr 13
Feb 13
Dec 12
Oct 12
Jun 12
Apr 12
Aug 12
Average post‐op LOS
40
35
20
Page 2 of 4
Printed 21/02/2014 08:46
Dec 13
Oct 13
Jun 13
Aug 13
Apr 13
Feb 13
Dec 12
Oct 12
Jun 12
Aug 12
Apr 12
Feb 12
Dec 11
Oct 11
Aug 11
Jun 11
Apr 11
Feb 11
Dec 10
Oct 10
Aug 10
Jun 10
0
Apr 10
Dec 13
Oct 13
Jun 13
Aug 13
Apr 13
Feb 13
Dec 12
Oct 12
Aug 12
Jun 12
Apr 12
Feb 12
Oct 11
Dec 11
Aug 11
Jun 11
Apr 11
Feb 11
Oct 10
Dec 10
Aug 10
Jun 10
15
Apr 10
Dec 13
Oct 13
Jun 13
Aug 13
Apr 13
0%
Feb 13
5
0%
Dec 12
10
10%
Oct 12
20%
10%
Aug 12
20%
Jun 12
30%
Apr 12
30%
Feb 12
40%
Dec 11
40%
Oct 11
50%
Aug 11
25
50%
Jun 11
30
60%
Apr 11
70%
60%
Feb 11
70%
Oct 10
80%
Dec 10
90%
80%
Aug 10
Feb 12
Average LOS
90%
Jun 10
Dec 11
Total LOS and LOS on post‐op ward (source: NHFDb)
100%
Apr 10
Oct 11
% Patients mobilised within 24 hours post‐op
100%
6d #NOFDashboard_1312_Dec_v2 (colour + all sheets).St Richard's Hospital
Aug 11
Jun 11
Apr 11
Feb 11
Oct 10
Dec 10
Aug 10
Jun 10
Apr 10
Dec 13
Oct 13
Aug 13
Jun 13
Apr 13
Feb 13
Dec 12
Oct 12
Aug 12
Jun 12
Apr 12
Feb 12
Dec 11
Oct 11
Aug 11
Jun 11
Apr 11
Feb 11
Dec 10
Oct 10
Aug 10
Jun 10
0%
Apr 10
0%
Mark Dennis, Head of Information Services
t: 01903 285273 (ext 5273)
FRACTURED NECK OF FEMUR DASHBOARD
Site: Worthing Hospital
Data for period:
DECEMBER 2013
version 1.5
% Patients operated on within 36 hours of A&E attendance (source: NHFDb)
% op < 36 hrs ‐ All patients
Mortality in hospital and within 30 days of admission (source: NHFDb/Sema Helix)
% op < 36 hrs ‐ Medically fit
% Deaths within 30 days of admission
100%
40%
90%
35%
80%
% Deaths in hospital
95% CI (Overall Nat. 30 day mortality)
30%
70%
60%
25%
50%
20%
40%
15%
30%
% Patients who saw Consultant Physician Pre‐op (source: NHFDb)
Dec 13
Oct 13
Aug 13
Jun 13
Apr 13
Feb 13
Dec 12
Oct 12
Jun 12
Apr 12
Aug 12
Average post‐op LOS
40
35
20
Page 3 of 4
Oct 13
Printed 21/02/2014 08:46
Dec 13
Aug 13
Jun 13
Apr 13
Feb 13
Dec 12
Oct 12
Jun 12
Aug 12
Apr 12
Feb 12
Dec 11
Oct 11
Jun 11
Aug 11
Apr 11
Feb 11
Dec 10
Oct 10
Jun 10
Aug 10
0
Apr 10
Dec 13
Oct 13
Jun 13
Aug 13
Apr 13
Feb 13
Dec 12
Oct 12
Aug 12
Jun 12
Apr 12
Feb 12
Oct 11
Dec 11
Aug 11
Jun 11
Apr 11
Feb 11
Oct 10
Dec 10
Aug 10
Jun 10
15
Apr 10
Dec 13
Oct 13
Jun 13
Aug 13
Apr 13
0%
Feb 13
5
0%
Dec 12
10
10%
Oct 12
20%
10%
Aug 12
20%
Jun 12
30%
Apr 12
30%
Feb 12
40%
Dec 11
40%
Oct 11
50%
Aug 11
25
50%
Jun 11
30
60%
Apr 11
70%
60%
Feb 11
70%
Oct 10
80%
Dec 10
90%
80%
Aug 10
Feb 12
Average LOS
90%
Jun 10
Dec 11
Total LOS and LOS on post‐op ward (source: NHFDb)
100%
Apr 10
Oct 11
% Patients mobilised within 24 hours post‐op
100%
6d #NOFDashboard_1312_Dec_v2 (colour + all sheets).Worthing Hospital
Aug 11
Jun 11
Apr 11
Feb 11
Dec 10
Oct 10
Jun 10
Apr 10
Dec 13
Oct 13
Aug 13
Jun 13
Apr 13
Feb 13
Dec 12
Oct 12
Aug 12
Jun 12
Apr 12
Feb 12
Dec 11
Oct 11
Aug 11
Jun 11
Apr 11
Feb 11
Dec 10
Oct 10
Aug 10
0%
Jun 10
5%
0%
Apr 10
10%
Aug 10
10%
20%
Mark Dennis, Head of Information Services
t: 01903 285273 (ext 5273)
Summary Table ‐ Data from NHFDb
DECEMBER 2013
St Richard's
39
31
1
3.2%
Worthing
45
42
4
9.5%
WSHT
84
73
5
6.8%
2
3
5
5.7%
12.7
8.6%
19.8
7.1%
18.6
Medically fit patients
Number operated wtihin 24 hours
% operated within 24 hours
Number operated wtihin 36 hours
% operated within 36 hours
34
23
67.6%
32
94.1%
41
26
63.4%
39
95.1%
75
49
65.3%
71
94.7%
All patients
Number operated wtihin 24 hours
% operated within 24 hours
Number operated wtihin 36 hours
% operated within 36 hours
38
23
60.5%
32
84.2%
43
26
60.5%
39
90.7%
81
49
60.5%
71
87.7%
Admissions
Discharges
Number of deaths in hospital
Hospital mortality rate %
Number of deaths within 30 days of admission
(for admissions in November 2013)
Mortality rate within 30 days of admission
Average LOS
6d #NOFDashboard_1312_Dec_v2 (colour + all sheets).MonthPage
summary
4 of 4
Printed 21/02/2014 08:46
To: Trust Board
Date of Meeting: 27th February 2014
Agenda Item: 7
Title
The purpose of this report is to provide the Trust Board with a third formal update on the progress of the
Western Sussex Hospitals Trust (WSHT) response to the recommendations of the Mid Staffordshire NHS
Foundation Trust Public Inquiry
Responsible Executive Director
Marianne Griffiths, Chief Executive Officer
Prepared by
Cathy Stone, Director of Nursing and Patient Safety
Status
Disclosable
Summary of Proposal
The report identifies the key actions and achievements to date regarding the priority areas for action with
reference to WSHT response to the Francis Inquiry.
Implications for Quality of Care
To consider areas of concern, high grade complaints and themes/trends in service and patient care.
Link to Strategic Objectives/Board Assurance Framework
Patient Safety agenda – improving the patient experience/learning lessons
Financial Implications
1. Financial penalties may be incurred in the event of a reported Never Event.
2. Subsequent patient litigation claims may occur.
3. Loss of Commissioner confidence may result in loss of Trust business.
Human Resource Implications
1. Professional performance management issues for individuals.
2. Learning and development requirements.
3. Organisational, behavioural and cultural issues.
Recommendation
The Committee is asked to note the report
Communication and Consultation
Appendices
1 Francis Inquiry
Western Sussex Hospitals NHS Foundation Trust response
“The Culture of Safe Compassionate Care”
1.0 Introduction
The purpose of this report is to provide the Trust Board with its third formal update on
the Western Sussex Hospitals NHS Foundation Trust (WSHFT) response to the
recommendations of the Mid Staffordshire NHS Foundation Trust Public Inquiry.
2.0 National response
This report and the Trust response is in line with the initial Government response
“Patients First and Foremost” (Published March 2013).
The initial Government response focused attention nationally on 5 key action areas;





Preventing problems
Detecting problems
Taking actions promptly
Ensuring robust accountability
Ensuring staff are trained and motivated
Key National themes for each priority
2.1 Preventing the problem





The appointment of a Chief Inspector of Hospitals
The development of fundamental national standards of care and care ratings
NHS cultural change
The provision of compassionate care
Berwick review of the National Health Service (NHS)
2.2 Detecting problems






2 The appointment of a Chief Inspector of Hospitals
Enhanced Care Quality Commission role
Development of a single rating system
Appointment of a Chief Inspector of Social Care
Implementation of a duty of candour
Implementation of a national complaints review
2.3 Taking action promptly




Development of consistent fundamental standards
Development of a time limited failure regime for quality as well as finance
NHS Trust Development Authority (NTDA), Care Quality Commission (CQC),
Monitor, Chief Inspector of Hospitals to take action on failing organisations
Development of a single set of expectations
2.4 Robust accountability


Enhanced role of the Health and Safety Executive
Implementation of faster proactive regulation
2.5 Well trained and motivated staff




3.0
12 month Healthcare Assistant (HCA) experience prior to nurse registration
Revalidation model for nurses
Code of conduct for HCA
Frontline experience for Department of Health (DOH) staff
Western Sussex Hospitals NHS Foundation Trust response
The key theme for WSHFT has been the acknowledgement that culture and leadership
are the key parameters which will secure the successful implementation and the
sustained delivery of safe patient care.
The Francis Inquiry made 290 recommendations with potentially 84 attributable to the
Trust.
The key response by the Trust was to establish a series of listening events led by the
Chief Executive over a 12 week period, meeting with cross-sectional representatives of
staff across the Trust. The report was also featured in the Trust’s monthly information
cascade with teams asked to discuss the findings.
The overview of the listening events has translated into 9 key action areas and can be
linked to the priority areas with the initial Government response.
Listening Event key action areas
The Culture of safe compassionate care
3 1.
24 hour service
 Executive Lead: Dr. George Findlay, Medical Director
2.
The culture of caring and leadership
 Executive Lead: Denise Farmer, Director of Organisational Development and
Leadership
3.
Nursing Leadership/workforce
 Executive Lead: Cathy Stone, Director of Nursing and Patient Safety
4.
Outlying patients
 Executive Lead: Jane Farrell, Chief Operating Officer
5.
Ownership of patients
 Executive Lead: Dr George Findlay, Medical Director
6.
The discharge process accounting for patient frailty
 Executive Lead: Jane Farrell, Chief Operating Officer
7.
The IT infrastructure challenge
 Executive Lead: Dr George Findlay, Medical Director
8.
Learning organisation/learning from complaints use of Datix
 Executive Lead: Cathy Stone, Director of Nursing and Patient Safety
9.
Implementation of key process changes directly relevant to the Francis Inquiry
•
4 Executive Lead: Cathy Stone, Director of Nursing and Patient Safety
4.0
Action Areas of Responsibility
Each lead Director has developed a series of delivery plans for each dedicated action area.
The First report identified the dedicated governance and reporting process relevant to each area.
This report provides an overview of the key actions identified and also provides an update on the progress to completion within Quarter 3.
Priority
Area
1
Action Area
Executive Lead
Actions Outlined
24 Hour
service
Chief Operating Officer and Chief of Medicine Chief of Medicine review of Consultant level
leadership
Gap analysis as an outcome of the review
plan for resourcing
Progress to Date









7 Day Week
1
5 Chief Operating
Officer
Define governance arrangements
Identify programme management support
Undertake external validation project
Link with early adopter site
Development of workforce case of need





24/7 Programme Board established, meeting fortnightly (Chair
COO)
Clinically led review and development of high level options for
development completed (bronze, silver, gold).
Informed by gap analysis against Keogh recommendations AND
external benchmarking, ‘early adopter’ sites etc.
Includes parallel enabling developments and/or doing things
differently, e.g. technology, skill mix, innovation.
Engagement and communication plan in train – CCG, wider
LHE
Presentation to CWS LHE Strategic Event January 2014, and
wider health and social care commitment secured.
Priority for CWS CCG confirmed.
Draft financial model completed
External visit to Salford April 2014, and Heart of England being
explored.
Project group maintained.
Extended working in MAU/EU implemented in line with activity
trends.
Consultant in residence service in Obstetrics.
Extension of the working day within Paediatrics.
Wider visibility of Consultant cover over the weekend in the
acute specialities.
Culture of
Caring and
Leadership
2
3
4
Nursing
Leadership
and
Workforce
Director of Nursing
and Patient Safety
Outlying
Patients
Chief Operating
Officer
Ownership of
Patients
5
6 Director of OD and
Leadership
Medical Director
Leadership development strategy – revised and
implemented
Customer care programme – developed and
implemented
Improved internal communications and
engagement
Health and Wellbeing strategy implemented
External review of baseline establishment of
nursing staff levels
Prioritise enhanced nursing levels within key
ward areas
Develop nurse leadership programme
Develop metrics to demonstrate sustained care
delivery.
Governance arrangements defined
Review of Site Management & Capacity
Escalation Plan
Outlier Audit underway – utilise findings to
inform further revisions to Site Management/
Flow Management plans
Ensure the parallel link with the Medical
Director’s work stream “Guidance on clinical
ownership of patients”.
Formalise the clinical ownership of Outlying
patients, and “Buddy Wards” in partnership with
Medical Director
Complete the bed capacity and clinical
alignment review
Ensure improved/potentially new working
arrangements are communicated effectively as
part of Seasonal planning arrangements
Produce draft guidance on clinical ownership of
patients at WSHFT



Third formal leadership programme commenced.
Stress workshops underway regarding targeted health and wellbeing projects i.e. MSK.
Values based recruitment in pilot phase.
Customer care programme has identified care navigators and
training sessions underway.
Review of staff catering and retail services underway.
IT infrastructure for the new website in place.
Review of ward staffing completed. All inpatient wards
established for a minimum of 1 Registered nurse to 7 patients
during the day.
Ward staffing levels displayed on acute inpatient wards.
Enhanced night nursing levels implemented.
Nurse leadership programme well underway.
Ward sisters have been invited to join the National Nurse
Leadership programme.
Student nurse Preceptorship has been enhanced
Strategic Operations Group” (Chair COO) established to
oversee development of this work stream and the required
synergy with day to day operational improvements e.g. new
clinical and operational site management arrangements;
strengthened escalation arrangements etc.
Review Site Management and Capacity Escalation Plan
completed and implemented/as above.
Outlier Audit to inform Improvement Plan completed and used to
inform improved day to day management BUT the further
improvement and sustainability required to manage peaks in
demand predicated on bed :clinical service strategy realignment.
Bed capacity and clinical alignment review has commenced and
bed modelling tool developed to inform scenario planning. Will
now be subsumed under the “Emergency Floor and 24/7
Development”, given these will influence LOS and bed capacity
assumptions.
Formalise clinical ownership of outlying patients.

A process of patient identification and “Buddy Wards”














Dissemination through Divisions before finalising
The
Discharge
Process
6
Chief Operating
Officer


Review Governance arrangements
Review South Coast Audit plan
Review existing stakeholder information
Develop action plan with internal and external
champions
Establish post implementation evaluation tool
With a focus on the elderly frail in particular
agree and implement a suite of new measures
to improve the patient experience on day of
discharge and provide active follow up.
Formalise the clinical ownership of Outlying
patients, and “Buddy Wards” in partnership with
MD – as relevant for this work stream as
‘Outlying Patients’
Formalise link with Pro Active Care Lead
Provider (SCT) arrangements and plans
focusing on day of discharge and follow up.






The IT
Infrastructure
7
The Learning
8
7 Director of Finance
Director of Nursing
Implementation of a new server and core
network infrastructure to replace the current
ageing hardware. The new infrastructure will
provide greater stability, performance and
disaster recovery capability.
Alongside the above, the plan is to provide
reduced sign-on functionality to key clinical
applications to speed up and simplify access to
clinical data. In addition key mobile clinicians
will be given access to virtual desktop
technology with means they will be able to
rapidly log into PCs in various locations around
the trust.
Undertake Trust wide review of clinical incident

established and implemented throughout the Trust.
A review of effectiveness is planned for Q1.
Review of Discharge Policy completed and aligned with South
Coast Audit Report recommendations.
Staff engagement event facilitated to test assumptions re “what
works and what doesn’t”
New multi-agency arrangements implemented - daily review of
all delayed discharges and patient level action plans.
Weekly review of all delays over 10 days with LHE partners – to
identify and unlock recurrent bottlenecks AND collate longer
term improvement themes. Escalation to weekly Strategic
Operations Group.
Presentation to CWS LHE Strategic Event January 2014 and
agreement to establish a multi-agency task force to re-design
the pathway for the ‘frail elderly and high risk’, with an emphasis
on improving “on the day arrangements and follow up”.
Alongside, “Early identification of admission/and discharge “
project launched - aimed at identifying the frail and high risk on
admission enabling Proactive Care Teams (SCT) to reach in
and case managing the patients discharge pathway.
Wider hospital engagement still required. A revised Project
Group to be launched and membership extended to Governors
to input and assist test and challenge.

Server/Core Network Infrastructure Procurement completed and
ready for implementation

Project commenced with equipment arriving on site from 1st
week in March (Phased 6 – 9 Month Deployment).

Introduction of Virtual Desktop and Single Sign On Technology
To Key Clinicians due to be implemented in First Phase (Q1
14/15).
Completed and publicised Datix incident reporting system review.
9
Organisation
and Patient Safety
Systems and
processes
relating
directly to the
Francis
Inquiry
Director of Nursing
and Patient Safety
reporting processes
Develop proposals for change
Propose enhancing current arrangements to
ensure organisational learning is sustained Trust
wide
Review complaints system pending the outcome
of the Clwyd Report.
Review Medical and Nurse education in line with
recommendation of Cavendish and Berwick









8 Implementation underway.
Refreshed RCA process and completed training to all Matrons.
Patient safety team now attend Divisional meetings on a monthly
basis.
Bi-monthly learning from incident section within team brief.
Website reviewed and complaints information now available on the
Trust Intranet as a separate page.
10% reduction in care complaints.
The Patient Association are undertaking a review of the complaints
handling process through the eyes of the public.
The Anne Clwyd report has been presented to the Patient
Experience & Feedback Committee.
Sustained reduction in upheld complaints referred to the office of
the Ombudsman.
5.0 Evidence of Impact
The key theme throughout the Francis Inquiry was ensuring that the culture and
leadership of the organisation focused on the sustained delivery of safe patient care.
The measurement of success cannot be easily identified by short term metrics, however
over the past quarter the Trust’s internal staff and inpatient surveys have demonstrated
year on year improvement, with key positive responses focused around;



A patient safety led culture within our organisation.
The care and compassion to patients provided by nursing staff.
Staff recommending Western Sussex Hospitals Foundation Trust (WSHFT) as both a
positive place to work and a place they would recommend for treatment.
The Trust has experienced 3 unannounced CQC visits since the last formal update, all
of which reported positive patient care, supported by Patient feedback.
The National Friends and Family Test (FFT) response rates for both Accident &
Emergency and inpatient wards place WSHFT above the national average.
During February the CQC produced the second draft intelligent monitoring report and
the Trust was rated as a 6.
This is the highest possible rating as it reflects a low level of risks within the
organisation.
6.0 Trust Engagement
In addition to the existing Trust Communication strategy a review of the Trust team brief
and cascade mechanism is underway.
The Medical Director is re-profiling the Clinical Leaders group.
7.0 Conclusion
All the priority areas have well established delivery plans, which are monitored through
the Executive team and the Workforce and the Organisational development group
provides a further level of scrutiny.
This paper demonstrates the on-going commitment to the successful delivery of the
Trust priority action areas.
The paper also identified positive indicators of improvement.
The key challenge for Quarter 4 is to sustain delivery against a background of increased
activity.
9 8.0 Recommendations
The Board is asked to note the content of the report. Endorse the key action areas and
the work undertaken to date.
The Board will receive a further update at the end of Quarter 4.
Cathy Stone
Director of Nursing and Patient Safety
February 2014
10 To: Trust Committee
Date of Meeting: 27th February 2014
Agenda Item: 8
Title
Month 10, 2013/14 Performance Report
Responsible Executive Director
Jane Farrell, Chief Operating Officer/Deputy Chief Executive
Prepared by
Adam Creeggan, Director of Performance
Giles Frost, Head of Operational Planning and Performance
Status
Public Domain
Summary of Proposal
The purpose of this paper is to inform the Trust Board of organisational compliance against national and local key
performance metrics. The report summarises both in year and projected year end performance for Western Sussex
Hospitals NHS Foundation Trust, as detailed in dedicated performance scorecards relating to Quality Board indicators
aligned to the Quality Strategy, the Monitor Risk Assessment Framework, and when relevant, other efficiency
indicators. This paper describes performance on an exceptional basis determined by RAG rating, national significance,
or in year trend analysis.
Implications for Quality of Care
Describes Quality Outcome KPIs
Link to Strategic Objectives/Board Assurance Framework
Trust Strategic Theme B - Provide the highest possible quality of care to our patients. This we will do through focusing
on a range of measures to improve clinical effectiveness.
Trust Strategic Theme G - Ensure the sustainability of our organisation by exceeding our national targets and financial
performance and investing in appropriate infrastructure and capacity
Trust Strategic Theme F - Improve our performance against a range of quality, access and productivity measures
through the introduction and spread of best practice throughout the organisation.
Financial Implications
Describes KPIs linked to financial performance
Human Resource Implications
Describes KPIs linked to workforce
Recommendation
The Board is asked to: NOTE
Communication and Consultation
Not applicable
Appendices
Appendix 1: Key Performance Deliverables, Operational Performance Scorecard, Monitor Risk Assessment Framework
Scorecard.
1
Western Sussex Hospitals Trust – Performance Report for Trust Board
To:
Trust Committee
Date: 27th February 2014
From:
Jane Farrell, Chief Operating Officer/Deputy Chief
Executive
Agenda Item: 8
FOR INFORMATION
WSHFT PERFORMANCE REPORT: MONTH 10, 2013/14
1.
INTRODUCTION
1.1
This report summarises both in year and projected year end performance for Western Sussex
Hospitals NHS Foundation Trust, detailed in dedicated performance scorecards relating to:

The Monitor Risk Assessment Framework under which the Trust is performance
managed following authorisation as a Foundation Trust effective July 1st 2013.

1.2
Other efficiency indicators, where relevant.
This paper describes performance on an exceptional basis determined by RAG rating, national
significance, or in year trend analysis.
1.3
In addition to the performance exception narrative, each exception is examined in detail in the
Key Performance Deliverables section of this report. Each metric under review examines detailed
trending, prevailing cause and effect, and summarises recovery programme actions.
2.
SUMMARY PERFORMANCE
2.1
The Trust generated a Monitor Risk Assessment Framework score of 2 points in Month 10, with
C.difficile and non-admitted Referral to Treatment (RTT) being non-compliant in Month. The Trust
had 7 cases of C.difficile in January generating a cumulative volume of 51 cases against the
cumulative target for the end of Quarter 4 of 46 cases. Non admitted RTT compliance was
90.45% against a target of 95%. Under the Monitor Risk Assessment Framework a single month
of non-compliance triggers a compliance failure for the entire Quarter, however formal ‘exception
reporting’ is not triggered in a specific metric unless three consecutive quarters of noncompliance is reported in the same metric.
2.2
Key indicators of operational pressure during January include:
2
Western Sussex Hospitals Trust – Performance Report for Trust Board

10,334 A&E attendances compared to 10,303 in January 2013 (+0.3%): when
scrutinised by age group: there was a 3.5% increase in 65-84 years and a 9.2%
decrease in >=85 years January 2014 compared to January 2013.

4071 emergency admissions compared to 4004 in January 2013 (+1.7%): when
scrutinised by age group: there was a 7.8% increase in 65-84 years and a 3.4%
decrease in >=85 years January 2014 compared to January 2013

Delayed transfers of care were 2.8% for January 2014.
3.
PERFORMANCE EXCEPTIONS
3.1
A&E Compliance
3.1.1
The Trust was fully compliant in January with 95.49% of patients waiting less than four hours
from arrival at A&E to admission, transfer, or discharge, against a national target of 95%.
3.1.2
For context and comparison, national data for the period 30th December to the 2nd February
relating to Type 1 (Major A&E) departments shows compliance of 92.67%, therefore, WSHFT
operated 2.8% ahead of the national average during the month. Compliance for Surrey and
Sussex Area providers (excluding WSHFT) for the same period showed 92.82% for Type 1 A&E
attendances, with WSHFT reporting the third highest performance within the sector.
3.2
Cancer
3.2.1
Based on provisional data the Trust achieved compliance against all seven cancer metrics
relevant to WSHFT in January 2013. Data becomes finalised following upload to the Open Exeter
national database by all national providers, which must occur by the 25th working day following
completion of the reporting month.
3.2.2
As reported to the Board through 2013/14, compliance is set against sustained increases in
cancer demand. Referrals under the Cancer 2 week rule have increased by circa 30%, with a
significant element of this growth occurring in 2013/14. This referral pathway is only available to
GPs, and within national guidance the receiving provider organisation cannot refuse or
downgrade any referral received.
3.2.3
Comparing January 2014 with January 2013, the Trust saw 13% more patients following 2 week
referral, and 46% more patients completed first treatment. These increases in throughput far
outstrip planned increases in operational resources in 2013/14, and therefore present a critical
risk to sustained compliance across all cancer metrics.
3
Western Sussex Hospitals Trust – Performance Report for Trust Board
3.3
Referral to Treatment (18 Weeks)
3.3.1
The Trust maintained full compliance against admitted and incomplete aggregate RTT pathway
targets in January with 90.29% (2,497 of 2,761 completed pathways) and 92.06% (25,408 of
27,600 patients waiting) respectively.
3.3.2
The Trust did not achieve compliance against the non-admitted aggregate compliance target of
95%, reporting a value of 90.48% for the month (6,086 of 6,726 patients waiting).
3.3.3
Compliance failure is set against the context of significant variance against demand plans in
2013/14 as cited in Performance Reports throughout 2013/14. This is set against a historic
context of changing demand profiles and consequent growth in elective waiting lists since spring
2012. Waiting list reduction prior to that point had been supported by reduced demand via PCT
led GP referral peer review programme.
3.3.4
The first half of 2012/13 saw a return to higher referral levels and the waiting list grew as a result,
with the only exceptions being periods with recovery programmes supported by recourse to
capacity outside the Trust.
3.3.5
The 2013/14 contract embedded a GP referral plan aligned to the peer review volumes, which in
turn were recognised as aligning to the capacity available at the Trust. This plan has not been
achieved, and we have observed a range of up to 29.3% above plan levels in key specialties from
April to January 2014:

Total referrals from all sources are up by 2.1% on plan

Total referrals from A&E are up by 5.8% on plan (predominately orthopaedic
trauma)

Total referrals from GPs and MSK are up by 0.6% on plan

GP/MSK referrals to Orthopaedics are up 7.6% on plan

A&E referrals to Orthopaedics (trauma) are up 4.1% on plan

GP referrals to Ophthalmology are up 16.9% on plan

GP referrals to Respiratory Medicine are up 29.3% on plan

GP referrals to Cardiology are up 13.6% on plan

GP referrals to Dermatology are -16.5% below plan, contrary to the planned 60%
reduction in CWSCCG QIPP plans for 2013/14
3.3.6
Crude volume increases have been exacerbated by increase in urgency, and in 2013/14 there
has been a 10% increase in waiting list size, but a 10% reduction in patients waiting 0-4 weeks.
This change in profile is due to a 10% increase in patients admitted 0-4 weeks (35-45%), and a
2% increase in non-admitted in the same group, with a clear connect back the increases in
cancer demand referenced in section 3.3 of this paper.
4
Western Sussex Hospitals Trust – Performance Report for Trust Board
3.3.7
This change in waiting list distribution would compromise RTT delivery alone, but this effect has
been exacerbated by the volume increase in the waiting list. The combined effect of these factors
has been profound. Taking the specialty of Ophthalmology as an example:

In year demand has been 16.9% higher than plan, due in part to changes in
DVLA eyesight requirements for drivers changing the threshold for referral. In
addition, licensing of Lucentis injections for the treatment of macular
degeneration has also stimulated demand, however this cohort of patients require
urgent treatment and repeat injection 3 months after initial treatment, and are
therefore more resource intensive.

April to January the Trust has seen 6.2% more outpatient first attendances than
the same period of 2012/13, but the cumulative gap been referrals received and
patient seen has been -2343 in that period.

April to January the Trust has admitted 31.9% more patients than the same
period of 2012/13, but the cumulative gap been the number of patients listed for
surgery and those admitted seen has been -388. That gap has widened since
summer, and the cumulative gap from July is -526.

The result is the outpatient waiting list has increased from 1396 to 2378 (+70.3%)
since April, and the inpatient/day case list has increased from 459 to 1141
(+148.6%) since June.

Ophthalmology represents around 1 in 6 patients waiting electively at the Trust,
and due to the factors above the percentage of patients waiting over 18weeks
has increased from around 2% to 13%.

As part of the recovery actions introduced in the specialty, an additional 167
pathways were completed in January, of which 130 pathways were patients over
18 weeks. This essential mitigating action to prevent further waiting list
deterioration has generated an unavoidable reduction in aggregate non-admitted
compliance beyond the scope of the Trust to mitigate. To quantify; offsetting the
impact of the 130 additional >18 waiters in January would have required 1170
additional completions for patient waiting <18 weeks, which is set against a
context of c2500 completed across the entirety of the Trust per month.
3.3.8
Plans to recover sustainable aggregate compliance are well advanced and will be shared with
Trust Board as an addendum to the February Performance Report.
3.3.9
Supporting delivery of RTT compliance, the Trust remained fully compliant against the maximum
waiting time for diagnostic tests in January. No greater than 1% of diagnostic patients should wait
greater than 6 weeks for their test, and during January 0.85% of patients waiting for diagnostic
tests waited more than 6 weeks (48 of 5,851 patients).
3.4
Fractured Neck of Femur (#NOF) operation within 36 hours of admission.
5
Western Sussex Hospitals Trust – Performance Report for Trust Board
3.4.1
During January 90% of medically fit Fractured Neck of Femur patients were operated on within 36
hours of admission against a target of 90%.
4
RECOMMENDATION
4.1
The Board is asked to receive and note the notional score of 2 points against the Monitor
Compliance Framework for January 2013. Both non-compliant metrics will generate penalty
points for the formal Quarter 4 Monitor Compliance Framework assessment, therefore 2 points is
the minimum score that can be achieved for the period.
Adam Creeggan, Director of Performance
Giles Frost, Head of Operational Planning and Performance
19th February 2014
6
Western Sussex Hospitals Trust – Performance Report for Trust Board
Mark Dennis, Head of Information Services
t: 01903 285273 (ext 5273)
JANUARY 2014
Key Performance Deliverables Report
A&E 4‐hour waiting time target
Description / Comments / Actions
Target
Month
YTD
Projected O/T
95%
95.49%
96.22%
>95%
Patients can expect to be admitted, tranfered or discharged in 4 hours from arrival in A&E
Significant increase in underlying acuity observed in 2013/14
100%
Actions:
1. Enhanced discharge planning arrangements 2. Augmented patient flow arrangements in conjunction with external partners
3. Dedicated operational delivery plan in place under the leadership of the Chief Operating Officer
95%
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
Mar
Feb
Jan
90%
Cancer ‐ Two weeks from urgent GP referral to first appointment
Description / Comments / Actions
Target
Month
YTD
Projected O/T
93.0%
97.02%
98.09%
>93%
Patients can expect to be seen within 2 weeks following an urgent GP referral for suspected cancer. This target is part of the NHS and Monitor performance frameworks for 2011/12.
Significant increases in demand level observed in 2013/14. 100%
95%
90%
Actions:
1. Dedicated weekly action focused delivery meeting under the leadership of the Chief Operating Officer
2. Mitigation actions agreed with health partners including enhanced advice and guidance for GP's from WSHT consultant staff prior to referral, improved feedback mechanism for GP on appropirateness of referral, and real time access to referral data by GP practice, conversion to a cancer pathways and volumes recieving definative treatment for malignancy. 85%
80%
75%
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
Mar
Feb
Jan
70%
Cancer ‐ Two weeks from urgent GP referral to first appt ‐ Breast symptoms
Description / Comments / Actions
Target
Month
YTD
Projected O/T
93%
97.33%
97.90%
>93%
Patients with breast symptoms can expect to be seen within 2 weeks following an urgent GP referral.
Significant increases in demand level observed in 2013/14. 100%
95%
90%
Actions:
1. Dedicated weekly action focused delivery meeting under the leadership of the Chief Operating Officer
2. Mitigation actions agreed with health partners including enhanced advice and guidance for GP's from WSHT consultant staff prior to referral, improved feedback mechanism for GP on appropirateness of referral, and real time access to referral data by GP practice, conversion to a cancer pathways and volumes recieving definative treatment for malignancy. 85%
80%
75%
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
Mar
Feb
Jan
70%
Cancer ‐ 62 days from referral to treatment following screening contact
Target
Month
YTD
Projected O/T
90%
90.70%
92.74%
>90%
Description / Comments / Actions
Patients with cancer can expect to commence treatment within 62 days following referral after a positive screening test.
Delays in receipt of onward referral from screening which reduces the time to secure capacity to treat patients.
100%
95%
90%
85%
80%
75%
Actual
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
Mar
Feb
Jan
70%
Actions:
1. Transitional leadership for MDT/tracking passed to GM ‐ Access. 2. Augmented pathway management/tracking with enhanced oversight through DCS led Cancer Delivery Group
3. Close working with the screening service to maximise the time available to the Trust to secure capacity
4. Dedicated weekly action focused delivery meeting under the leadership of the Chief Operating Officer
Target
8b Key deliverables report M10_v2 (colour).Exception Report
Page 1 of 2
Printed 21/02/2014 08:47
Mark Dennis, Head of Information Services
t: 01903 285273 (ext 5273)
JANUARY 2014
Key Performance Deliverables Report
Cancer ‐ 62 days from referral to treatment following urgent referral by a GP.
Description / Comments / Actions
Target
Month
YTD
Projected O/T
85%
85.20%
86.65%
>85%
Patients with cancer can expect to commence treatment within 62 days following urgent referral by a GP.
Demand pressure exposing pathway efficiencies. Reduces the time to secure capacity to treat patients.
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
Mar
Feb
Jan
Actions:
1. Transitional leadership for MDT/tracking passed to GM ‐ Access. 2. Augmented pathway management/tracking with enhanced oversight through DCS led Cancer Delivery Group
3. Close working with the screening service to maximise the time available to the Trust to secure capacity
4. Dedicated weekly action focused delivery meeting under the leadership of the Chief Operating Officer
Referral to treatment ‐ Admitted patients
Description / Comments / Actions
Target
Month
YTD
Projected O/T
90.0%
90.29%
0.00%
> 90%
All patients can expect to commence treatment within 18 weeks of a referral to consultant. This standard continues to be monitored within the 2011/12 NHS Performance Framework.
An imbalance of demand and capacity has resulted in an increase in the backlog of patients waiting over 18 weeks. Detailed recovery options submitted to SECSHA, NHS Sussex and CWS CCG.
100%
95%
90%
Actions:
1. Short term increase in internal capacity
2. Additional capacity commissioned by CWSCCG in private sector
3. Further mitigation actions agreed with health partners including further roll of of enhanced triage 4. Dedicated weekly action focused delivery meeting under the leadership of the Chief Operating Office
85%
80%
75%
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
Mar
Feb
Jan
70%
Referral to treatment ‐ Non Admitted patients
Description / Comments / Actions
Target
Month
YTD
Projected O/T
95.00%
90.48%
0.00%
> 95%
All patients can expect to commence treatment within 18 weeks of a referral to consultant. This standard continues to be monitored within the 2011/12 NHS Performance Framework.
An imbalance of demand and capacity has resulted in an increase in the backlog of patients waiting over 18 weeks. Detailed recovery options submitted to SECSHA, NHS Sussex and CWS CCG.
100%
95%
90%
85%
80%
75%
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
Mar
Feb
Jan
70%
Actions:
1. Short term increase in internal capacity
2. Launch of Triage + to enhance orthopaedic referral routing to appropriate treatment options in LHE
3. Further mitigation actions agreed 14 August 2012 with health partners including further roll of of enhanced triage options in Colorectal Surgery, Gastroenterology and Upper GI surgery. 4. Dedicated weekly action focused delivery meeting under the leadership of the Chief Operating Office
% Medically fit hip fracture patients going to theatre within 36 hours
Description / Comments / Actions
Target
Month
YTD
Projected O/T
90%
90.00%
0.00%
>90%
To ensure the best possible outcomes, hip fracture patients who are medically fit should be operated on within 36 hours of admission. This standard is part of the 'Best Practice' payment process under PbR.
Increased levels of demand have impacted sustained compliance. Mitigating actions implemented by the Surgical Division have significantly improved performance.
100%
98%
96%
94%
92%
90%
88%
86%
84%
82%
80%
8b Key deliverables report M10_v2 (colour).Exception Report
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
Mar
Feb
Jan
Actions:
1. 60% increase in trauma capacity to mitigate demand pressure. 2. Improved tracking and escalation processes in place to manage fluctuations in demand on daily basis
3. Dedicated weekly action focused delivery meeting under the leadership of the Chief Operating Officer
Page 2 of 2
Printed 21/02/2014 08:47
Mark Dennis, Head of Information Services
t: 01903 285273 (ext 5273)
JANUARY 2014
OPERATIONAL PERFORMANCE
SCORECARD
PATIENT EXPERIENCE
O01
O02
O03
O04
O05
O06
O07
O08
Cancer: 2 week GP referral to 1st outpatient ‐ breast symptoms
Cancer: 31 day second or subsequent treatment ‐ surgery
Cancer: 31 day second or subsequent treatment ‐ drug
Cancer: 31 day diagnosis to treatment for all cancers
Cancer: 62 day referral to treatment from screening Cancer: 62 day referral to treatment from hospital specialist 2013/14
Target
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
JAN
FOT
94.00%
95.26%
97.65%
95.99%
97.78%
97.24%
97.44%
96.02%
95.54%
95.36%
96.06%
94.89%
95.49%
96.22%
95%
>95%
96.30%
97.41%
98.25%
96.89%
97.83%
97.34%
98.84%
98.42%
98.05%
99.17%
98.71%
98.12%
97.02%
98.09%
93%
>93%
96.08%
97.84%
96.84%
98.77%
97.69%
94.89%
98.88%
97.06%
100.0%
99.4%
95.9%
99.3%
97.3%
97.90%
93%
>93%
100.0%
100.0%
93.8%
100.0%
100.0%
97.06%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
94.1%
99.29%
94%
>94%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.00%
98%
100%
99.10%
97.75%
99.43%
99.48%
100.0%
100.0%
99.6%
96.4%
98.3%
99.6%
100.0%
100.0%
99.5%
99.27%
96%
>96%
89.80%
84.00%
96.77%
97.62%
89.36%
92.86%
97.67%
91.07%
89.66%
94.34%
92.45%
92.31%
90.70%
92.74%
90%
>90%
74.19%
76.00%
85.71%
77.78%
80.00%
92.86%
93.10%
75.00%
88.10%
96.00%
95.24%
100.0%
82.35%
87.60%
N/A
>85%
85%
>85%
Trend
NB
A&E : Four‐hour maximum wait from arrival to admission, transfer or discharge
Cancer: 2 week GP referral to 1st outpatient
Jan
2013/14 YTD
1
1
1
1
1
1
1
1
O09
Cancer: 62 days urgent GP referral to treatment of all cancers 83.94%
89.81%
91.11%
92.73%
87.13%
87.56%
85.66%
87.66%
84.76%
86.82%
87.50%
87.79%
85.20%
86.65%
O10
Number of complaints relating to staff attitude or behaviour/10,000 admissions
4.02
5.45
7.35
6.21
6.08
4.23
2.02
2.07
5.08
3.73
2.91
2.03
2.84
3.71
O11
Number of nursing complaints per 10,000 bed days
1.07
1.16
2.26
1.12
0.38
1.65
1.25
1.22
0.00
1.12
0.00
1.13
1.06
0.89
4.35
O12
RTT ‐ Admitted ‐ 90% in 18 weeks
90.19%
90.01%
90.04%
90.11%
90.22%
90.11%
90.12%
90.06%
90.88%
90.85%
90.27%
90.07%
90.29%
0.00%
90%
>90%
O13
RTT ‐ Non‐admitted ‐ 95% in 18 weeks
96.64%
97.28%
97.40%
96.43%
96.56%
96.90%
96.19%
96.28%
95.50%
95.46%
95.58%
95.17%
90.48%
0.00%
95%
>95%
O14
RTT ‐ Incomplete ‐ 92% in 18 weeks
92.27%
92.17%
92.91%
93.69%
94.34%
94.43%
94.39%
93.14%
93.13%
92.56%
92.31%
92.04%
92.06%
0.00%
92%
>92%
O15
RTT delivery in all specialties
9
9
6
4
5
3
7
9
10
9
12
16
0
8
0
0
O16
Diagnostic Test Waiting Times
0.22%
0.09%
0.39%
0.16%
0.86%
0.57%
1.21%
0.92%
0.65%
0.05%
0.32%
0.18%
0.86%
0.58%
<1%
<1%
O17
Cancelled operations not re‐booked within 28 days
1
6
1
2
2
0
0
0
0
0
1
0
1
6
‐
O18
Urgent operations cancelled for the second time
0
0
0
0
0
0
0
0
0
0
0
0
0
0
‐
O19
Mixed Sex Accommodation breaches
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
OUTCOMES
O20
Crude mortality (Trust‐wide) rate
4.13%
3.69%
4.10%
3.76%
3.18%
2.83%
3.51%
2.66%
2.80%
2.77%
2.81%
3.46%
3.79%
3.16%
3.24%
3.29%
O21
HSMR (Trust‐wide)
101.4
99.4
100.5
99.2
99.0
97.9
98.3
96.5
95.8
94.8
93.9
#N/A
#N/A
95.8
100
<100
O22
SMR #NOF
123.9
129.0
125.2
127.3
125.4
121.5
119.1
115.5
113.1
117.0
114.7
#N/A
#N/A
113.1
100
<100
O23
% hip fracture repair within 36 hours
96.9%
89.8%
86.9%
93.4%
90.5%
100.0%
92.1%
90.6%
100.0%
96.5%
95.0%
98.6%
90.0%
0.0%
90%
>90%
O24
Patients that have spent more than 90% of their stay in hospital on a stroke unit+
87.9%
79.3%
78.3%
78.2%
81.7%
76.6%
80.5%
80.0%
86.9%
76.8%
82.0%
83.8%
#N/A
80.5%
80%
>80%
68.4%
85.7%
70.0%
58.8%
75.0%
81.8%
29.2%
34.6%
70.0%
33.3%
60.9%
31.3%
42.1%
48.9%
60.0%
>60%
12.3%
12.6%
11.9%
11.7%
11.3%
12.4%
12.4%
12.5%
11.6%
12.0%
11.5%
12.2%
13.1%
12.3%
12.2%
>90%
O25
% Higher risk TIA patients scanned & treated within 24 hrs+
O26
30 day emergency readmissions
8c Operational performance scorecard M10_v3 (colour).SCORECARD
1
1
Page 1 of 2
Printed 21/02/2014 08:47
Mark Dennis, Head of Information Services
t: 01903 285273 (ext 5273)
JANUARY 2014
OPERATIONAL PERFORMANCE
SCORECARD
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
JAN
2013/14 YTD
2013/14
Target
18.89
13.90
17.30
17.87
11.12
14.87
15.47
11.37
16.20
16.84
12.13
15.40
15.59
14.76
15.41
< 12/13 baseline
FOT
Trend
SAFETY
O27
Number of reported patient falls per 10,000 bed days
O28
Incidence of C Diff.
5
4
9
13
5
7
2
7
3
3
2
2
7
51
46
46
O29
Incidence of MRSA
0
1
0
0
0
0
1
1
0
0
2
0
0
4
2
<2
O30
Number of prescribing‐associated incidents graded moderate or severe
1
0
0
0
2
1
0
0
0
0
2
0
0
5
8
<8
O31
Pressure Ulcer Incidence per 1000 occupied bed days
0.43
0.23
0.49
0.45
0.35
0.29
0.38
0.37
0.20
0.30
0.23
0.30
0.35
0.32
0.36
<0.36
95.03%
95.00%
94.01%
94.40%
95.23%
95.60%
0.00%
96.00%
96.51%
96.57%
96.36%
96.48%
96.06%
96.05%
95%
>90%
3.1%
2.7%
3.4%
3.9%
3.8%
3.2%
2.3%
2.3%
3.0%
2.6%
3.0%
2.3%
2.8%
3.0%
3.5%
<3.5%
4,002
3,638
4,005
3,863
3,876
3,668
3,804
3,849
3,798
4,006
3,919
4,218
4,071
39,072
<12/13
<11/12
O32
% inpatients assessed for VTE risk using national tool
2
BEING JOINED UP
O33
Delayed transfers of care
O34
Number of Emergency admissions
2
IMPROVEMENT
O36
Average length of stay ‐ Elective
3.28
3.03
3.43
3.04
3.27
3.16
3.06
3.05
2.99
3.05
2.96
3.58
2.73
3.09
3.72
3.6
O37
Average length of stay ‐ Non‐elective Surgery
5.48
5.77
5.03
5.22
5.58
5.21
5.60
5.22
5.33
5.35
5.06
5.88
5.35
5.39
6.07
6.0
O38
Average length of stay ‐ Non‐elective Medicine
7.92
8.01
7.87
8.02
8.01
7.90
7.63
7.37
7.23
7.86
7.36
7.49
7.68
0.00
7.80
7.8
O39
Day case surgery rate (BADS Directory source: Dr Foster)
84.10%
82.13%
81.85%
82.49%
81.71%
82.83%
81.80%
81.24%
82.00%
83.72%
#N/A
#N/A
#N/A
82.50%
75.0%
80%
O40
Elective day of surgery rate (DOSR)
95.6%
95.4%
96.4%
96.1%
96.5%
97.1%
97.0%
97.2%
96.4%
96.0%
96.6%
96.5%
97.3%
96.6%
90.0%
95%
O41
Did not attend rate (outpatients)
6.71%
6.26%
6.89%
6.25%
6.39%
6.31%
6.42%
6.63%
6.81%
6.78%
6.72%
7.15%
7.20%
6.61%
7.65%
6.0%
O42
HSCIC Data validity summary (YTD)
97.5
97.5
97.2
94.9
95.8
95.8
96.6
96.8
97.7
98.0
98.3
#N/A
#N/A
98.3
96.0
97.0
SUSTAINABILITY
O43
Bank staff ‐ % of all staff pay
‐
‐
‐
6.93%
4.54%
4.78%
6.35%
6.96%
6.11%
5.24%
5.41%
6.38%
4.79%
5.84%
7%
O44
Agency staff ‐ % of all staff pay
‐
‐
‐
2.70%
3.96%
3.84%
5.30%
4.81%
5.94%
5.73%
5.24%
4.76%
6.42%
4.61%
2%
O45
Nurse:bed ratio
‐
‐
‐
1.847
1.852
1.853
1.854
1.842
1.857
1.946
1.949
1.949
1.970
1.915
‐
O46
% nurses who are registered
‐
‐
‐
73.80%
73.93%
74.15%
73.85%
73.76%
73.62%
72.29%
73.65%
73.36%
72.58%
73.49%
‐
O47
% Staff appraised
87.42%
87.79%
85.14%
84.90%
86.70%
85.00%
81.56%
79.37%
79.41%
80.54%
80.50%
81.94%
82.43%
82.43%
95%
4.06%
3.70%
3.5%
3.64%
3.46%
3.43%
3.65%
3.73%
3.85%
3.90%
4.15%
3.81%
#N/A
3.74%
3.3%
8.80%
8.57%
8.54%
8.63%
8.48%
8.10%
8.12%
7.74%
7.63%
7.66%
7.48%
7.23%
7.24%
7.24%
11%
O48
Sickness Absence: % Sickness (reported one month in arrears)
O50
Staff Turnover: Turnover rate (YTD position)
3
Notes
1
National reporting for these performance measures is on a quarterly basis. Data are subject to change up to the final submission deadline due to ongoing data validation and verification. 2
Data are provisional best estimates and will be amended to reflect the position signed‐off in the relevant statutory returns in due course. 3
Staff sickness is reported one month in arrears. 8c Operational performance scorecard M10_v3 (colour).SCORECARD
Page 2 of 2
Printed 21/02/2014 08:47
Mark Dennis, Head of Information Services
t: 01903 285273 (ext 5273)
JANUARY 2014
Monitor Risk Assessment Framework
Threshold
Apr
May
Jun
Q1
Weighted
Score
90%
90.11%
90.22%
90.11%
90.15%
0.0
90.12%
90.06%
90.88%
90.35%
0.0
90.85%
90.27%
90.07%
90.40%
0.0
95%
96.43%
96.56%
96.90%
96.63%
0.0
96.19%
96.28%
95.50%
95.99%
0.0
95.46%
95.58%
95.17%
95.40%
92%
93.69%
94.34%
94.43%
94.16%
0.0
94.39%
93.14%
93.13%
93.55%
0.0
92.56%
92.31%
92.04%
95%
95.99%
97.78%
97.24%
97.01%
0.0
97.44%
96.02%
95.54%
96.36%
0.0
95.36%
96.06%
85%
92.73%
87.13%
87.56%
88.96%
85.66%
87.66%
84.76%
85.19%
86.82%
87.50%
Jul
Aug
Sep
Q2
Weighted
Score
Oct
Nov
Dec
Q3
Weighted
Score
Jan
Q4
Weighted
Score
90.29%
90.29%
0.0
0.0
90.48%
90.48%
1.0
92.30%
0.0
92.06%
92.06%
0.0
94.89%
95.43%
0.0
95.49%
95.49%
0.0
87.79%
87.08%
85.20%
85.20%
90.70%
90.70%
94.12%
94.12%
100.00%
100.00%
99.54%
99.54%
97.02%
97.02%
97.33%
97.33%
Feb
Mar
ACCESS
M1
M2
M3
M5
M6a
M6b
M7a
M7b
Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted
Maximum time of 18 weeks from point of referral to treatment in aggregate – non‐admitted
Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway
A&E: maximum waiting time of four hours from arrival to admission/transfer/discharge
All cancers : 62‐day wait for first treatment following urgent GP Referral
All cancers : 62‐day wait for first treatment following consultant screening service referral
All cancers : 31‐day wait for second or subsequent treatment ‐ surgery
treatments
All cancers : 31‐day wait for second or subsequent treatment ‐ drug treatments
0.0
90%
97.62%
89.36%
92.86%
93.57%
94%
100.00% 100.00% 97.06%
98.92%
0.0
97.67%
91.07%
89.66%
92.17%
98%
100.00% 100.00% 100.00% 100.00%
M8
All cancers : 31‐day wait from diagnosis to first treatment
96%
99.48% 100.00% 100.00% 99.84%
M9a
Cancer : two week wait from referral to date first seen ‐ All patients
93%
96.89%
M9b
Cancer : two week wait from referral to date first seen ‐ Symptomatic breast patients
97.83%
97.34%
0.0
99.59%
96.35%
98.26%
98.21%
98.84%
98.42%
98.05%
98.46%
0.0
98.77%
97.69%
94.89%
97.25%
92.45%
92.31%
93.23%
100.00% 100.00% 100.00% 100.00%
0.0
100.00% 100.00% 100.00% 100.00%
97.37%
93%
94.34%
100.00% 100.00% 100.00% 100.00%
0.0
0.0
0.0
100.00% 100.00% 100.00% 100.00%
0.0
99.63% 100.00% 100.00% 99.86%
99.17%
98.71%
98.12%
97.06% 100.00%
98.53%
0.0
98.68%
0.0
98.88%
0.0
0.0
0.0
99.44%
95.88%
99.27%
98.14%
0.0
0.0
OUTCOMES
M17
Clostridium Difficile – meeting the Clostridium Difficile objective
46
13
5
7
25
1.0
2
7
3
12
1.0
3
2
2
7
1.0
7
7
1.0
M18
MRSA – meeting the MRSA objective
0
0
0
0
0
0.0
1
1
0
2
0.0
0
2
0
2
see note i
0
0
see note i
M27
Certification against compliance with requirements re access to healthcare for people with a learning disability
YES
YES
YES
YES
YES
0.0
YES
YES
YES
YES
0.0
YES
YES
YES
YES
0.0
YES
YES
0.0
Monitor Compliance Framework Score
1.0
Green : 0 1.0
Amber/Green : 1
Amber : 2
1.0
Amber/Red : 3
2.0
Red : 4 or more
Notes
i From 1 October 2013 MRSA was removed from the Monitor Risk Assessment Framework
8d Monitor scorecard M10_v3 (colour).SCORECARD
Page 1 of 1
Printed 21/02/2014 08:48
WESTERN SUSSEX HOSPITALS NHS FOUNDATION TRUST
To: Board
Date of Meeting: 27th February 2014
Agenda Item:9
Title:
Report on Organisational Development and Workforce performance
Responsible Executive Director
Denise Farmer, Director of OD and Leadership
Prepared by
Claire Castle, Workforce Manager
Status
Disclosable
Summary of Proposal
The report describes the organisations performance against the delivery of the Workforce and OD
strategies
Implications for Quality of Care
Supports the delivery and sustainability of safe, high quality care through investment in the
development of the workforce and a culture of staff engagement
Financial Implications
Supports good financial performance
Human Resource Implications
As described
Recommendation
The Board is asked to NOTE the report
Consultation
n/a
Appendices
Workforce data report
Update on Customer Care programme
This report can be made available in other formats and in other languages. To discuss your requirements please
contact Graham Lawrence, Company Secretary, on [email protected] or 01903 285288.
To: Trust Board From: Denise Farmer, Director of Organisational Development and Leadership Date: 27th February 2014 Agenda Item: 9 FOR [INFORMATION] 1.0
1.01 ORGANISATIONAL DEVELOPMENT AND WORKFORCE REPORT INTRODUCTION This sets out the key performance indicators relating to the Trust’s workforce and organisational development at 31st January 2014. 2.0 SUMMARY OF PROPOSAL 2.01 Workforce Capacity The total workforce capacity used during January continued to exceed 100% of budgeted establishment, specifically within the Medicine Division. The data for the Corporate Division is skewed due to recharges related to Deanery funding Whilst the number of substantive staff rose in month by 46.2 wte and the number of staff in post has increased by 214 wte since January 2013 activity remains high with escalation beds remaining open. This, along with nurse vacancies, has led to continued heavy reliance on temporary staffing. As reported last month, the supply of bank and agency staff fell over December. In response a bank recruitment day was held on 24th January where a total of 59 staff were recruited, 51 of which were Healthcare Assistants and eight Registered Nurses. Further bank recruitment days are planned to take place on a quarterly basis. In addition, a pool of bank staff is currently being set up in Medicine, which offers flexibility in deploying bank staff to fill gaps on a daily basis and offers existing staff the ability to fix their shifts. In order to reduce the number of qualified nurse vacancies (particularly in Medicine) an overseas recruitment campaign took place at the beginning of February and has resulted in 31 nurses being offered positions in the Trust. Further Skype and face‐to‐face interviews with more Spanish nurses are due to be held over 18th – 21st February. 2.02 Workforce Efficiency Sickness absence at the end of December was 3.8%, a decrease from the previous month. A decrease was seen across all divisions apart from Facilities and Estates where there was an increase of 0.1% (to 6%). As sickness absence remains high across the Trust divisions, working closely with the HR team, are focusing on ensuring this is being managed effectively. Turnover across the Trust continues to remain at below 8% with the Corporate and Core Divisions remaining as outliers. Corporate directorates saw turnover increase in January by 0.3% to 11.2%, whereas turnover fell in Core by 0.8% to 9.6%. Appraisal levels in month increased to 82.4% at the end of January. Within the Medicine and Corporate divisions there was a marked improvement of 2.8% and 3.2% respectively. Appraisal rates fell however within Surgery and Women and Child Health by 3.8% and 2.1% respectively. 2.03 2.04 2.05 Real time Staff Feedback The number of staff participating in the Family and Friends tests reduced further during January due to reduced training numbers during this period. Service changes Divisional Restructuring – A consultation is underway to change the operational management structure. The aim of the change is to reflect and support the Clinical Leadership structure and help to deliver better integration of the quality, safety and performance agendas which will help us progress the development of a more Business Unit focus. Consultation commenced for a 30 day period and ends on 25th February. We do not anticipate redundancies as a result of the proposed change. Pharmacy Pre‐Pack service – Following the Boards decision to cease providing this service ‘in house’, the Pharmacy pre‐packing unit at Southlands will close once alternative arrangements for supply are in place. There are eight members of staff currently affected by this change: there is the potential for some redundancies should redeployment not be possible. Bowel Screening – As part of the Western Sussex Bowel Cancer Screening Programme, two Specialist Screening Practitioners (SSP) will be transferring under TUPE arrangements to WSHFT from BSUH and Portsmouth Hospitals on 1st April to support the new programme. Developing a culture of care and compassion The Trust is currently piloting a new values based recruitment and selection process designed to ensure that we recruit a skilled workforce with the right attitudes and behaviours to deliver the Trusts vision “We Care”. Following shortlisting, candidates invited to interview are asked to complete a short on‐line questionnaire, the purpose of which is to reinforce our expectations to candidates and to supplement the informational available when making decisions to recruit staff. The toolkit offers psychometric profiles that assess the likely behaviours of each applicant and produces a profile report which highlights key strengths and areas of challenge linked to key skills such as empathy; communication; dealing with challenging behaviour etc. Feedback to date has been positive from areas that have used the tool to enhance the recruitment and selection process of staff. Once evaluated, we expect to roll out some form of values based recruitment as part of the process for all staff. A summary of other activity in relation to improving the experience of patients is attached for information. We are in the process of developing the business case for the roll out of the programme in 2014/15. Page 2 of 4
2.06 2.07 Senior Appointments The Trust is currently seeking to recruit two Non‐Executive Directors (NEDs). The advertisement closes on 2nd March and interviews are scheduled to take place on 31st March and 1st April. Selection to the Director of Clinical Services post for Surgery is scheduled to take place on 24th/25th February. Workforce Skills and Development Statutory and Mandatory Training Attendance on all of the core statutory and mandatory training has achieved or exceeded the Trust target of 90% and rates as at 31st January are shown on the attached data report. Adult Protection is a recent addition to the statistics and is still slowly increasing. Attendance is at 75.8% (an increase of 0 .3% since last month.) Additional stand‐alone courses have been organised to improve the position. The current high rates of recruitment, resulting in up to 120 new starters per month, is creating a significant pressure, particularly for the large number of Trust ‘Subject Matter Experts’ who deliver the training at induction. This increase is also causing challenges in finding sufficient large training room, especially on the Worthing sites and external venues are being used to host some of the training. Apprentices A Pilot group of 10 Apprentice HCAs started in January across the Medicine Division on 58 week contracts. A total of 33 apprentices have been appointed since March 2013. Work Experience Two Work Experience weeks for years 10 and 11 will take place at St Richard’s Hospital in March and Worthing Hospital in July. Local schools have been asked to submit applications and initial indications are that the demand will be high. 2.08 2.09 3.0 Staff Survey 2013 NHS England published the staff survey results for all Trusts in England on 25th February. A verbal update will be given to the Board. Equality and Diversity A separate report is available, detailing the outcomes of the 3rd Annual Equality & Diversity Monitoring Report. This paper has been ratified by the Diversity Matters Group and highlights how representative of the local area the Trust’s staff and patients are and how the Trust is performing with regard to each of the protected characteristics shown in the Equality Act 2010. Communications and Engagement The BBC News Channel spent two days at the Trust in February, filming in the A&E department at St Richard’s. The result was a combination of pre‐recorded and live interviews which were Page 3 of 4
broadcast throughout 7th February on the BBC’s 24‐hour rolling news channel, and as part of news bulletins elsewhere on the network. The filming was part of the BBC’s NHS Winter project. Trust staff explained why they work in A&E, and why the Trust has been able to perform so well in terms of hitting national waiting time targets, generating strong feedback from the Friends and Family Test, and how they work with local partners – through the One Call One Team initiative – to ensure that patients get the best possible unscheduled care. Staff from our partner organisations, including West Sussex Clinical Commissioning Group, Sussex Community Trust and South East Ambulance also took part. The BBC has created a Facebook page for the NHS Winter project, including many of the pre‐
recorded interviews they conducted with our colleagues, and we have also put many of their posts onto our own page, at www.facebook.com/WesternSussexHospitals. We would like to thank the team in A&E, Laura Robertson from Coastal West Sussex CCG and other partners who took part as well as Dr Amanda Wellesley, A&E Consultant and Clinical Director for Emergency Medicine and Nicholas Brooks from the Communications team for making it such a success. 3.01 3.02 3.03 3.04 A Stakeholder Forum meeting was held this month and included an update on dementia care, information about our inpatient survey and a talk on the new technology used in outpatients. There was also a very useful breakout session about our Sit and See project. Our next Medicine for Members event is on the topic of Stroke ‐ treatment, care and support ‐ and is being presented by Consultant Physician, Dr Rajen Patel on Tuesday 18th March, 2pm ‐ 4pm in the Boardroom at Worthing Hospital. The event will be videoed and available on our website. To book a place please email [email protected] or call 01903‐205 x85140. The first meeting of the Trust’s new Membership Committee took place on 6th February and included staff and public Governors. The committee discussed the current membership strategy, membership profile and current engagement activities as well as plans for future and further engagement. Governors are very keen to engage with the public and staff that they represent and we will be developing a programme, incorporating Medicine for Members events to support them in doing that. The second annual audit of staff communications has also been launched this month focusing on the effectiveness of Trust Brief, the Trust’s method for cascading news and information. It is anticipated that a report with the findings of the audit will be provided to the Board in the Spring. 4.0 RECOMMENDATION[S] The Board/Committee is asked to NOTE the report Page 4 of 4
Western Sussex Way – Progress Update
February 2014
Following agreement by the Trust board in November 2013 to commission a pilot phase of the
Western Sussex Way (Customer Care Initiative) an implementation strategy for the Western Sussex
Way has been set out and agreed by the Improving Customer Care Working Group.
The strategy sets out the key strands for delivering the culture change element of the Customer
Care programme:





Recruitment and Selection
Training and Development
Structured support for Cultural Change
Specific Customer Care Initiatives
Communication
The following achievements have been made:
Recruitment and Selection

A values based recruitment tool (led by HR) has begun pilot phase with initial feedback
being positively received. Small group trials are currently underway. Training will then
be given to those involved in the recruitment and interviewing process to provide support
around the use of the tool.
Training and Development

The redesign of Trust Induction is underway with Subject Matter Experts in support of
proposals and draft format.The plan consists of reducing Induction to a single day
conference format with a Trust branded resource pack and dynamic delivery approach
which places an emphasis on the role all staff play in improving customer service and the
Trust’s ‘We Care’ Values.

Successful identification of three pilot groups for delivery of the Western Sussex Way to
existing teams:
o Recruitment and Learning & Development teams
o Ophthalmology
o Outpatients Reception
Dates have been set for delivery in March and April, training plans and area specific content
has been designed and resource development is currently underway. Agreed format will
consist of a 3.5 hour delivery model supported by a resource pack.
Structured Support for Cultural Change

An initial ‘navigator’ group has been successfully established with 20 navigators self
nominating or nominated by their line managers. The group has met to establish the
expectations of the role, these are:
o
o
o
o
o
Acting as facilitators in a team or area for the Western Sussex Way (Customer Care
Training)
Supporting new staff into their area as part of local Induction
Responsibility for promoting, recognising and celebrating good practice in their area.
Cross group support for other Navigators
Acting as a role model to others.
Further nominations are already being received and areas currently not represented have
been approached to ask for nominations.
Specific Customer Care Initiatives
Current projects to develop specific areas of customer care support currently include:




‘Host Role’ pilot to identify the benefits of a meet and greet service at first point of contact
when entering a ward environment. This pilot consists of a two week pre pilot questionnaire
to support a baseline of response from visitors. The two questions asked are:
o ‘How would you rate your welcome when you arrived on the ward today?’
o ‘Did the welcome you received make a difference to how you felt about the ward?’
This will be followed by two weeks of colleagues giving volunteered time (30 to 60 minutes)
during visiting times to specifically meet and greet patients, visitors and colleagues as they
enter the ward. The same two questions will be asked during this pilot period.
Breast Centre Call Handling – Following concerns raised from patients related to length of
call waiting when contacting the Breast Centre along with misdirected calls, a multi
disciplinary team has successfully implemented changes in the way patients are asked for
information by switchboard and also how calls are handled when they come through to the
Breast Care Centre along with an answerphone service to back up these two approaches.
New Breast Care Centre signage and information – Following feedback from patients
arriving at the old breast care centre by mistake, a multidisciplinary groups has worked to
ensure information sent to patients contains increased awareness of the new Breast Care
Centre location. In addition Communications and facilities and Estates have increased
signage to direct patients to the new centre but also to place signage before patients enter
the wrong car park directing them to the new centre.
Removing Barriers – the layout of the Brooklands Wards reception area prevents staff from
welcoming patients, visitors and others onto the wards, making immediate first contact less
likely and not allowing staff to greet and support visitors. The removal of one small section
of wall would allow for the reception areas to be easily redesigned and greatly increase
opportunities for good customer care. Facilities and Estates have worked with Brooklands
ward to identify this work as a Capital Project.
Communication
The Communications department has begun work on branding for the ‘Western Sussex Way’ in
preparation for a Trust wide launch once pilot phases have been successfully completed. Work is
also underway in the redesign of video resources to support the Trusts ‘We Care’ values and will
include content on patient experience and customer care.
Key performance Indicators
1) WORKFORCE CAPACITY
WC‐BF
Total FTE Used
WC‐VB
Total FTE Used Variance from Budget
WC‐TV
Total FTE Used Vacancy Factor
WC‐SF
Substantive Contracted FTE
WC‐SV
Substantive FTE Used Vacancy Factor
WC‐BP
Bank Usage As % Of Total FTE Used
WC‐AP
Agency Usage As % Of Total FTE Used
2) WORKFORCE EFFICIENCY
WE‐SA
In Month Sickness Absence %
WE‐ML
In Month Maternity Leave %
WE‐OA
In Month Other Absence %
WE‐TA
In Month Total Absence %
WE‐LT
% Total Sickness Days Lost Due To Long Term Sickness Absence (28 Days Or More)
WE‐SR
% Of Total Sickness Attributed To Stress
WE‐MS
% Of Total Sickness Attributed To Musculo Skeletal
WE‐RT
Rolling 12 Month Turnover
40
January 2014
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
JAN
2013/14 YTD
2013/14
Target/ Ceiling
5995.8
5995.8
5988.8
6038.0
6038.8
6041.6
6134.2
6136.7
6134.6
6155.8
6159.5
6171.7
6173.4
6118.4
N/A
N/A
5954.9
6058.2
6052.7
6002.2
5880.5
5928.0
6142.3
6016.5
6124.7
6181.8
6189.7
6192.5
6235.2
6089.3
N/A
N/A
‐40.9
62.4
63.9
‐35.8
‐158.3
‐113.7
8.1
‐120.1
‐9.9
26.0
30.3
20.8
61.8
N/A
N/A
N/A
Amber Limit
NB
Budgeted FTE
WC‐FU
16
x
WSHT WORKFORCE SCORECARD
1
1
1
1
1
0.7%
‐1.0%
‐1.1%
0.6%
2.6%
1.9%
‐0.1%
2.0%
0.2%
‐0.4%
‐0.5%
‐0.3%
‐1.0%
0.5%
N/A
N/A
5425.1
5448.1
5426.4
5434.2
5440.6
5442.0
5446.8
5461.3
5507.2
5548.7
5568.7
5593.7
5639.9
5508.3
N/A
N/A
9.5%
9.1%
9.4%
10.0%
9.9%
9.9%
11.2%
11.0%
10.2%
9.9%
9.6%
9.4%
8.6%
10.0%
N/A
N/A
6.8%
7.8%
8.2%
8.3%
5.5%
6.0%
9.0%
6.4%
7.5%
7.4%
7.5%
7.4%
6.4%
7.1%
N/A
N/A
2.1%
2.3%
2.1%
1.2%
2.0%
2.2%
2.4%
2.9%
2.6%
2.8%
2.6%
2.3%
3.1%
2.4%
N/A
N/A
4.2%
3.9%
3.6%
3.8%
3.5%
3.4%
3.6%
3.7%
3.8%
3.9%
4.1%
3.8%
3.7%
3.3%
3.3%
2.6%
2.6%
2.5%
2.4%
2.4%
2.3%
2.4%
2.5%
2.5%
2.4%
2.5%
2.5%
2.4%
N/A
N/A
0.8%
1.0%
1.1%
1.1%
1.1%
1.1%
1.1%
0.8%
1.2%
1.4%
1.4%
0.9%
1.1%
N/A
N/A
NB
2
2
2
2
2
7.6%
7.4%
7.2%
7.3%
6.9%
6.8%
7.1%
7.0%
7.5%
7.8%
8.1%
7.2%
7.3%
N/A
N/A
47.8%
48.4%
50.2%
51.4%
51.3%
41.8%
46.9%
51.1%
50.3%
46.9%
43.3%
48.4%
47.9%
N/A
N/A
10.8%
13.4%
15.6%
15.7%
16.5%
15.1%
18.8%
20.8%
15.9%
9.5%
12.0%
12.1%
15.1%
N/A
N/A
19.7%
18.7%
18.3%
16.4%
21.4%
21.3%
20.3%
18.8%
20.7%
18.7%
19.1%
19.8%
8.8%
8.6%
8.5%
8.6%
8.5%
8.1%
8.1%
7.7%
7.6%
7.7%
7.5%
7.2%
19.6%
N/A
N/A
7.2%
N/A
11.0%
11.0%
3) TRAINING AND PERSONAL DEVELOPMENNB
TD‐AP
% Appraisals Up To Date
TD‐MP
% In Date ‐ All Mandatory Training
TD‐FP
% In Date ‐ Fire
85.5%
85.3%
86.0%
88.0%
87.8%
89.7%
88.8%
88.2%
87.5%
88.4%
TD‐IC
% In Date ‐ Infection Control
87.1%
86.8%
84.3%
86.4%
86.7%
88.3%
87.3%
88.0%
87.9%
88.3%
TD‐BT
% In Date ‐ Role Specific Back Training
87.5%
86.5%
90.1%
91.7%
91.9%
92.9%
92.5%
92.5%
92.7%
92.2%
TD‐CP
% In Date ‐ Child Protection
95.4%
95.2%
95.2%
95.6%
95.2%
96.1%
95.6%
95.7%
95.5%
96.0%
TD‐IG
% In Date ‐ Information Governance
85.1%
85.0%
85.7%
TD‐AP
% In Date ‐ Adult Protection
4) REAL-TIME STAFF FEEDBACK
SF‐TR
SF‐Q1
SF‐Q2
3
87.4%
87.8%
85.1%
84.9%
85.7%
85.0%
81.6%
79.4%
79.4%
80.5%
80.5%
81.9%
82.4%
N/A
90.0%
80.0%
78.8%
77.7%
76.7%
79.8%
80.4%
82.2%
81.9%
81.3%
81.3%
81.9%
83.6%
84.5%
85.7%
N/A
90.0%
80.0%
89.2%
90.0%
90.9%
N/A
90.0%
80.0%
89.2%
90.1%
90.7%
N/A
90.0%
80.0%
92.9%
93.2%
94.2%
N/A
90.0%
80.0%
96.6%
96.9%
97.3%
N/A
90.0%
80.0%
3
87.5%
89.3%
88.4%
87.9%
87.4%
88.3%
89.1%
89.8%
90.6%
N/A
90.0%
80.0%
76.1%
75.0%
73.6%
73.8%
73.9%
74.4%
75.1%
75.5%
75.8%
N/A
90.0%
80.0%
NB
Total Respondents To Survey
% Respondents who would recommend this trust as a place to work % Respondents happy with standard of care if a friend or relative needed treatment
87.7%
75.8%
4
4
59
39
52
58
68
127
177
127
214
136
180
42
27
1156
N/A
N/A
72.9%
82.1%
82.7%
75.9%
76.5%
85.8%
77.4%
89.0%
80.4%
79.4%
78.3%
69.0%
74.1%
80.0%
N/A
N/A
79.7%
79.5%
84.6%
75.9%
75.0%
81.1%
81.4%
83.5%
79.4%
82.4%
82.8%
81.0%
74.1%
80.7%
N/A
N/A
Notes
1
Bank FTE used figures are not available for April and May and been approximated as follows: Monthly Bank Spend / June Average Cost Per Bank FTE
2
Absence data is available one month in arrears
3
Adult Protection is not currently included in the criteria when determining whether an employee is up to date with their mandatory training
4
% of staff who responded "Agree" or "Strongly Agree" to the question
Trend
To: Board of Directors
Date of Meeting: 27th February 2014
Agenda Item: 10
Title
Financial Performance Report (Month 10)
Responsible Executive Director
Karen Geoghegan, Director of Finance
Prepared by
Chris Nevell, Assistant Director of Finance
Status
Confidential
Summary of Proposal
The financial position for January is a surplus of £373k and a year to date surplus of £522k, after
adjustment for technical items.
The Trust’s Continuity of Services risk rating under Monitor’s Risk Assessment Framework is 3,
consistent with last month.
Implications for Quality of Care
Not applicable
Link to Strategic Objectives/Board Assurance Framework
G1: Maintain an acceptable Financial Risk Rating
Financial Implications
Financial Performance Report
Human Resource Implications
Not applicable
Recommendation
The Board is asked to note the financial performance report for January 2014.
Communication and Consultation
Not applicable
Appendix
1: Capital Programme
-1-
To:
Date: 27th February 2014
Board of Directors
From: Karen Geoghegan, Director of Finance
Agenda Item:10
FOR DECISION
Financial Performance Report
1
Introduction
1.1.
The Board is presented with the Trust’s financial performance for January 2014.
2
Summary
2.1.
The financial position for January is a surplus of £373k and a year to date surplus of
£522k, after adjustment for technical items. The Trust is forecasting a £1.023m surplus at
year-end.
2.2.
The position by division is shown below:
Annual
Budget
£000s
Income
Pay
Non-Pay
EBITDA
Budget
£000s
In Month
Actual
£000s
Variance
£000s
Budget
£000s
Year to Date
Actual
£000s
Variance
£000s
Forecast
£000s
374,728
(240,788)
(105,253)
28,687
32,532
(20,331)
(8,746)
3,456
33,457
(21,322)
(10,299)
1,836
925
(991)
(1,553)
(1,620)
313,124
(200,591)
(86,654)
25,878
315,719
(205,814)
(92,276)
17,628
2,595
(5,223)
(5,622)
(8,250)
378,028
(245,799)
(109,441)
22,788
(23,487)
(1,957)
(1,547)
410
(19,573)
(18,050)
1,523
(22,627)
Retained Surplus/(Deficit)
5,200
1,499
289
(1,209)
6,306
(421)
(6,727)
161
Donated asset accounting
Impairment accounting
Control Total Performance
0
0
5,200
0
0
1,499
84
0
373
84
0
(1,125)
0
0
6,306
(129)
1,072
522
(129)
1,072
(5,784)
(210)
1,072
1,023
Non-Operating Items
2.3.
The cash position remains an on-going risk. Cash is lower than planned due to a
combination of lower cash savings being realised from the cost improvement programme
and delays in receiving payment for over-performance from NHS England.
2.4.
The Trust is achieving a Continuity of Services risk rating of 3, with performance against
the individual components as show in the table below.
Year to Date
Liquidity ratio rating
Capital servicing capacity
Plan
3
3
Actual
3
3
3
Recommendation
3.1.
The Board is asked to note the financial performance report for January 2014.
-2-
4
Financial Performance
4.1.
The following table shows the income and expenditure account for January 2014.
Annual
Budget
£000s
Income
Income from Activities
Other Income for Patient Care
Education Training and Research
Other Operating Income
Total Income
In Month
Actual
£000s
Budget
£000s
Variance
£000s
Year to Date
Actual
£000s
Budget
£000s
Variance
£000s
326,783
8,378
18,002
21,565
374,728
28,528
717
1,504
1,784
32,532
29,536
847
1,532
1,542
33,457
1,008
130
28
(242)
925
273,506
6,945
15,004
17,669
313,124
275,948
6,445
15,439
17,886
315,719
2,442
(499)
435
217
2,595
Pay
Medical Staff
Nursing Staff
Professions Allied to Medicine
Professional and Technical Staff
Admin and Managerial Staff
Estates Staff
Agency Staff
Other Pay Costs
Total Pay Costs
(66,667)
(95,499)
(18,024)
(16,381)
(33,308)
(15,420)
(486)
4,997
(240,788)
(5,674)
(8,129)
(1,552)
(1,377)
(2,797)
(1,291)
(23)
512
(20,331)
(5,516)
(7,588)
(1,459)
(1,303)
(2,818)
(1,268)
(1,370)
(55,565)
(79,243)
(15,066)
(13,650)
(27,779)
(12,848)
(414)
3,973
(200,591)
(53,135)
(74,830)
(14,179)
(12,978)
(27,622)
(12,586)
(10,484)
(21,322)
158
541
93
73
(21)
23
(1,347)
(512)
(991)
(205,814)
2,430
4,414
887
672
157
261
(10,070)
(3,973)
(5,223)
Non-Pay
Drugs
Clinical Supplies and Services
General Supplies and Services
Establishment Expenses
Premises Costs
Services from NHS Bodies
Services from Non NHS Providers
Other Operating Costs
Total Non-Pay Costs
(26,824)
(34,649)
(3,783)
(6,962)
(15,466)
(9,963)
(1,811)
(5,796)
(105,253)
(2,234)
(2,943)
(317)
(575)
(1,306)
(828)
(145)
(398)
(8,746)
(2,798)
(2,994)
(441)
(587)
(1,732)
(914)
(187)
(646)
(10,299)
(565)
(51)
(123)
(12)
(425)
(85)
(42)
(249)
(1,553)
(22,387)
(28,763)
(3,142)
(5,754)
(12,825)
(8,306)
(1,447)
(4,030)
(86,654)
(24,969)
(28,453)
(3,559)
(5,780)
(13,214)
(8,240)
(1,745)
(6,315)
(92,276)
(2,582)
310
(417)
(27)
(390)
66
(298)
(2,284)
(5,622)
28,687
3,456
1,836
(1,620)
25,878
17,628
(8,250)
(14,986)
(1,249)
(1,123)
(55)
126
(55)
(12,489)
(1,029)
(86)
(623)
(1,957)
17
4
319
410
(857)
(7,472)
(23,487)
(69)
4
(304)
(1,547)
(6,227)
(19,573)
(10,583)
91
(1,072)
(778)
40
(5,748)
(18,050)
1,906
91
(1,072)
80
40
479
1,523
5,200
1,499
289
(1,209)
6,306
(421)
(6,727)
(1,048)
1,048
0
0
(87)
87
84
84
87
(3)
84
(873)
873
0
(970)
841
(129)
1,072
(96)
(32)
(129)
1,072
5,200
1,499
6,306
522
(5,784)
EBITDA
Non Operating Items
Depreciation and Amortisation
Profit/(Loss) on Disposal
Impairment of fixed assets
Finance Costs
Interest Receivable
Public Dividend Capital Dividend
Total Non-Operating Items
Net Surplus/(Deficit)
Add back:
Donated Asset Income
Donated Asset Depreciation and Amortisation
Impact of Donated Asset Accounting
Impairment of Fixed Assets
Performance against Control Total
4.2.
0
373
(1,125)
The run rate of operational expenditure increased significantly in the month. This was due
to the operational pressures of winter, leading to a rise in non-elective admissions and the
need to open additional capacity. This increase in operational expenditure means that
delivering the forecast surplus will be a significant challenge.
-3-
4.3.
Income: Income from activities reflects the current activity and contractual position.
4.4.
Other income for patient care includes a favourable variance on private patient income in
the Chichester Suite (£213k) offset in part by lower private patient imaging income (£23k)
and lower RTA income than budgeted (£55k).
4.5.
The adverse variance on other operating income includes a lower recharge on work
performed at Bognor War Memorial Hospital (£60k) and there being no donated asset
credits in month (£87k), although the latter is excluded from the Trust’s control total.
4.6.
Pay: Pay budgets were exceeded by £991k in month (December: £423k, November:
£902k), with agency costs incurred to cover vacancies.
4.7.
The following table reallocates year to date agency costs reported in the income and
expenditure account (section 4.1) across the different staff classifications:
Medical Staff
Nursing Staff
Professions Allied to Medicine
/Professional and Technical
Admin & Managerial
Estates Staff
Other Pay Costs
Budget
£000s
5,699
8,129
2,927
2,797
1,291
20,842
(512)
20,331
In Month
Actual
Variance
£000s
£000s
6,156
(457)
8,085
44
0
2,943
(17)
2,850
(53)
1,288
2
21,322
(480)
0
(512)
21,322
(991)
Year-to-Date
Budget
Actual
Variance
£000s
£000s
£000s
55,851
58,320
(2,470)
79,243
78,088
1,155
28,844
27,779
12,848
204,565
(3,973)
200,591
28,533
28,048
12,823
205,814
0
205,814
311
(270)
24
(1,249)
(3,973)
(5,223)
4.8.
Consistent with past months, the greatest adverse variance by staff group remains with
medical staff where there are still a number of vacancies that are proving to be difficult to
fill. The variance on other pay costs reflects unfulfilled CIPs.
4.9.
After several months of decline agency costs have climbed steeply. The Director of
Finance and Chief Operating Officer have met with each of the Divisions to discuss
actions that can be taken in the remainder of the year to control costs.
Agency Expenditure
1,600
1,400
1,200
£000s
1,000
800
600
400
200
Apr
May
Jun
Jul
2010/11
Aug
Sep
Oct
2011/12
-4-
Nov
2012/13
Dec
2013/14
Jan
Feb
Mar
Agency Expenditure by Staff Group
1,000
900
800
700
600
£000s
500
400
300
200
100
Jan-13
Feb-13
Medical
Mar-13
Apr-13
May-13
Nursing
Jun-13
Jul-13
Aug-13
Other Clinical
Sep-13
Oct-13
Nov-13
Admin and Clerical
Dec-13
Jan-14
Estates
Agency Expenditure by Division
800
700
600
£000
500
400
300
200
100
0
-100
Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13
Jul-13
Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14
-200
Surgery
4.10.
Medicine
Core
Women & Children
Corporate
Non-Pay: The following table reports net expenditure on drugs and clinical supplies after
taking into account Payment by Results (PbR) excluded transactions and pharmacy
trading.
Annual
Budget
£000s
Drugs
Income - PbR excluded
Income - Pharmacy trading
Drugs expenditure total
Drugs expenditure net of PbR excluded
and trading income
PbR Excluded Devices
Income - PbR excluded
Clinical Supplies & Services expenditure total
Clinical Supplies & Services expenditure net of
PbR excluded income
Budget
£000
In Month
Actual
£000
Variance
£000
Budget
£000
Year to Date
Actual
Variance
£000
£000
15,701
4,779
(26,824)
(6,344)
1,308
398
(2,234)
(527)
1,713
362
(2,798)
(723)
405
(36)
(565)
(197)
13,084
3,982
(22,387)
(5,321)
14,155
4,342
(24,969)
(6,472)
1,071
359
(2,582)
(1,152)
2,830
(34,649)
236
(2,943)
244
(2,994)
8
(51)
2,358
(28,763)
1,725
(28,453)
(633)
310
(31,819)
(2,707)
(2,750)
(43)
(26,405)
(26,729)
(324)
NB: PbR excluded income is derived from the costs of purchasing the drugs/devices
4.11.
There has been a continued rise in expenditure on drugs that are within the PbR tariff.
This is due to a combination of changes to NICE guidelines and increased levels of
activity.
-5-
4.12.
Similar to last month, greater expenditure than budgeted in-month on catering (£36k) and
cleaning materials and equipment (£40k) has led to an adverse variance on general
supplies and services. The line also reflects the higher levels of inpatient activity leading
to an adverse variance on bedding and linen costs of £15k.
4.13.
Premises costs have increased due to a rise in utility costs, business rates and increased
maintenance contract charges.
4.14.
The adverse variance within Services from NHS bodies includes greater outgoings in
month for R&D (£23k) and CLRN (£18k). This is offset by income.
5
Statement of Financial Position
5.1.
The Statement of Financial Position is shown below.
Western Sussex Hospitals NHS Foundation Trust
Statement of Financial Position
as at
31 January 2014
Opening
Balance
£000s
Non-Current Assets
Property, Plant and Equipment
Intangible Fixed Assets
Trade and Other Receivables
Total Non-Current Assets
In Month
Closing
Balance
£000s
Movement
£000s
Opening
Balance
£000s
Year to Date
Closing
Balance
Movement
£000s
£000s
248,195
1,022
248,998
978
804
(44)
241,139
1,413
248,998
978
7,859
(435)
249,216
249,976
760
242,552
249,976
7,424
6,843
18,141
17,250
1,283
43,517
2,600
46,117
6,434
14,133
17,637
2,257
40,460
2,600
43,060
(409)
(4,009)
387
974
(3,057)
6,060
11,889
4,279
12,528
34,756
(3,057)
34,756
6,434
14,133
17,637
2,257
40,460
2,600
43,060
374
2,244
13,358
(10,271)
5,704
2,600
8,304
(34,124)
(3,421)
(986)
(73)
(540)
(39,144)
(31,494)
(3,421)
(986)
(201)
(455)
(36,557)
2,630
(128)
85
2,587
(26,921)
(2,421)
(900)
(239)
(640)
(31,121)
(31,494)
(3,421)
(986)
(201)
(455)
(36,557)
(4,573)
(1,000)
(86)
38
185
(5,436)
6,973
6,503
(470)
3,635
6,503
2,868
Non Current Liabilities
Working Capital Loan
Capital Investment Loan
Borrowings
Provisions for Liabilities and Charges
Total Non Current Liabilities
(9,703)
(16,959)
(2,463)
(2,574)
(31,699)
(9,703)
(16,959)
(2,463)
(2,574)
(31,699)
(2,413)
(13,271)
(2,493)
(2,574)
(20,751)
(9,703)
(16,959)
(2,463)
(2,574)
(31,699)
(7,290)
(3,688)
30
()
(10,948)
Net Assets
224,490
224,780
289
225,436
224,780
(656)
Taxpayers' Equity
Public Dividend Capital
Retained Earnings
Revaluation Reserve
237,784
(41,789)
28,495
237,784
(41,500)
28,495
289
237,785
(41,082)
28,733
237,784
(41,500)
28,495
(1)
(418)
(238)
Total Taxpayers's Equity
224,490
224,780
289
225,436
224,780
(656)
Current Assets
Inventories
Trade and Other Receivables
Prepayments & Accrued income
Cash and Cash Equivalents
Sub Total Current Assets
Non-Current Assets Held for Sale
Total Current Assets
Current Liabilities
Trade and Other Payables
Working Capital Loan
Capital Investment Loan
Borrowings
Provisions for Liabilities and Charges
Total Current Liabilities
Net Current Assets/(Liabilities)
-6-
5.2.
Property, Plant & Equipment and Intangible Fixed Assets: The capital position is set out in
Appendix 1. This highlights actual expenditure against the capital budget advised to
Monitor. Total expenditure for the year to date is £21,928k, which is an adverse variance
of £531k to Plan. This is less than 3% from Plan and Monitor identifies a threshold of 15%
beyond which plans have to be restated.
5.3.
Forecast outturn expenditure is between £28,482k and £29,132k which is 2 - 4% higher
than the forecast outturn advised to Monitor. The range reflects potential timing issues
within several schemes for this financial year. Most of the difference between available
resource and planned expenditure relates to the Emergency Floor scheme with resource
reassigned to next year.
5.4.
Current Assets & Current Liabilities: The receipt of £5.2m of income from NHS England in
January has reduced trade and other receivables in-month. The cash has been applied to
reduce outstanding payables and also increased the cash position.
-7-
Appendix 1
CAPITAL PROGRAMME 2013/14: as at 31st January 2014
Capital Resource
2013/14 Plan
£000s
Capital Programme "core" resource
Outturn
£000s
13,837
13,837
Capital resource brought forward
6,402
6,402
Capital resource brought forward - Breast Unit
6,286
6,286
New Capital Investment Loan - Emergency Floor
4,224
6,314
Existing loans
(900)
(900)
New loans
(169)
(169)
Improving the birthing environment (PDC receivable in 13/14)
350
350
Donations - Love Your Hospital
111
111
Donations - Friends
175
175
Donations - CT Scanner (Friends/Love Your Hospital)
828
828
31,144
33,234
less: Capital Investment Loan Repayments on:
-8-
In Month
Expenditure
2013/14 Plan
£000s
Re-Phased
Budget
£000s
Year to Date
Actual
£000s
Variance
£000s
Re-Phased
Budget
£000s
Actual
£000s
Variance
£000s
Outturn
£000s
Charitable additions
Charitable donation expenditure
(286)
(50)
0
50
(150)
(142)
8
(286)
(1,017)
(50)
(22)
28
(918)
(858)
59
(1,017)
(180)
0
0
0
(101)
(101)
0
(101)
(1,197)
(50)
(22)
28
(1,018)
(959)
59
(1,118)
(3,050)
(350)
(747)
(397)
(2,330)
(2,685)
(354)
(3,050)
(10)
CT Scanner
CT Scanner & Equipment
CT Scanner - Building works
Emergency Floor
Emergency Floor
(10)
0
0
0
0
0
0
(1,164)
0
0
0
0
0
0
(4,224)
(350)
(747)
(397)
(2,330)
(2,685)
(354)
(3,060)
Breast Screening - New Build
(4,187)
(50)
46
96
(4,137)
(4,013)
124
(4,187)
Breast screening - New Build Equipping
(2,500)
(150)
(4)
146
(1,207)
(1,062)
145
(2,760)
(6,687)
(200)
42
242
(5,344)
(5,075)
269
(6,947)
(1,508)
(360)
(475)
(115)
(1,015)
(1,024)
(9)
(1,405)
Theatre high priority capital items
(258)
0
0
0
(201)
(205)
(4)
(258)
Equip a theatre at Worthing (proposed CIP to increase T&O income)
(173)
0
0
0
(172)
(186)
(15)
(187)
(17)
0
0
0
0
0
0
0
(240)
0
(123)
(123)
(226)
(343)
(117)
(343)
Emergency Floor Equip
Emergency Floor C/F
Breast Care Centre
Medical equipment
General medical equipment
Endoscopy scopes
Ultrasound (obstetric) equipment replacement
(139)
0
0
0
(144)
(144)
0
(144)
(2,335)
(360)
(598)
(238)
(1,757)
(1,902)
(145)
(2,337)
Day Surgery Conversions - pre admission Chanctonbury
(750)
(25)
(0)
25
(580)
(555)
25
(580)
MFU / ENT consolidation
(408)
0
(2)
(2)
(413)
(418)
(5)
(418)
SSD - centralisation of ENT probes
Pre-Admissions
Day Surgery dependency - Refurb ENT for DOME offices
(330)
0
0
0
(260)
(249)
11
(255)
(1,488)
(25)
(3)
22
(1,253)
(1,222)
31
(1,253)
-9-
In Month
Expenditure
2013/14 Plan
£000s
Re-Phased
Budget
£000s
Year to Date
Actual
£000s
Variance
£000s
Re-Phased
Budget
£000s
Actual
£000s
Variance
£000s
Outturn
£000s
Southlands
Southlands Ophthalmology
(650)
(200)
0
200
(674)
(480)
194
(674)
Southlands Infrastructure
(610)
(12)
(1)
11
(610)
(584)
26
(610)
(1,260)
(212)
(1)
211
(1,284)
(1,064)
220
(1,284)
Imaging - Interventional Radiology
Interventional Room - Equipping SRH
(489)
0
(3)
(3)
(481)
(462)
19
(481)
Interventional Room - Reporting rooms SRH
(983)
0
0
0
(991)
(960)
31
(991)
Interventional Rroom - Build costs Wor
(500)
0
0
0
0
0
0
(50)
(489)
0
0
0
0
0
0
0
(2,461)
0
(3)
(3)
(1,472)
(1,422)
50
(1,522)
Endoscopy SRH
(600)
0
0
0
(0)
(0)
0
0
Endoscopy Wor
(642)
0
(10)
(10)
(25)
(36)
(10)
(36)
Pre-assessment relocation (dependency for Endoscopy programme Worthing
(350)
0
0
0
0
0
0
0
(1,592)
0
(10)
(10)
(25)
(36)
(10)
(36)
(550)
(151)
(56)
95
(325)
(266)
59
(486)
Interventional Room - Equipping Wor
Endoscopy
Worthing Health Education Centre
Education Centre
Pathology
Diagnostic Block Roofs
(150)
0
0
0
(150)
4
154
0
Move Chemistry into Haematology Lab, incl. consultants & secretaries
(100)
0
65
65
(44)
(103)
(59)
(103)
Order Comms: Tablets / hardware only
(50)
0
0
0
0
0
0
(50)
Worthing Maintenance
(70)
0
0
0
0
(69)
(69)
(69)
Purchase of Blood Track Courier Fridge Control System
Pathology re-modelling of vacant space
SRH Additional Infrastructure - Path MES
(26)
0
0
0
0
0
0
0
(124)
0
0
0
(43)
(28)
15
(139)
(784)
(36)
(113)
(77)
6
(113)
(119)
(994)
(1,304)
(36)
(48)
(12)
(231)
(308)
(77)
(1,355)
- 10 -
In Month
Expenditure
2013/14 Plan
£000s
Re-Phased
Budget
£000s
Year to Date
Actual
£000s
Variance
£000s
Re-Phased
Budget
£000s
Actual
£000s
Variance
£000s
Outturn
£000s
Estates enabled schemes
Sustainability Initiatives
(470)
0
0
0
(135)
(91)
44
(202)
West Wing Refurbishment - Infrastructure
(660)
(48)
64
112
(120)
55
175
(240)
Main Ward Block upgrades (lighting upgrades etc)
(270)
(100)
1
101
(213)
(119)
94
(270)
Lift refurbishment programme
(270)
(90)
(0)
90
(126)
(50)
76
(270)
Outpatient department
(345)
(139)
(6)
133
(345)
(293)
51
(296)
(50)
(20)
0
20
(30)
0
30
(10)
Targeted Backlog: High risk remedial
(122)
(25)
(30)
(5)
(354)
(362)
(8)
(416)
Targeted Backlog: Built environment infrastructure
(275)
(150)
(65)
85
(275)
(186)
89
(291)
Targeted backlog: M&E backlog
(308)
(94)
(40)
54
(114)
(67)
47
(308)
Fire: Compliance with standards
(476)
(60)
(18)
42
(349)
(258)
91
(321)
ITU refurbishment
(50)
0
0
0
0
0
0
(30)
Catering Project
(290)
0
(55)
(55)
(332)
(384)
(52)
(384)
Minor works and small schemes
(939)
(68)
(59)
9
(939)
(920)
19
(939)
Security
(15)
0
0
0
0
0
0
(15)
PLACE (was PEAT)
(75)
(10)
(18)
(8)
(48)
(37)
11
(75)
Outpatient Landscaping & Planning Conditions
(95)
(30)
42
72
(72)
(17)
55
(87)
Residential Accommodation improvements
Non Medical Equipment
(50)
0
0
0
(20)
(9)
11
(50)
(4,760)
(834)
(185)
649
(3,472)
(2,739)
733
(4,204)
- 11 -
In Month
Expenditure
2013/14 Plan
£000s
Re-Phased
Budget
£000s
Year to Date
Actual
£000s
Variance
£000s
Re-Phased
Budget
£000s
Actual
£000s
Variance
£000s
Outturn
£000s
IM&T enabled solutions
IM&T infrastructure and resilience (procurement)
Call Management System
IT Server Location
(1,640)
(106)
(15)
91
(3,196)
(3,046)
150
0
0
0
0
(265)
(265)
0
(4,040)
(265)
(80)
(72)
0
(84)
0
84
(112)
PACS
(287)
0
0
0
(288)
(288)
0
(288)
IT maintenance / PC refresh etc
(377)
(50)
(216)
(166)
(275)
(421)
(146)
(421)
(19)
0
0
0
(25)
(25)
0
(25)
Medical Revalidation and Appraisal
(150)
0
0
0
(50)
0
50
0
E-prescribing
(416)
0
0
0
0
0
0
(9)
Clinical systems
Maternity Information system (community solution)
Critical Care Information System
Theatre system
TOTAL
Unallocated and adjusted for optimism bias
TOTAL including optimism bias
(75)
(23)
(23)
0
(65)
(65)
0
(75)
(312)
0
0
0
0
0
0
(9)
(20)
0
0
0
0
0
0
0
(3,376)
(251)
(253)
(74)
(4,248)
(4,110)
138
(5,244)
(31,520)
(2,519)
(1,883)
564
(22,909)
(21,928)
981
(29,132)
376
200
0
(200)
450
0
(450)
650
(31,144)
(2,319)
(1,883)
364
(22,459)
(21,928)
531
(28,482)
- 12 -
To: Trust Board
Date of Meeting: [insert date of meeting]
Agenda Item: 11
Title
Annual Equality & Diversity Monitoring Report 2013
Responsible Executive Director
Denise Farmer
Prepared by
Natalie Bailey, Workforce Manager for Surgery and Equality & Diversity Lead
Status
Disclosable
Summary of Proposal
This report seeks to update the Trust Board on the annual equality and diversity monitoring data and actions
to be taken as a result of this analysis.
Implications for Quality of Care
To gain greater understanding of the needs and cultures of all patients and thereby communicating more
effectively with them. Employing a diverse workforce reflective of the population served which is better able
to support excellent patient care.
Link to Strategic Objectives/Board Assurance Framework
As above
Financial Implications
Increase in staff satisfaction and therefore less time and finance spent on employee relations issues.
Human Resource Implications
As described above. Also meets the requirements to publish annual data as part of the Equality Act 2010.
Recommendation
The Board/Committee is asked to: Approve the paper for publication
Communication and Consultation
Via staff forums
Appendices
[list any appendices]
This report can be made available in other formats and in other languages. To discuss your requirements please
contact the Company Secretary.
Annual Equality & Diversity
Monitoring Report 2013
Published 31st January 2014
Data Compiled From Period 1st October 2012 to 30th September 2013
1
Table Of Contents
FOREWORD AND INTRODUCTION ............................................... 4
EXECUTIVE SUMMARY……………………………………………….5
1) DO THE STAFF WE EMPLOY REPRESENT THE LOCAL
POPULATION?................................................................................. 8
1.1 Age.............................................................................................................................. 8
1.2 Gender ........................................................................................................................ 9
1.3 Disability.................................................................................................................... 10
1.4 Ethnicity .................................................................................................................... 10
1.5 Religion or Belief ....................................................................................................... 12
1.6 Sexual Orientation..................................................................................................... 13
1.7 Marital Status ............................................................................................................ 13
2) HAVE THOSE THAT WERE RECRUITED TO POSTS BEEN
RECRUITED FAIRLY? ................................................................... 15
2.1 Age............................................................................................................................ 15
2.2 Gender ...................................................................................................................... 15
2.3 Disability.................................................................................................................... 16
2.4 Ethnicity .................................................................................................................... 16
2.5 Religion or Belief ....................................................................................................... 16
2.6 Sexual Orientation..................................................................................................... 16
2.7 Marital Status ............................................................................................................ 17
3) ARE THERE ANY ISSUES IN RELATION TO STAFF LEAVING
THE ORGANISATION? .................................................................. 18
3.1 Age............................................................................................................................ 18
3.2 Gender ...................................................................................................................... 19
3.3 Disability.................................................................................................................... 19
3.4 Ethnicity .................................................................................................................... 20
3.5 Religion or Belief ....................................................................................................... 20
3.6 Sexual Orientation..................................................................................................... 20
3.7 Marital Status ............................................................................................................ 21
4) ARE THERE ANY ISSUES IN RELATION TO EMPLOYEE
RELATIONS CASES WITHIN THE ORGANISATION? ................. 22
4.1 Age............................................................................................................................ 22
4.2 Gender ...................................................................................................................... 23
4.3 Disability.................................................................................................................... 24
4.4 Ethnicity .................................................................................................................... 24
4.5 Religion or Belief ....................................................................................................... 25
4.6 Sexual Orientation..................................................................................................... 26
2
4.7 Marital Status ............................................................................................................ 28
5) IS ACCESS TO TRAINING FAIR FOR ALL STAFF? ............... 29
5.1 Age............................................................................................................................ 29
5.2 Gender ...................................................................................................................... 29
5.3 Disability.................................................................................................................... 29
5.4 Ethnicity .................................................................................................................... 30
5.5 Religion or Belief ....................................................................................................... 30
5.6 Sexual Orientation..................................................................................................... 30
5.7 Marital Status ............................................................................................................ 31
6) ARE ALL AREAS OF THE TRUST ENSURING THAT THEIR
STAFF ATTEND EQUALITY & DIVERSITY TRAINING EVERY 3
YEARS?.......................................................................................... 32
6.1 E & D Training Across WSHFT ................................................................................. 32
6.2 E & D Training By Division ........................................................................................ 32
6.3 E & D Training By Staff Group .................................................................................. 32
6.4 E & D Training By Payband ...................................................................................... 33
7) ARE THE NUMBERS OF STAFF BY PAYBAND
REPRESENTATIVE OF THE TOTAL STAFF WE EMPLOY?....... 34
7.1 Age............................................................................................................................ 34
7.2 Gender ...................................................................................................................... 34
7.3 Disability.................................................................................................................... 35
7.4 Ethnicity .................................................................................................................... 35
7.5 Religion or Belief ....................................................................................................... 35
7.6 Sexual Orientation..................................................................................................... 36
7.7 Marital Status ............................................................................................................ 36
8)HOW SATISFIED ARE STAFF?..................................................36
9) WHAT DO OUR STAFF TELL US IN REALTIME?....................39
10) DO THE PATIENTS WE SERVE REPRESENT THE LOCAL
POPULATION?............................................................................... 40
11) HOW SATISFIED ARE OUR PATIENTS WITH OUR
SERVICES?................................................................................... 46
12) WHAT DO OUR PATIENTS TELL US IN REALTIME?...........48
13) APPENDIX.............................................................................. 555
3
FOREWORD
I’m very proud of the role our hospitals play in the community they serve. With hundreds of thousands of
people using their services every year, we have enormous potential to act as a positive influence on the lives
of people across all sections of society and to improve the quality of life they and their families can enjoy.
It is now more than four years since our trust was formed, and since that time we have successfully forged a
new, single organisation and demonstrated significant improvements in patient care with a clear focus on
safety and quality - this work was recognised this year with our authorisation as a Foundation Trust.
Our staff deserve great credit for these achievements and together we are determined to turn a very good
organisation into a great one. Ensuring high quality, safe services are available to all sections of the
community and provided by a workforce that reflects the diversity of our population is an essential part of this
journey.
This annual report provides us with an opportunity to celebrate the progress we have made so far, provide
key information in relation to equality and diversity and express our commitment to removing inequalities and
promoting equality and diversity.
Finally, I would like to thank and recognise our staff and supporters for embracing and promoting equality and
diversity at Western Sussex Hospitals NHS Foundation Trust.
Marianne Griffiths
Chief Executive
INTRODUCTION
This is the third published report explaining how Western Sussex Hospitals NHS Foundation Trust
(WSHFT/The Trust) assures itself that our staff and patients are not disadvantaged on the basis of group
membership of one of the protected characteristics. These being:
1 Age
2 Gender
3 Gender reassignment
4 Disability
5 Ethnicity
6 Religion or belief
7 Sexual orientation
8 Marital status
9 Pregnancy and maternity
This report will do this by asking relevant questions and seeking to answer these both visually through the use
of graphs and with some narratives, drawing out the key headlines and areas to focus on.
Any reference to the local demographic is now taken from the 2011 Census figures for West Sussex as the
results from this survey have recently been published. This will enable us now to compare the Trust data with
more up to date demographic information.
The first part of the report is in relation to the workforce of the Trust, the second part is for the patients we
have treated in the past year. This report will satisfy the legal obligation from the Equality Act 2010 to publish
our equality monitoring data by 31st January each year. In addition to this, the Trust published an update to
its equality objectives in April 2013, and these are monitored on a quarterly basis via the Diversity Matters
Group. A further update will be provided in April 2014.
This full report was presented to the Trust Board and Diversity Matters Groups in January 2014, before
publication on the Trust’s intranet and internet sites.
Natalie Bailey
Workforce Manager – Surgery Division and Strategic Lead for Equality & Diversity
4
Executive Summary
This report has been compiled using data from various sources for the period between 1st October 2012 and
30th September 2013. The report satisfies the obligations in the Equality Duty and in the specific duties, as
part of the Equality Act 2010, to publish equality monitoring data each year by 31st January. Gender
reassignment has not been addressed as this information is not currently collected for either staff or patients.
Various questions in relation to the protected characteristics have been addressed throughout the report and
are summarised below, with the full data contained in the main report;
1.
Do the staff we employ represent the local population?
Yes, again this year the age of staff follows a normal distribution curve and is generally reflective of the
population we serve, save for the under 20’s and over 60’s for which we employ less. Our staffing split by
gender is proportionate to the NHS nationally, but not the local population. The Trust employs less disabled
staff than in the local population as shown in the 2011 Census. However, following a data cleanse exercise
and staff census, the staff declaration rates of disability status have improved again this year. The Trust has
a disability rate of 4% of staff, the same as last year. There are higher levels proportionately of BME staff
employed at the Trust than in the local population. However, we have seen an increase in the diversity of the
population reflected in the updated Census results, particularly in the White non-British category. This
category has also seen an increase for staff within the last year. The religion and beliefs of staff are very
similar to last year and to the local area, however the “other” category is still higher. A questionnaire will be
sent to those declaring “other” to establish examples of what this means to them. Declaration rates for
religion/belief are similar to last year, and the “other” category is still high. There has been a further increase
of staff declaring their sexual orientation and this is now 68%. A Lesbian Gay Bisexual and Transgender
(LGBT) Forum has recently been established at the Trust and therefore it is anticipated that changes will take
place in this category over the next year. Marital status of staff is reflective of that of the local population and
has not changed greatly since the last reporting period.
2.
Have those that were recruited to posts been recruited fairly?
There are some actions to take forward in relation to this section. Although the percentage of staff appointed
by gender is reflective of those already employed, there is a drop in the level of males being successful
through the recruitment process and therefore it is recommended that a recruitment report is run to
understand whether there is a particular job category that sees a drop in male appointments. In terms of
disability, there has been a lower percentage of disabled staff appointed than applied and this is also lower
than the percentage currently employed. For the third year running, when looking at recruitment by ethnicity
there is a much higher percentage of white British staff appointed than applied for posts and therefore the
success rates in all other categories is lower. This requires further exploration by the BME Forum.
3.
Are there any issues in relation to staff leaving the organisation?
The turnover rate in general has decreased this year to 8.16% compared to 9.48% in the last reporting period.
In the youngest age group turnover was highlighted as an issue in last year’s report but, positively, this has
reduced by more than 50% this year. In general the eldest and youngest age categories are still the highest
in terms of turnover. The level of disabled staff leaving is higher than non-disabled and is also much higher
than the percentage employed. Because of this a report into the reasons for disabled staff leaving was run
and from it we can see that disabled members of staff made up 17.6% of those staff who were dismissed and
15% of those staff who left voluntarily but for health related reasons. Whilst these figures are much higher
than the proportion of disabled staff in the trust (4.1% of those who declared either way), it must be noted that
the numbers are very small so not much statistical significance can be attached to them. The turnover rate
for each ethnicity is lower than the Trust average apart from mixed race and Black/Black British where it is
higher. A survey will be sent to these disabled staff and BME staff to understand further, their reasons for
leaving. There does not appear to be any issues in relation to leavers by religion/belief or marital status and
for sexual orientation, the picture is improved since last year with a fairly even split between each category.
4.
Are there any issues in relation to employee relations cases within the organisation?
In total there were 78 formal disciplinary hearings, an increase from 52 the previous year. When looking at
the disciplinaries by protected characteristics, further exploration is required for gender as there are more for
males than the percentage we employ, as well as ethnicity where again this year there are a higher
percentage for non white-British staff than those we employ. The BME forum will explore this and together
with the Employee Relations team develop a plan to ensure all staff, in particular those from overseas and our
5
male staff are aware of the expectations of the Trust. The number of grievances in this reporting period was
8, a decrease from 12 the previous year. All protected characteristics are reflective apart from ethnic origin
which requires further exploration by the BME Forum. The behaviour management cases combined for the
last 3 years will be reported to the Diversity Matters Group in April 2014.
5.
Is access to training fair for all staff?
Yes, this is an area of the report where for each protected characteristic reported on, take up of training is
reflective of the number of staff employed.
6.
Are all areas of the Trust ensuring their staff attend equality and diversity training every 3
years?
The Trust has met its target of 90% for E&D training in the last year and in fact, has almost tripled the amount
of people up to date over the last two years. E&D sessions have been running on each health and safety
update and full day and induction course on each site, as well as ad hoc sessions and the content of the
sessions has been updated and improved. Future plans for E&D training will incorporate rolling out the on
line training designed for Doctors to include other types of staff. All divisions have seen a vast improvement
in the training rates however further thought should be given to improving the uptake from students and
medical/dental staff.
7.
Are the number of staff by pay band representative of the total staff we employ?
Overall, the picture for AFC Pay bands is fairly representative by the protected Characteristics and some
areas have seen improvements since last year. However pay bands by ethnicity still requires further work
and an action plan by the BME Forum and this should be focused on the white non-British staff who are
underrepresented in the higher pay groups.
8.
How satisfied are our staff?
Results from the 2012 staff survey show that in general, staff are satisfied and the Trusts staff engagement
score had improved since the previous year. The Trust was in the top 20% of acute Trusts in some areas and
this included percentage of staff having E&D training. This area had also improved again since last year’s
survey. In terms of equality and diversity areas of the survey, the level of discrimination appears to be similar
to the scores from last year’s survey and the biggest categories affected appear to be age and ethnic origin.
The Trust will soon be receiving the first cut of results from the 2013 staff survey and therefore a detailed
analysis of discrimination results will be presented to the Diversity Matters Group in April 2014.
9.
What do our staff tell us in real time?
Overall, real time information shows us that staff are satisfied. However there are fluctuations on the levels
month on month and between divisions.
10. Do the patients we serve represent the local population?
In general they do for the data we hold, however, as has been the case for the previous two years, further
work is required to ensure patient data is recorded for all the protected characteristics consistently in order to
give an accurate picture.
11. How satisfied are our patients with our services?
The outpatient survey has not been updated nationally since the last report and therefore an update is not
available. Similarly, although an updated maternity services survey has been conducted, the results are not
yet available. An inpatient survey was carried out in 2012 and the Trusts response rate for this was 60%,
compared to 63% the previous year. In most categories the Trust was rated “about the same” as other
Trusts. In addition, real time patient satisfaction surveys have been developed and this will be a focus for
next year’s E&D report.
12. What are the level of complaints by protected characteristic?
This information has been included in the appendix of the report.
6
13. What do our patients tell us in real time?
For the data that has begun to be gathered in real time, we can see that the patients treated are reflective in
general with the levels reported through the access team and of the population served. Further analysis on
the actual satisfaction of our patients using internal real time results from surveys will be analysed in next
year’s report.
Summary of the key actions required from the report:
 A questionnaire to be sent to all those declaring themselves “other” religion/belief in order
to understand some examples of other
 For recruitment, a report to be run into whether there is a particular job category that sees
a drop in male candidates and the BME forum to look further into BME staff being less
successful through the recruitment process.
 Consider sending a questionnaire to the disabled and BME leavers to better understand
their reasons for leaving.
 Behaviour Management cases by protected characteristic to be analysed and reported to
the DMG in April 2014.
 BME Forum to be renamed to appeal and relate to more staff.
 Lead for religion and belief to ensure religion/belief recorded for patients.
 The formal disciplinaries and grievances for male staff and those from a non-white British
background to be explored.
 Learning and development unit to explore how best to engage with students and medical
staff in relation to E&D training.
 BME forum to look into the White non-British staff pay progression
 Further work to be carried out into patient data and patient survey collection to ensure
consistency of surveying and of recording information.
 Ensure the patient survey analysis includes satisfaction of patients and not just
demographic data for next year.
 Analysis of flexible working requests to be included in 2014 report.
 Equality and Diversity staff survey results to be reported to DMG in April 2014.
The future of this report
This is now the third consecutive year of publishing this report and improvements have been made to it each
time. However, it is clear that the Trust needs to move away from publishing its equality data, with some
actions and towards a much more in depth equality and diversity report, backed up by data.
From the 2014 reporting period therefore, it is anticipated that this report will still hold all the relevant data and
information but as an appendix and the main body of the report will highlight and dig deeper into the findings
from this. In addition, some targeted work into specific areas of interest or issues highlighted by for example
the staff or patient survey will be included in much more detail.
Further work is required to ensure the Trust can report on pregnancy/maternity and gender reassignment
characteristics, at least in some form, from 2014.
7
1) DO THE STAFF WE EMPLOY REPRESENT THE LOCAL
POPULATION?
1.1 Age
The graph below compares the age spread of the local demographic and WSHFT staff as at 30th September
2013:
Graph 1.11 – Age Band: Comparison between 2011 Census and WSHFT Staff
14%
Census 2011
12%
WSHT 2013
10%
8%
6%
4%
2%
0%
Under
20
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
70 - 74
75 - 79
Please Note: This graph only includes Census data for ages 16-79 since this is the age range of
WSHFT staff.
The data in 1.11 is showing less under 20 year olds and over 60 year olds than in the general population and
percentage wise more 25-59 year olds.
Graph 1.12 compares the WSHFT age spread at the start of the reporting period in 2012 and the end period
in 2013. Each year of reporting the distribution for age of staff for WSHFT has been normal and there have
been very few fluctuations in the percentages in each category. There has again been a very slight increase
in the over 65 year old staff employed.
Graph 1.12 – Age Band: Comparison between 2012 and 2013 WSHFT Staff Age Profile
14%
WSHT 2012
12%
WSHT 2013
10%
8%
6%
4%
2%
0%
Under
20
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
70 - 74
75 - 79
8
1.2 Gender
The charts below display the gender split in WSHFT staff and the proportion of each gender in the local
population:
Graph 1.21 – Census 2011
Graph 1.22 – WSHFT 2012
Graph 1.23 – WSHFT 2013
Male
22%
Male
48%
Male
22%
Female
52%
Female
78%
Female
78%
The gender split has not changed over the last year period, and has also not changed since the start of the
reporting periods in 2010, therefore it has remained static for 3 years. Although the gender split in the Trust
does not reflect the local population, it is reflective of the NHS nationally.
The following graphs compare work patterns by gender across the reporting period.
Graph 1.24 – Female Work Patterns
Graph 1.25 – Male Work Patterns
100%
100%
90%
90%
80%
Part Time
Part Time
Full Time
Full Time
2012
2013
80%
Part Time
Part Time
70%
70%
60%
60%
50%
50%
40%
40%
30%
30%
Full Time
Full Time
20%
20%
10%
10%
0%
0%
2012
2013
This data shows that out of our female staff, approximately half of them are full time and half are part time.
The remaining 22% of our staff are male and within this, approximately 84% are working fulltime, 16% part
time. Again this picture has stayed the same for the last two years. It is important to note that there are also
other options of flexible working as well as part time working such as compressed hours, term time only
contracts, annualised hours and others.
9
1.3 Disability
The following charts show the proportion of WSHFT staff who declared a disability at the start and end of the
reporting period, and also shows the proportion of the local population - of working age - who declared in the
2011 census that they had a limiting long term illness:
Graph 1.31 – Census 2011
Graph 1.32 – WSHFT 2012
Graph 1.33 – WSHFT 2013
4%
4%
7%
10%
83%
96%
96%
Day to day activities limited a lot
Day to day activities limited a little
Day to day activities not limited
Disabled
Not Disabled
Disabled
Not Disabled
It is clear from the above data that the number of staff declaring they have a disability has not changed over
the course of the reporting period. There was 2% increased in staff declaring a disability since the previous
year (October 2011) and it was believed this was due to a staff census exercise taking place.
Updated census information is now differentiating disability, between those whose day to day activities are
limited a lot and limited a little and with both categories included there has been an increase to 17% of the
local population believing they have a disability. Although it is expected that more of the general local
population would consider themselves disabled proportionately than the percentage we employ, this figure
has increased from 11% in the census 2001 results. It might be worth considering having the same 2 options
internally for staff within the Trust in order to see if the declaration rate increases or not.
1.4 Ethnicity
In the following two graphs people who have not declared their ethnic origin have been excluded (this figure
stood at 5.1% for WSHFT staff on 30th September 2013).
Graph 1.41 - Ethnicity: Comparison Between 2011 Census and WSHFT Staff
10%
Census 2011
9%
WSHT 2013
8%
7%
6%
5%
4%
3%
2%
1%
0%
White (Non British)
Mixed
Asian Or Asian
British
Black Or Black
British
Chinese
Any Other Ethnic
Group
Please Note: 88.9% of the local population and 79.2% of WSHFT staff are in the ethnicity group “White
British”. These figures are not displayed on the graph to allow easy comparison between the smaller
groupings.
10
The difference between the 2001 and 2011 census results for ethnic origin is dramatic as you might expect
with the laws on EU immigration having been relaxed over this time period. There has been an increase in
each ethnic minority category within the general population apart from mixed.
The percentage of staff not declaring their ethnic origin has increased from 3.8% in last years report to 5.1%
this year. There has been a very slight increase in white non-British staff and a slight decrease in white
British staff. It has been interesting to note by running a specific report during the reporting period, that the
ethnic diversity of our staff covers 72 countries. This was celebrated at the Trusts equality & diversity and
conference weeks by hanging each country’s flag on our display boards. This prompted much discussion
with staff.
Graph 1.42 details any changes in the relative proportions of the ethnic groups in WSHFT in the reporting
period.
Graph 1.42 - Ethnicity: Comparison between 2012 and 2013 WSHFT Staff Ethnicity Profile
10%
WSHT 2012
9%
WSHT 2013
8%
7%
6%
5%
4%
3%
2%
1%
0%
White (Non British)
Mixed
Asian Or Asian
British
Black Or Black
British
Chinese
Any Other Ethnic
Group
Please Note: 80.0% of WSHFT staff in 2012 and 79.2% of WSHFT staff in 2013 are in the ethnicity
group “White British”. These figures are not displayed on the graph to allow easy comparison
between the smaller groupings.
Action - As agreed at November DMG, work is to be carried out to explore different options of forum
for ethnicity as it does not seem that staff can connect with the term BME.
11
1.5 Religion or Belief
Graph 1.51 compares the religion or belief of the local population as compared to WSHFT staff. 34.3% of staff
have not disclosed their religion or belief and have been excluded from this analysis. This is a similar figure
to those not declaring last year (35.1%)
Graph 1.51 – Religion or Belief: Comparison Between 2011 Census and WSHFT Staff
30%
Census 2011
WSHT 2013
25%
20%
15%
10%
5%
0%
Atheism
Buddhism
Hinduism
Islam
Judaism
Sikhism
Other
Please Note: Christianity makes up 66.9% of the declared beliefs of the local population and 74.8% of
WSHFT staff. These figures are not displayed on the graph to allow easy comparison between the
smaller groupings.
Interestingly, the percentage of Christians in the local population has decreased in the 10 year period since
the previous Census, from 80.3% in 2001 to 66.9% in 2011. This is likely to be in part related to the change
in ethnic origin of the location population and partly just people viewing religion differently now to 10 years
ago.
There has also been a large increase in Atheists in the local population in the 10 year period, and the Trust
now has considerably less atheist staff than within the demography.
Graph 1.52 compares the religion or beliefs of WSHFT staff over the reporting period. It is clear there has
been very little change in this category over the course of the year.
Graph 1.52 - Religion Or Belief: Comparison Between 2012 and 2013 WSHFT Staff Religion Or Belief
30%
WSHT 2012
WSHT 2013
25%
20%
15%
10%
5%
0%
Atheism
Buddhism
Hinduism
Islam
Judaism
Sikhism
Other
12
1.6 Sexual Orientation
There is no available census data on sexual orientation so a comparison cannot be drawn between our staff
and the local population. Heterosexual staff are not displayed on Graph 1.61 but made up 98.2% of those
who have declared their sexual orientation in September 2013, a slight drop from the figure of 98.4% in
September 2012.
Graph 1.61 – Sexual Orientation: Comparison between 2012 and 2013 WSHFT Staff Sexual Orientation
1.0%
WSHT 2012
0.9%
WSHT 2013
0.8%
0.7%
0.6%
0.5%
0.4%
0.3%
0.2%
0.1%
0.0%
Bisexual
Gay
Lesbian
68% of staff disclosed their sexual orientation this year. A very slight increase from the previous year.
Since the last report, a local Lesbian Gay Bisexual and Transgender (LGBT) group has been established and
the Trust is hoping to build a network of staff to support Pride in Brighton at the 2014 event. It is anticipated
that a further staff census will be completed in 2014 and it is hoped that following the establishment of an
LGBT group additional staff may feel more comfortable declaring their sexual orientation.
1.7 Marital Status
Graph 1.71 compares the marital status of the local demographic to WSHFT staff. There are slightly more
married/civil partnered staff and less widowed staff compared to in the local population and this was also the
case last year.
Graph 1.71 – Marital Status: Comparison between 2011 Census and WSHFT Staff
60%
Census 2011
WSHT 2013
50%
40%
30%
20%
10%
0%
Divorced
Legally Seperated
Married or Civil
Partnership
Single
Widow ed
13
Graph 1.72 shows the difference in marital status from the beginning to the end of the reporting period and we
can see that this has remained fairly static.
Graph 1.72 – Marital Status: Comparison between 2012 and 2013 WSHFT Staff Marital Status
60%
WSHT 2012
WSHT 2013
50%
40%
30%
20%
10%
0%
Divorced
Legally Seperated
Married or Civil
Partnership
Single
Widow ed
14
2) HAVE THOSE THAT WERE RECRUITED TO POSTS BEEN
RECRUITED FAIRLY?
The following tables give the % chance that someone with a particular protected characteristic will apply, will
be interviewed or will be appointed to a vacancy.
This has been calculated using 2011 Census data in conjunction with recruitment data taken from NHS Jobs
over the period 1st October 2012 to 30th September 2013. No figures are quoted for Marital Status as NHS
jobs does not hold information on this characteristic. Those who did not declare the characteristic in question
have been excluded entirely from these figures.
The tables should be interpreted as, for example taking the first line of data “out of those who applied for
posts in the reporting period, 4.2% were under 20, out of those interviewed in the reporting period 4.9% were
under 20 and out of those appointed in the reporting period 6.9% were aged under 20.
2.1 Age
Characteristic Category
Under 20
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
70 - 74
75 - 79
% Total
Applicants
% Total
% Total Staff
% Local
% WSHT Staff
Candidates
Appointed To Population
(September
Interviewed
Roles
2013)
4.2%
4.9%
6.9%
6.0%
0.4%
17.7%
16.2%
16.4%
6.7%
5.2%
21.2%
16.2%
15.9%
7.2%
11.7%
14.8%
13.8%
14.6%
7.6%
11.1%
12.0%
12.5%
11.4%
8.4%
12.9%
10.1%
12.0%
11.4%
9.8%
13.6%
8.1%
9.8%
11.4%
10.0%
13.8%
6.8%
8.2%
7.1%
8.9%
12.8%
3.8%
4.8%
3.7%
7.9%
10.7%
1.0%
1.4%
1.2%
8.9%
5.6%
0.3%
0.2%
0.1%
7.4%
2.0%
0.0%
0.0%
0.0%
6.1%
0.3%
0.0%
0.0%
0.0%
5.3%
0.0%
The above data shows a similar picture to last year’s recruitment results by age; up to and including the age
categories 30-34, a higher percentage have applied, been interviewed and been appointed than those we
currently employ. Again, past the age of 40 the Trust has appointed proportionately less staff than those
already employed but it is encouraging to see that the percentages are low for this category from application
stage onwards and are not significantly dropping throughout the recruitment process for any age category.
2.2 Gender
Characteristic Category
Female
Male
% Local
% WSHT Staff
% Total Staff
% Total
(September
Appointed To Population
Candidates
2013)
Roles
Interviewed
64.9%
72.9%
78.4%
51.6%
78.1%
35.1%
27.1%
21.6%
48.4%
21.9%
% Total
Applicants
The percentage of staff appointed is almost exactly the same as the percentage already employed. We know
this is reflective of the NHS in general, however for the second year running the percentage of males
appointed to applied is significantly lower and requires further exploration
15
Action – Run and analyse a recruitment report to understand whether there is a particular job
category that sees a drop in male appointments.
2.3 Disability
Characteristic Category
% Local
% WSHT Staff
% Total Staff
% Total
(September
Appointed To Population
Candidates
2013)
Roles
Interviewed
3.2%
4.0%
2.6%
7.5%
3.9%
96.8%
96.0%
97.4%
92.5%
96.1%
% Total
Applicants
Disabled
Not Disabled
There has been a lower percentage of disabled staff appointed compared to applied for posts and the level of
appointments in this category is also lower than the percentage currently employed.
Action – further exploration required by the Disability Forum.
2.4 Ethnicity
Characteristic Category
% Total
Applicants
% Total
% Total Staff
% Local
% WSHT Staff
Candidates
Appointed To Population
(September
Interviewed
Roles
2013)
52.7%
68.5%
76.8%
88.9%
79.2%
13.1%
10.5%
8.9%
4.8%
7.2%
2.1%
1.1%
0.9%
1.5%
0.9%
21.8%
13.5%
8.8%
3.1%
8.5%
6.6%
4.2%
2.6%
0.9%
1.7%
0.5%
0.4%
0.2%
0.4%
0.5%
3.2%
2.0%
1.8%
0.3%
1.9%
White British
White (Non British)
Mixed
Asian Or Asian British
Black Or Black British
Chinese
Any Other Ethnic Group
The recruitment picture by ethnicity has been fairly similar for the third year running and shows that in the
main, the percentage of staff appointed by each ethnic category is reflective of those currently employed.
However, there is a higher percentage of white British people appointed than applied and therefore in all other
non-white British categories the success rate for these groups is lower.
Action – this area requires further exploration now by the BME Forum as the picture has not improved
over the last year period.
2.5 Religion or Belief
Characteristic Category
Christianity
Atheism
Buddhism
Hinduism
Islam
Judaism
Sikhism
Other
% Total
Applicants
% Total
% Total Staff
% Local
% WSHT Staff
Candidates
Appointed To Population
(September
Interviewed
Roles
2013)
57.5%
65.1%
66.9%
66.9%
74.8%
12.5%
14.9%
17.4%
29.1%
11.8%
1.6%
0.8%
0.6%
0.4%
1.1%
5.9%
3.6%
1.7%
1.0%
2.1%
11.9%
3.4%
1.1%
1.7%
1.5%
0.3%
0.1%
0.1%
0.2%
0.2%
0.4%
0.2%
0.1%
0.2%
0.4%
10.0%
11.8%
12.1%
0.6%
8.1%
This table shows that again, although applicants from an Islamic faith do not have as much success
throughout the recruitment process as applicants from other religions or beliefs, the percentage appointed is
more or less in line with those already employed and those within the local population. It is encouraging to
16
observe that the percentage employed for each category is very reflective of both the local population and the
percentage already employed. The other category still requires exploration in order for us to understand
some examples of what people believe this category includes. The number of atheists appointed has
increased slightly from last year and is higher than those applied or already in post, however this category has
increased in the local population recently.
Action – send out a questionnaire to all those who answered “other” to religion or belief asking what
other means to them.
2.6 Sexual Orientation
Characteristic Category
Heterosexual
Bisexual
Gay
Lesbian
% Total
Applicants
% Total
% Total Staff
% Local
% WSHT Staff
Candidates
Appointed To Population
(September
Interviewed
Roles
2013)
97.1%
96.9%
97.9% Not Available
98.2%
1.3%
1.3%
0.6% Not Available
0.6%
1.1%
1.1%
0.7% Not Available
0.7%
0.6%
0.6%
0.7% Not Available
0.5%
Similar to last year, there does not appear to be any great disparity between the stages of recruitment for any
category within sexual orientation or any real difference between the levels appointed or already employed at
the Trust.
2.7 Marital Status
Marital status is not recorded on NHS Jobs during the recruitment process.
17
3) ARE THERE ANY ISSUES IN RELATION TO STAFF LEAVING
THE ORGANISATION?
The following tables break down WSHFT turnover by protected characteristics. The turnover figures quoted
have been calculated by working out the average number of staff in the given category over the reporting
period and dividing by the total leavers from that particular category over the same period. Any staff who have
not disclosed a given characteristic have been excluded from the figures, as have staff on fixed term
contracts.
Leavers:
Mean
Turnover %
01/10/12 Headcount
30/09/13
ALL STAFF
524
6418
8.16%
Characteristic Category
Overall, the turnover figure for the Trust is relatively low at 8.16% and has decreased from 9.48% last year.
3.1 Age
Characteristic Category
Under 20
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
70 - 74
75 - 79
Undisclosed
Leavers:
Mean
01/10/12 Turnover %
Headcount
30/09/13
4
20.5
19.51%
50
336.5
14.86%
51
731.5
6.97%
57
730
7.81%
67
851
7.87%
54
867
6.23%
52
882.5
5.89%
50
828.5
6.04%
55
674
8.16%
69
361
19.11%
11
112.5
9.78%
4
20
20.00%
0
3
0.00%
0
0
0.00%
Turnover rates seem to have stabilised more over the past year within the age protected characteristic, with
under 20 year old turnover reducing by more than 50%. The extreme younger and older workers are still the
highest in terms of turnover but this does not give great cause for concern.
18
3.2 Gender
Leavers:
Mean
Turnover %
Characteristic Category
01/10/12 Headcount
30/09/13
Female
408
5012
8.14%
Male
116
1406
8.25%
Undisclosed
0
0
0.00%
The difference in percentage turnover between the two genders is not significant and has not changed very
much since last year and therefore does not highlight any issues to be addressed.
3.3 Disability
Leavers:
Mean
Turnover %
Characteristic Category
01/10/12 Headcount
30/09/13
Disabled
21
132.5
15.85%
Not Disabled
278
3181
8.74%
Undisclosed
225
3104.5
7.25%
The turnover rate of disabled staff has increased since last year and is quite a lot higher than for non-disabled
staff.
Given the high turnover for disabled staff over the period 1st Oct 2012 to 30th Sept 2013 (15.85% for disabled
staff compared to 8.16% for WSHFT) a further report has been developed into the reasons for leaving. The
table below shows the results:
Not
Disabled/Not
Disabled
Declared
Dismissed
17
3
Other Reason
29
2
Retirement
118
3
Voluntary Resignation
319
10
Voluntary Resignation - Health Related 20
3
Grand Total
503
21
Grouped Reason
%
Leavers
With
Declared Disability
17.6%
6.9%
2.5%
3.1%
15.0%
4.2%
Reading the above table we can see that disabled members of staff made up 17.6% of those staff who were
dismissed and 15% of those staff who left voluntarily but for health related reasons. Whilst these figures are
much higher than the proportion of disabled staff in the trust (4.1% of those who declared either way), it must
be noted that the numbers are very small so not much statistical significance can be attached to them.
Action – Possibility of a retrospective E&D specific exit questionnaire to be sent to home addresses
19
3.4 Ethnicity
Leavers:
Mean
Characteristic Category
01/10/12 Turnover %
Headcount
30/09/13
White British
407
4887
8.33%
White (Non British)
36
421
8.55%
Mixed
11
61
18.03%
Asian Or Asian British
34
528.5
6.43%
Black Or Black British
13
105
12.38%
Chinese
1
30.5
3.28%
Any Other Ethnic Group
5
107
4.67%
Undisclosed
17
278
6.12%
The turnover rate for each ethnicity is lower than the Trust average apart from those who are mixed race
where it is 18.03% and Black or Black British staff.
Action – As the actual number of leavers in these 2 categories are small, BME Forum to look into
sending an E&D specific retrospective exit questionnaire to home addresses to get a better
understanding of whether there is an actual problem or not.
3.5 Religion or Belief
Leavers:
Mean
Turnover %
Characteristic Category
01/10/12 Headcount
30/09/13
Christianity
274
3162.5
8.66%
Atheism
34
487.5
6.97%
Buddhism
8
46.5
17.20%
Hinduism
8
89.5
8.94%
Islam
7
66.5
10.53%
Judaism
0
8.5
0.00%
Sikhism
0
13
0.00%
Other
17
334.5
5.08%
Undisclosed
176
2209.5
7.97%
There does not appear to be any issues in relation to leavers by religion or belief. Although those with a
Buddhist or Islamic religions appear high at 17.20% and 10.53% respectively this only equates to a few staff.
3.6 Sexual Orientation
Leavers:
Mean
Turnover %
Characteristic Category
01/10/12 Headcount
30/09/13
Heterosexual
348
4293
8.11%
Bisexual
2
22.5
8.89%
Gay
2
31.5
6.35%
Lesbian
2
20.5
9.76%
Undisclosed
170
2050.5
8.29%
20
Table 3.6 is showing a much improved picture since last year in this category with a fairly even percentage
spread between each group. This is very encouraging.
3.7 Marital Status
Characteristic Category
Divorced
Legally Seperated
Married or Civil Partnership
Single
Widowed
Undisclosed
Leavers:
Mean
01/10/12 Turnover %
Headcount
30/09/13
48
465.5
10.31%
10
80
12.50%
264
3612
7.31%
165
1881.5
8.77%
13
90.5
14.36%
24
288.5
8.32%
As was the case in last year’s results, there does not appear to be any significant issues for leavers by marital
status and although this is slightly higher in the widowed category, this may be related to age.
21
4) ARE THERE ANY ISSUES IN RELATION TO EMPLOYEE
RELATIONS CASES WITHIN THE ORGANISATION?
This section is concerned with looking at the formal Disciplinary Hearings and Grievances raised, by each of
the protected characteristics monitored at the Trust between the aforesaid periods.
A separate report into the Behaviour Management cases raised over the last 3 years will be presented to the
Diversity Matters Group in April 2014. This will include analysis on the protected characteristics of the
individuals raising concerns and the individuals the allegations are against.
In total there have been 78 Disciplinaries in the reporting period and 8 Grievances raised. Both areas have
seen an increase over the last 3 years as shown in the graph below. This increase has been acknowledged
and the human resources department have recently undergone a restructure, in part to better manage the
increased employee relations activity and there now exists a dedicated employee relations team. This team
are currently working on the reporting tool for cases and analysing the breakdown of cases in order to support
managers in proactively managing some of the reasons. It is also true that in recent years cultural issues
have been reinforced and expectations made clearer which may have resulted in more issues being tackled
and managed than before.
4.1Age
22
There has been an increase in the number of disciplinaries for the 45-49 year old age category since last
year. However, from a more positive perspective , this now represents a more normal distribution than it did
last year and is more in line with the staff we employ as shown in fig 1.12.
The grievances raised appear to be mainly from the 45-49 year olds, which is reflective of where the majority
of our staff are aged.
4.2 Gender
23
Similarly to the last two years, there are a higher percentage of disciplinaries for males than the percentage
we employ. When looking at the cases used in this reporting period, there are a number of medical cases
involving male staff, many of which are from an overseas background. Again, the learning and cultural issues
are being reinforced through the Trust’s Managing in the NHS Programme and at Induction. The number of
grievances raised is more reflective of the staff employed.
4.3 Disability
There does not appear to be any issues with disciplinaries for disabled staff as these equate to 1% of the
hearings and there were no grievances raised by disabled staff in the reporting period.
4.4Ethnicity
68% of the disciplinaries held were for staff from a white British background, compared to 79.2% of our total
employed staff being white British.
Action – BME Forum to focus on this area as the level of disciplinaries for white non-British staff is
disproportionately high. ER team in HR to focus on cases in relation to staff from overseas and
24
ensure the expectations are made clear at Trust induction and through the Managing in the NHS
Programme.
Although the number of grievances are smaller, there are more raised by Black African staff than you might
expect.
Action - BME Forum to look into also
4.5 Religion or Belief
The number of disciplinaries and grievances by religion or belief appears to reflect that of the total staff we
employ.
25
26
4.6 Sexual Orientation
The level of staff declaring their sexual orientation in the Trust in general has again increased this year. From
the data we have, it appears that the largest majority of disciplinaries were for heterosexual staff, followed by
those who did not disclose their sexuality. This is in line with the staff already employed.
Again, there do not appear to be any issues in relations to grievances raised by sexual orientation.
27
4.7 Marital Status
The level of disciplinaries by marital status is in line with the marital status the staff employed.
For grievances raised, there are slightly more from legally separated than the number we employ, however in
total this only equates to 1 grievance.
28
5) IS ACCESS TO TRAINING FAIR FOR ALL STAFF?
The tables below show the results of a simple analysis of training courses completed by WSHFT staff. All
training courses successfully completed over the reporting period are included and broken down by protected
characteristics. Any E-Learning undertaken has been excluded from this analysis.
5.1 Age
Characteristic Category
% Of Workforce
Under 20
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
70 - 74
75 - 79
% Of Total Training
0.3%
6.9%
11.9%
12.0%
14.7%
14.2%
14.7%
12.3%
8.3%
3.6%
0.8%
0.1%
0.0%
0.4%
5.2%
11.7%
11.1%
12.9%
13.6%
13.8%
12.8%
10.7%
5.6%
2.0%
0.3%
0.0%
The percentage of training undertaken by age is reflective of the percentage of the workforce and therefore
there are no issues to address within this category.
5.2 Gender
Characteristic Category
% Of Workforce
Female
Male
% Of Total Training
85.8%
14.2%
78.1%
21.9%
This is proportionate to the percentage of staff employed and is the same as last year’s results.
5.3 Disability
Characteristic Category
Disabled
Not Disabled
% Of Workforce
% Of Total Training
3.8%
96.2%
3.9%
96.1%
This is proportionate to the percentage of staff employed and is similar to last year’s results.
29
5.4 Ethnicity
Characteristic Category
% Of Workforce
White British
White (Non British)
Mixed
Asian Or Asian British
Black Or Black British
Chinese
Any Other Ethnic Group
% Of Total Training
80.3%
7.2%
0.7%
8.1%
1.3%
0.6%
1.7%
79.2%
7.2%
0.9%
8.5%
1.7%
0.5%
1.9%
This is proportionate to the percentage of staff employed in these categories and is similar to last year’s
results.
5.5 Religion or Belief
Characteristic Category
% Of Workforce
Christianity
Atheism
Buddhism
Hinduism
Islam
Judaism
Sikhism
Other
% Of Total Training
76.8%
11.2%
0.9%
1.1%
1.2%
0.2%
0.3%
8.4%
74.8%
11.8%
1.1%
2.1%
1.5%
0.2%
0.4%
8.1%
This is proportionate to the percentage of staff employed in these categories and is similar to last year’s
results.
5.6 Sexual Orientation
Characteristic Category
Heterosexual
Bisexual
Gay
Lesbian
% Of Workforce
% Of Total Training
98.7%
0.4%
0.5%
0.3%
98.2%
0.6%
0.7%
0.5%
Access to training by sexual orientation is comparative to the overall number of staff employed within this
category.
30
5.7 Marital Status
Characteristic Category
Divorced
Legally Seperated
Married or Civil Partnership
Single
Widowed
% Of Workforce
% Of Total Training
7.4%
1.4%
57.6%
32.3%
1.3%
7.5%
1.3%
58.7%
31.1%
1.4%
Access to training by marital status is comparative to the overall number of staff employed within this
category.
31
6) ARE ALL AREAS OF THE TRUST ENSURING THAT THEIR
STAFF ATTEND EQUALITY & DIVERSITY TRAINING EVERY 3
YEARS?
The tables below show the percentages of staff that were up to date with Equality and Diversity training in
WSHFT as of 30th September 2013.
6.1 E & D Training Across WSHFT
WSHT
Grand Total
% Up To Date
% Up To Date
30th Sept 2012 30th Sept 2012
68.3%
91.3%
The Trust has met its target of 90% for E&D training in the last year and in fact, has almost tripled the amount
of people up to date over the last two years. E&D sessions have been running on each health and safety
update and full day and induction course on each site, as well as ad hoc sessions. E&D training will be
removed from the health and safety updates for the next year but will continue during induction, full health &
safety day and as part of other courses such as Managing in the NHS and ad hoc sessions. The content of
the E&D training has been updated and improved within the last year and there are plans to roll out the on
line training designed for Doctors to include other types of staff.
6.2 E & D Training By Division
Division
Core Services
Corporate
Facilities & Estates
Medicine
Surgery
Women & Children
% Up To Date
% Up To Date
30th Sept 2012 30th Sept 2012
86.4%
96.3%
78.3%
93.2%
64.6%
95.1%
58.1%
88.5%
54.4%
89.4%
76.1%
88.0%
All divisions now have more than 85% of their staff up to date with E&D training.
6.3 E & D Training By Staff Group
% Up To Date
% Up To Date
30th Sept 2012 30th Sept 2012
Add Prof Scientific and Technic
82.6%
93.7%
Additional Clinical Services
63.8%
90.4%
Administrative and Clerical
78.1%
96.0%
Allied Health Professionals
85.7%
96.3%
Estates and Ancillary
64.9%
94.5%
Healthcare Scientists
95.1%
97.8%
Medical and Dental
71.7%
77.3%
Nursing and Midwifery Registered
65.3%
91.8%
Students
50.0%
50.0%
Staff Group
32
Again, there has been much improvement made when looking at the percentages up to date by staff group,
however the medical and dental staff and students are still the groups with the least compliance and
discussion should take place with the learning and development team to see how this can be improved.
6.4 E & D Training By Payband
Payscale Description
Band 1
Band 2
Band 3
Band 4
Band 5
Band 6
Band 7
Band 8+
Medical
Other
% Up To Date
% Up To Date
30th Sept 2012 30th Sept 2012
63.4%
94.2%
61.6%
91.7%
81.6%
94.9%
72.9%
93.8%
55.8%
91.9%
78.1%
94.1%
81.5%
95.6%
81.0%
94.3%
71.9%
77.3%
33.3%
95.0%
As shown in the training by staff group category at 6.3, the medical and dental paybands are less up to date
than the other paybands.
Action – discuss with learning and development how to engage with medical and dental staff and
students in order to ensure these groups are at least 90% up to date.
33
7) ARE THE NUMBERS OF STAFF BY PAYBAND
REPRESENTATIVE OF THE TOTAL STAFF WE EMPLOY?
The following tables show how the total number of staff at a given payband is distributed by protected
characteristic categories. For example, reading off the top row of table 7.1 we can see that whilst the under
20s make up 0.4% of the WSHFT workforce on agenda for change (AfC) payscales, they constitute 0.9% of
the total staff on paybands 1-3.
7.1 Age
Characteristic Category
Under 20
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
70 - 74
75 - 79
% In Category For Paygroup % Medical % In Category For Paygroup
Staff In
Medical Medical Medical Medical
Band 1-3 Band 4-6 Band 7+
Category 20k-40k 40k-60k 60k-80k 80k+
0.4%
0.9%
0.1%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
5.3%
7.8%
4.7%
0.0%
4.7% 10.1%
0.0%
0.0%
0.0%
10.2% 10.3% 12.1%
2.6%
24.2% 52.3%
0.0%
0.0%
0.0%
10.6%
9.5% 12.4%
7.2%
15.4% 24.9% 31.0%
3.3%
0.0%
12.9% 10.1% 15.1% 14.1%
12.7%
7.8% 31.0% 33.7%
4.9%
13.5% 12.1% 14.0% 15.8%
14.2%
2.9% 31.0% 22.8% 21.7%
14.2% 11.5% 14.8% 20.4%
10.0%
1.4%
3.6% 17.4% 22.6%
13.3% 12.7% 12.1% 19.5%
8.7%
0.6%
2.4%
8.7% 23.5%
11.3% 13.0%
8.9% 14.5%
6.3%
0.0%
1.2%
7.6% 17.3%
5.8%
7.6%
4.5%
5.4%
3.1%
0.0%
0.0%
5.4%
8.0%
2.1%
3.6%
1.2%
0.7%
0.7%
0.0%
0.0%
1.1%
1.8%
0.3%
0.8%
0.0%
0.0%
0.1%
0.0%
0.0%
0.0%
0.4%
0.1%
0.1%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
% AfC
Staff In
Category
Agenda for change:
When looking at the paybands by age categories we can see that the middle aged groups more dominate the
higher pay bands, however the spread appears to be normal and there does not appear to be any group that
stands out.
Medical staff:
Similarly to last year, the pay for medical staff follows a normal career/training pattern with salary increasing
with age up until the age of 54 where it reduces again nearing retirement.
7.2 Gender
Characteristic Category
Female
Male
% AfC
Staff In
Category
82.3%
17.7%
% In Category For Paygroup % Medical % In Category For Paygroup
Staff In
Medical Medical Medical Medical
Band 1-3 Band 4-6 Band 7+
Category 20k-40k 40k-60k 60k-80k 80k+
76.0%
24.0%
88.2%
11.8%
80.5%
19.5%
46.5%
53.5%
59.2%
40.8%
38.1%
61.9%
52.2%
47.8%
27.9%
72.1%
Agenda for change:
The picture by payband appears to have improved since last year when nearly 50% of staff at pay band 1
were male. However although this appears more reflective of the percentages we employ this year, the
paybands have been grouped more.
Medical staff:
Again this is a similar picture to last year with a much higher percentage of the top earners being male than
the proportion employed. It should be noted that this report is based on earnings, rather than grades and
therefore part time working would be included.
34
7.3 Disability
Characteristic Category
Disabled
Not Disabled
% AfC
Staff In
Category
4.2%
95.8%
% In Category For Paygroup % Medical % In Category For Paygroup
Staff In
Medical Medical Medical Medical
Band 1-3 Band 4-6 Band 7+
Category 20k-40k 40k-60k 60k-80k 80k+
5.3%
94.7%
3.3%
96.7%
3.9%
96.1%
1.2%
98.8%
1.3%
0.0%
0.0%
98.7% 100.0% 100.0%
1.9%
98.1%
As the numbers within the disabled category are fairly small, a slight change can look alarming, however it
should be noted that there are very few disabled medical staff and none in the £40-80k category. In addition,
disabled staff are slightly under represented in the agenda for change paybands 4+.
7.4 Ethnicity
Characteristic Category
White British
White (Non British)
Mixed
Asian Or Asian British
Black Or Black British
Chinese
Any Other Ethnic Group
% In Category For Paygroup % Medical % In Category For Paygroup
Staff In
Medical Medical Medical Medical
Band 1-3 Band 4-6 Band 7+
Category 20k-40k 40k-60k 60k-80k 80k+
81.7% 81.3% 79.4% 91.3%
57.7% 56.4% 33.8% 56.2% 67.8%
6.8%
8.6%
5.9%
4.3%
11.0% 10.9% 16.2%
6.7% 11.2%
0.7%
0.7%
0.8%
0.7%
2.8%
4.0%
1.5%
4.5%
0.9%
7.2%
6.4%
9.3%
1.9%
20.1% 19.6% 36.8% 21.3% 15.0%
1.5%
1.2%
2.2%
0.4%
3.1%
4.0%
2.9%
5.6%
0.9%
0.4%
0.4%
0.4%
0.6%
1.4%
1.5%
1.5%
0.0%
1.9%
1.7%
1.4%
2.1%
0.8%
3.9%
3.6%
7.4%
5.6%
2.3%
% AfC
Staff In
Category
Agenda for change:
The spread over paybands is reflective of the percentage of staff employed for all ethnic categories listed,
apart from white British where there are nearly 10% more in band 7 and above than the percentage we
employ in total and 2.5% less white non-British staff in band 7 above roles.
Action – this requires further exploration by the BME Forum who should now give some focus to
eliminating any discrimination for white non-british staff.
Medical staff:
The picture here is fairly reflective of the numbers employed overall throughout the different pay. However,
there are 5% less Asian Medical staff in the £80k category than employed overall.
7.5 Religion or Belief
% In Category For Paygroup % Medical % In Category For Paygroup
Staff In
Medical Medical Medical Medical
Band 1-3 Band 4-6 Band 7+
Category 20k-40k 40k-60k 60k-80k 80k+
Christianity
78.3% 77.9% 78.4% 79.4%
48.5% 45.1% 31.5% 50.0% 61.2%
Atheism
10.6%
8.9% 11.2% 13.2%
21.1% 26.9% 13.0% 15.7% 16.4%
Buddhism
0.6%
0.9%
0.5%
0.6%
4.1%
4.3%
9.3%
5.7%
0.7%
Hinduism
0.9%
1.1%
0.8%
1.0%
10.8%
7.1% 27.8% 10.0% 11.2%
Islam
0.7%
0.8%
0.8%
0.2%
7.4%
8.3% 14.8%
8.6%
2.2%
Judaism
0.1%
0.2%
0.1%
0.2%
1.0%
0.8%
1.9%
1.4%
0.7%
Sikhism
0.2%
0.1%
0.2%
0.2%
1.6%
2.4%
0.0%
1.4%
0.7%
Other
8.5% 10.0%
8.1%
5.2%
5.5%
5.1%
1.9%
7.1%
6.7%
There does not appear to be any significant results here other than a higher percentage of Christian Medical
staff earning over £80k compared to other beliefs and compared to the percentage of Medical staff in general.
Characteristic Category
% AfC
Staff In
Category
35
7.6 Sexual Orientation
Characteristic Category
% In Category For Paygroup % Medical % In Category For Paygroup
Staff In
Medical Medical Medical Medical
Band 1-3 Band 4-6 Band 7+
Category 20k-40k 40k-60k 60k-80k 80k+
98.2% 98.2% 98.1% 98.5%
97.8% 96.4% 100.0% 98.6% 99.3%
0.6%
0.7%
0.6%
0.4%
0.6%
1.1%
0.0%
0.0%
0.0%
0.7%
0.7%
0.7%
0.8%
0.9%
1.1%
0.0%
1.4%
0.7%
0.5%
0.5%
0.5%
0.4%
0.7%
1.4%
0.0%
0.0%
0.0%
% AfC
Staff In
Category
Heterosexual
Bisexual
Gay
Lesbian
Again, here the percentages are so small but do not show any cause for concern. When looking at pay the
picture appears fairly reflective of the sexual orientation profile of the workforce in general.
7.7 Marital Status
Characteristic Category
Divorced
Legally Seperated
Married or Civil Partnership
Single
Widowed
% In Category For Paygroup % Medical % In Category For Paygroup
Staff In
Medical Medical Medical Medical
Band 1-3 Band 4-6 Band 7+
Category 20k-40k 40k-60k 60k-80k 80k+
8.3%
9.9%
7.0%
8.0%
1.7%
0.0%
0.0%
4.5%
3.9%
1.4%
1.5%
1.2%
1.6%
0.4%
0.0%
0.0%
1.1%
1.0%
58.8% 54.8% 59.4% 69.2%
57.5% 25.2% 81.3% 79.8% 89.8%
29.9% 31.5% 31.3% 19.9%
40.4% 74.8% 18.8% 14.6%
5.3%
1.6%
2.3%
1.1%
1.3%
0.0%
0.0%
0.0%
0.0%
0.0%
% AfC
Staff In
Category
Agenda for change
There appears to be less single higher earners and more married higher earners than employed in general,
however this would make sense when looking at the picture from a career pathway point of view.
Medical Staff
The picture for medical staff is similar to agenda for change above, however there is a significant drop in the
number of single medical staff earning more than £80k compared to employed in general.
Actions – The picture for AFC and Medical staff earnings is fairly representative by the protected
characteristics and indeed some areas have improved. However when looking at ethnicity there are
still differences between the categories and this is more evident for the white non-British staff who
appear to be very underrepresented in the higher earning categories. BME Forum to explore this and
come up with an action plan to begin to tackle.
36
8) HOW SATISFIED ARE OUR STAFF?
1.00
INTRODUCTION
1.01
The National Staff Survey is undertaken each year by all NHS Trusts within England and Wales. For the
2012 survey, roll out to all substantive staff in the Trust was undertaken for a 3rd year. Quality Health
administered the survey for the Trust.
2.00
SUMMARY OF RESULTS
2.01
Our overall response rate for the staff survey was 47%, compared to 50% in 2011. The Care Quality
Commission (CQC) have now analysed the staff survey results for all organisations in the NHS and have
published detailed comparative analysis.
2.02
Overall indicator of staff engagement.
– a composite ‘headline’ indicator is put together for staff
engagement on the basis of evidence that correlates the level of staff engagement with patient experience
and outcomes. Our results show the Trust was average when compared with other acute Trusts in relation
to these indicators i.e. staff ability to contribute towards improvements at work, staff recommendation of the
Trust as a place to work or receive treatment and staff motivation at work.
2.03
The Trusts top 5 ranking scores compared to other acute Trusts:
1. Percentage of staff receiving health and safety training in the last 12 months (Trust score 92%,
National average % score for acute trusts 74%). Best 20% of acute trusts
2. Percentage of staff appraised in last 12 months (Trust score 93%, National average score for acute
trusts 84%) Best 20% of acute trusts
3. Percentage staff having equality and diversity training in the last 12 months (Trust score 72%,
National average % score for acute trusts 55%) Best 20% of acute trusts
4. Staff recommendation of the Trust as a place to work or receive treatment (Trust score 3.69,
National average % score for acute trusts 3.57%)
5. Percentage of staff having well-structured appraisals in last 12 months (Trust score 38%, National
average % score for acute trusts 36%)
2.04
The largest local changes where staff experience has improved since the 2011 survey. This is a positive
local result. (The higher the score the better)
1. Percentage of staff able to contribute towards improvements at work (Trust score 2012, 65%, %
score in 2011 survey 57%)
2. Percentage of staff appraised in last 12 months (Trust score 2012, 93%, score in 2011 survey 83%)
37
3. Staff job satisfaction (Trust score 2012 3.53, score in 2011 survey 3.42)
4. Fairness and effectiveness of incident reporting procedures (Trust score 2012, 3.47, score in 2011
survey 3.34)
5. Percentage of staff having equality and diversity training in last 12 months (Trust score 2012, 72%,
score in 2011 survey 53%)
2.05
The bottom 5 ranking scores compared to other acute Trusts:
1. Percentage of staff experiencing physical violence from patients, relatives or the public in the last 12
months (Trust score 19%, National average score for acute trusts 15%). Worst 20% of acute
trusts
2. Percentage of staff experiencing physical violence from staff in the last 12 months (Trust score 54%,
National average for acute trusts 66%)
3. Staff motivation at work (Trust score 3.76, National average for acute trusts 3.84)
4. Percentage of staff feeling pressure in the last 3 months to attend work when feeling unwell (Trust
score 32%, National average for acute trusts 29%)
5. Percentage of staff working extra hours (Trust score 72%, National average for acute trusts 70%)
2.06
The two key findings where staff experiences have deteriorated since the 2011 survey:
1. Percentage of staff suffering work-related stress in the last 12 months (Trust score 2012, 46%,
score in 2011 survey 28%)
2. Percentage of staff saying hand washing materials are always available (Trust score 2012, 53%,
score in 2011 survey 65%)
3.0
CONCLUSIONS AND ACTIONS
3.01
Against the key areas of focus from last year’s staff survey results and action plan we have seen positive
improvements in our survey results. This includes appraisal, health and safety training, staff satisfaction
and overall staff engagement.
3.02
A key area for improvement is the health and wellbeing of staff. This is reflected in survey findings and the
increased work pressure felt by staff; the rise in the percentage of staff working extra hours; the percentage
of staff suffering from work related stress and the percentage of staff experiencing physical violence and
harassment, bullying or abuse. A key piece of work for 2013 is the Health and Wellbeing Strategy and the
development and implementation of the annual Health Improvement Plan.
3.03
Further analysis of the full results was undertaken by division and action plans refreshed and updated
appropriately.
Discrimination
In the last annual report there was a focus on discrimination as part of this section as there had been a 5% increase
from the previous year overall. The results for 2012 are shown below:

Does your organisation act fairly with regard to career progression /promotion, regardless of ethnic
background, gender, religion, sexual orientation, disability or age?
Yes
No
Don’t know
Missing
Total
1806
175
1033
43
2011
60%
6%
34%
Total
1614
160
881
62
2012
61%
6%
33%
Total
43062
6242
24992
1879
All
58%
8%
34%
There is a very slight improvement with regard to fairness in pay progression compared to last year.
38

In the last 12 months, have you personally experienced discrimination at work from your manager /
team leader or other colleagues?
Total
2011
Total
2012
Total
All
Yes
245
8%
210
8%
5619
8%
No
2753
92%
2437
92%
68277
92%
Missing
59
70
2279
This result is the same as last year. Although the divisions have not focused on this as an area of
improvement this is because the result has not worsened. However, the result is still fairly high and therefore
it is recommended that this is looked again specifically as part of the 2013 staff survey results which will be
available in early 2014.

On which grounds have you experienced discrimination?
Total
2011
Total
2012
Ethnic
153
37%
128
41%
Background
Missing
263
184
Gender
61
15%
40
13%
Missing
355
272
Religion
18
4%
10
3%
Missing
398
298
Sexual
17
4%
14
4%
Orientation
Missing
399
298
Disability
30
7%
14
4%
Missing
386
298
Age
76
18%
61
20%
Missing
340
251
Other
131
31%
92
29%
Missing
285
220
Total
3167
5007
1222
6952
333
7881
293
7881
529
7645
1380
6794
2635
5539
All
39%
15%
4%
4%
6%
17%
32%
There appears to be slightly more discrimination taking place on the grounds of age and ethnic background than the
year before.
During 2013, the Trust had 2 separate equality and diversity weeks. The first was in May and the focus was on
ethnicity and celebrating the cultural diversity of our staff. The second week focused on age and encouraged staff
to participate in quizzes and interactive exercises. Each event promoted the PFD (personal, fair and diverse)
champion campaign and the Trusts various equality forums. As a result we now have approximately 20 PFD
champions.
Action – to analyse the 2013 staff survey results in relation to discrimination and report back to the
Diversity Matters Group in April 2014. (NB)
39
9) WHAT DO OUR STAFF TELL US IN REAL TIME?
Over the last 15 months the Trust has been engaging with its staff in order to understand staff feelings and
attitudes in real time rather than just waiting for yearly staff survey results.
This engagement takes place each week at the mandatory training updates on each site in the form of a
written questionnaire and is based on specific themes or areas it is felt require further feedback.
Regular reports on the findings from these questionnaires are given to the Trust Board and any areas that
require actions are passed to the relevant lead or head of service.
Questions asked
Each month there are specific themes that are focussed on as part of the real time questionnaires. These are
planned mainly on a quarterly basis and the responses to these questions are given back to the manager for
that area and are presented to the Trust Board. Examples of these themes are discrimination, where as a
result of the 2011 staff survey results, further questions were asked of staff, stress, and communication.
These questions allow the Trust to gather rich data as a snapshot of how staff are feeling about current
problem topics or areas of focus in the here and now.
In addition to the themes each month, 2 specific questions have been asked each month since the
introduction of the surveys in September 2012. These are:
1 – I would recommend my Trust as a place to work.
2 – If a friend or relative needed treatment, I would be happy with the standard of care provided by this
organisation.
The results from these questions are analysed month against month, cumulatively as a Trust and also by
Division. This information is presented and discussed at Trust Board and at each Divisional Board meeting.
As of November 2013, just over 80% of staff would recommend the Trust as a place to work and again just
over 80% as a place to receive treatment.
40
10) DO THE PATIENTS WE SERVE REPRESENT THE LOCAL
POPULATION?
Demographic Figures October 2012 to September 2013
The following data is based on the activity for the 1 October 2012 to 30 September 2013. In each point of
delivery (i.e. A&E, inpatient or outpatient) patients have only been counted once, but the groups are not
treated as mutually exclusive (i.e. a patient may be counted up to three times – as an inpatient, outpatient and
A&E attendance).

There were a total of 117,245 inpatient admissions (electives, day-cases, emergencies and other
categories) between 1 October 2012 and 30 September 2013. This was slightly higher than last
year’s results. This comprised of 74,716 different patients.

There were a total of 456,660 outpatient attendances for 150,741 different patients, slightly less than
in last year’s reporting period.

There were a total of 133,117 A&E attendances for 95,490 different patients, slightly more than the
last two years results.
Gender
(2012)
Inpatients
(2012)
Outpatients
(2012)
Local
Population
A&E
(Census
2011)
48,012
50%
52%
(50%)
32,321 (43%) 43%
64,696 (43%)
43%
47,478
50%
48%
Male
(50%)
The table above shows that the percentage of males to female inpatients, outpatients and A&E attendees
Female
42,395 (57%)
57%
86,045 (57%)
57%
treated within the last year is similar to the gender split as shown in the 2011 Census data and has not
changed significantly over the last 3 years within the Trust.
Marital status (patients aged > 15)
(2012)
Inpatients
(2012)
Outpatients
(2012)
Local
Population
A&E
(Census 2011)
Single
Married/Separated
Widowed
Not known
Divorced
11,189
(17%)
25,061
(39%)
4504 (7%)
17%
21,556 (16%)
16%
39%
48,747 (37%)
37%
7%
6253 (5%)
5%
21,781
(34%)
2373 (4%)
33%
20,382 (38%)
39%
4%
4392 (3%)
3%
20,519
(27%)
23,762
(31%)
3820
(5%)
26,317
(34%)
2019
(3%)
28%
31%
31%
54%
5%
7%
34%
n/a
3%
7%
41
The picture for patients treated by marital status within the Trust is almost exactly the same as the results by
each category in the last reporting period.
The data shows that there is some disparity, with the key
differences being the high percentage (above 30% in all types of patients) of not known for patients within the
Trust, as well as us having treated in general approximately 20% less married/separated patients than the
proportion of the population we serve. In general the Trust seems to have treated less of a percentage in all
categories of marital status (apart from single persons in A&E which is 4% higher than the Census data),
however with such a high level of unknowns, these figures would obviously increase in each category if we
had full data.
It should also be noted that within the Census data there has been an increase in the single population from
24% to 31% over the last 10 years.
Ethnic Origin
(2012)
Inpatients
(2012)
Outpatients*
(2012)
A&E*
Local
population
(Census 2011)
African
104 (0%)
0%
155 (0%)
0%
105 (0%)
0%
Asian
207 (0%)
0%
357 (0%)
0%
237 (0%)
0%
Black
37 (0%)
0%
66 (0%)
0%
79 (0%)
0%
187 (0%)
0%
345 (0%)
0%
256 (0%)
0%
mixed
258 (0%)
0%
397 (0%)
0%
498 (1%)
0%
White
3145 (4%)
4%
5712 (4%)
4%
4790 (5%)
5%
Bangladeshi
108 (0%)
0%
166 (0%)
0%
115 (0%)
0%
British
78%
0%
70,741
(74%)
27 (0%)
74%
0%
107,124
(71%)
47 (0%)
72%
Caribbean
58,143
(78%)
25 (0%)
0%
Chinese
82 (0%)
0%
145 (0%)
0%
93 (0%)
0%
Indian
167 (0%)
0%
291 (0%)
0%
209 (0%)
0%
Irish
235 (0%)
0%
413 (0%)
0%
266 (0%)
0%
Any
other
background
Any
other
background
Any Other ethnic
Group
Any
other
background
Any
other
7.2%
background
Mixed
White
&
126 (0%)
0%
159 (0%)
0%
136 (0%)
0%
White
&
84 (0%)
0%
119 (0%)
0%
95 (0%)
0%
&
63 (0%)
0%
87 (0%)
0%
74 (0%)
0%
88.9%
Asian
Mixed
Black African
Mixed
White
Black Caribbean
42
16%
34,360 (23%)
22%
Not Known
11,497
(15%)
211 (0%)
0%
734 (0%)
Pakistani
37 (0%)
0%
64 (0%)
Not given
0%
17,435
(18%)
296 (0%)
18%
0%
0%
38 (0%)
0%
(All BME or non- white)
3.9%
Local Census data shows that the ethnicity of the local population is 88.9% White British and 3.9% BME and
7.2% white non-British. This has changed somewhat since the last Census in 2001. The data above appears
to show that we are treating less White British patients overall, as well as less BME staff overall in each of the
inpatient, outpatient and A&E categories. However, as discussed previously our internal data has a fairly high
percentage for not given or not known, as compared to none from the Census data and therefore it is fairly
difficult to accurately ascertain whether we treat patients reflective of the population we serve in terms of
ethnicity.
Internally, the picture has not changed significantly since last year’s report.
Age at first appointment, admission or attendance
Inpatients
(2012)
Outpatients
(2012)
A&E
(2012)
Local population
(Census 2011)
11%
8798 (6%)
6%
8215 (9%)
8%
5 to 9
7569
(10%)
1025 (1%)
1%
5210 (3%)
3%
4585 (5%)
5%
10 to 14
934 (1%)
1%
4405 (3%)
3%
5149 (5%)
6%
15 to 19
1735 (2%)
2%
4688 (3%)
3%
6244 (7%)
7%
20 to 24
2721 (4%)
4%
5076 (3%)
4%
6872 (7%)
8%
6.8%
25 to 29
3314 (4%)
4%
6381 (4%)
4%
5720 (6%)
6%
7.1%
30 to 34
3608 (5%)
5%
6829 (5%)
5%
5058 (5%)
5%
7.6%
35 to 39
2968 (4%)
4%
6231 (4%)
4%
4469 (5%)
5%
8.2%
40 to 44
3198 (4%)
5%
7555 (5%)
5%
5305 (6%)
6%
9.8%
45 to 49
3709 (5%)
5%
8587 (6%)
6%
5464 (6%)
6%
10%
50 to 54
3745 (5%)
5%
9030 (6%)
6%
4918 (5%)
5%
8.8%
55 to 59
3871 (5%)
5%
9155 (6%)
6%
4229 (4%)
4%
8%
60 to 64
4802 (6%)
7%
11,046 (7%)
8%
4237 (4%)
5%
8.9%
65 to 69
6484 (9%)
8%
14,114 (9%)
9%
4905 (5%)
5%
Over 65 in Census
date – 18.8%
70 to 74
5906 (8%)
8%
12,304 (8%)
8%
4159 (4%)
4%
75 to 79
5992 (8%)
8%
11,707 (8%)
8%
4487 (5%)
5%
80 to 84
5573 (7%)
7%
9916 (7%)
6%
4512 (5%)
5%
85+
7562
(10%)
9%
9709 (6%)
6%
6962 (7%)
7%
0 to 4
(Under 20 in 2011
Census – 6%)
The picture of patients by age has changed very little internally since last year, however there have been
some slight increases in the age spread of the local population, the Trust is still reflective of the population it
serves. There are some disparities within this, in particular in relation to the older population where the level
of inpatients is higher, as it is in the level of 0-4 year olds for obvious reasons. Between the ages of 20 and
65 the Trust is treating less proportionately of patients than the population we serve.
43
Religion
Religion is recorded for less than 40% of the cases therefore little can be drawn from the following
information. From those patients that religion or belief has been recorded, the information shows that the
number of beliefs recorded is less, i.e. the information is not broken down further by for example Hinduism,
Buddhism etc. and the percentage in each category is less. The picture in this reporting period is not
significantly different internally, to that of last year. Interestingly, in the local Population the percentage of
those considering themselves a Christian is significantly less than in the last census 10 years previous.
Action – The lead for Religion and Belief could put an action plan together to ensure that the religion
or belief of our patients is collected and monitored.
Inpatients
Church
of
England
Roman
(2012)
Outpatients
(2012)
Not Known
Local Population
(Census 2011)
26%
36,626
(24%)
25%
19,663
(21%)
21%
66.9%
2727 (4%)
4%
5103 (3%)
3%
2885
(3%)
3%
Not known
2588 (3%)
3%
4727 (3%)
3%
3652
(4%)
4%
33.1%
4976 (7%)
6%
8100 (5%)
5%
6577
(7%)
7%
N/A
45,248
(61%)
60%
96,185
(64%)
64%
62,713
(66%)
64%
N/A
religions
None
(2012)
19,177
(26%)
Catholic
Other
A&E
Learning disability
During the data period 364 outpatients, 196 inpatients and 262 patients who attended A&E were recorded as
having learning disabilities.
Other protected characteristics
As was the case last year, although there are spaces for recording those who are registered disabled on
Sema Helix these are not routinely completed.
In addition data is not collected for patients in relation to sexual orientation or gender reassignment
Pregnancy
The following shows a specific breakdown of ethnicity and age for patients admitted under or attending
outpatient appoints under the 501 (Obstetric) or 506 (Midwifery) specialty codes.

4827 admissions for 4134 different women, down slightly from the previous two reporting periods

30,586 appointments for 7692 patients, down slightly from the previous two reporting periods
This outpatient figure includes a handful of male patients. Furthermore given the very low age of some
outpatients (and the discrepancy between the inpatient and outpatient figures) it is likely that in a few cases
the appointment will have been booked in the infant’s name rather than the mother – although it might be
wrongly attributed to the specialty).
44
Ethnic code (obstetrics and midwifery only)
Inpatients
Outpatients
African
16 (0%)
25 (0%)
Any other Asian background
19 (0%)
35 (0%)
Any other Black background
3 (0%)
4 (0%)
Any Other ethnic Group
20 (0%)
38 (0%)
Any other mixed background
14 (0%)
19 (0%)
Any other White background
281 (7%)
515 (7%)
Bangladeshi
16 (0%)
25 (0%)
British
2502 (61%)
4398 (57%)
Caribbean
1 (0%)
1 (0%)
Chinese
8 (0%)
19 (0%)
Indian
21 (1%)
35 (0%)
Irish
11 (0%)
18 (0%)
Mixed White & Asian
2 (0%)
3 (0%)
Mixed White & Black African
4 (0%)
6 (0%)
Mixed
1 (0%)
2 (0%)
Not given
1195 (29%)
2500 (33%)
Not Known
13 (0%)
42 (1%)
Pakistani
7 (0%)
7 (0%)
White
&
Black
Caribbean
Again there is a large percentage (29% and 34%) of ethnic backgrounds not being recorded or given and
therefore it is still difficult, as was the case last year, to ascertain whether the proportion of BME persons
accessing these services is reflective of the population we serve.
The picture has not changed significantly over the last two reporting year periods.
Action – It does not seem that a high priority is being given to ensuring staff at the Trust collect this
data or our patients are informed of why we need to collect this data. An action plan to be developed
to address this.
45
Age at first appointment, admission or attendance (obstetrics / midwifery only)
Inpatients
(2012)
Outpatients
(2012)
Local
Population
(Census 2011)
<15
0 (0%)
0
8 (0%)
0
Under 20, 6%
15 to 19
191 (5%)
4%
373 (5%)
5%
20 to 24
632 (15%)
17%
1274 (17%)
17%
6.8%
25 to 29
1122 (27%)
25%
2111 (27%)
27%
7.1%
30 to 34
1281 (31%)
31%
2365 (31%)
29%
7.6%
35 to 39
684 (17%)
18%
1215 (16%)
17%
8.2%
40 to 44
213 (5%)
5%
318 (4%)
4%
9.8%
45 to 49
9 (0%)
0
22 (0%)
0
10%
>50
2 (0%)
0
6 (0%)
0
44.5%
We have treated a higher percentage of 20 to 39 year olds in obstetrics and maternity than the population we
serve, as this is the main age for women to bear children. The results have not changed significantly since
last year.
(Data provided by Jamie Cochrane, Operational Planning and Performance Manager, November 2013).
46
11) HOW SATISFIED
SERVICES?
ARE
OUR
PATIENTS
WITH
OUR
11.1 Inpatient Survey 2012
A further adult inpatient survey was conducted at the Trust between September 2012 and January 2013. A
questionnaire was sent to 850 recipients and 481 patients responded, equating to a response rate of 60%.
Slightly lower than the 63% last year.
On 68 out of 70 areas, our Trust was rated “about the same as others”. In one area (Acknowledging patients
– for nurses not talking in front of them as fi they weren’t there) we were better and one area (Understandable
letters – for letters between the hospital doctors and family GP being written in a way patients could
understand) we were worse than other Trusts.
As part of the results, there were 7 areas where that Trust had improved since last year. There were not any
areas where the Trust had deteriorated.
Director of Nursing & Patient Safety, Cathy Stone leads on this area and action arising from it will be
monitored by the Trust Board.
Background information
Unfortunately the responses to the survey are not broken down by protected characteristic, i.e. no of males
satisfied with our service. However, the background information generally into the level of respondents has
been broken down and analysed below (the census data for age is from different categories to that of the
survey and therefore the figures have been approximated):
The sample
This trust
All trusts
Number of respondents
Response
Rate
(percentage)
Demographic
characteristics
Gender (percentage)
Male
Female
Age group (percentage)
Aged 16-35
Aged 36-50
481
60
64505
51
This trust
All trusts
(%)
45
55
(%)
5
9
(%)
46
54
(%)
7
13
Aged 51-65
23
25
Aged 66 and older
62
55
Ethnic group (percentage)
(%)
(%)
White (British and non)
93
90
Multiple ethnic group
0
1
Asian or Asian British
1
3
Black or Black British
Arab or other ethnic group
Not Known
0
0
5
1
0
5
47
Analysis by protected characteristic
In relation to gender, our Trust is very similar to the percentage split of all Trusts and to the local population
according to the 2011 Census, which is encouraging.
As was the case in last years inpatient survey demographics, there does not seem to be any large disparity
between the age groups internally and when looking at all Trusts, apart from in the over 66 year olds where
our Trust has more. However this is reflected in the local population statistics also and is understood and
expected for this geographical area.
In terms of ethnicity, the level of white patients responded is 3% higher than all Trusts but is in line with the
population in this area.
It is encouraging to see 2 more protected groups have been added to the demographic breakdown for the
inpatient survey in 2012 and for religion, we can see that the Trusts respondents from a Christian religion are
slightly higher than all Trusts but none of the results are significantly different.
Also new for this year is the collection of sexual orientation data and again although not significantly different
to all Trusts in any area, The Trusts respondents who are heterosexual were 2% higher. Data on sexual
orientation is not collected as part of the Census unfortunately.
The National outpatient survey has not been re-distributed since the last E&D report and although a maternity
survey was conducted in 2013, the results are not yet available for analysis.
48
12) WHAT DO OUR PATIENTS TELL US IN REAL TIME?
This is the second year running that we have included this data as part of annual E&D report. The adult
inpatient survey was conducted between 1st October 2012 and 30th September 2013 in line with this E&D
report. In total there were 4431 responses and it was undertaken randomly at the inpatients bedside. The
results from last year’s report are shown in the appendix.
12.1 Gender (Question 30)
From those sampled 56.72% were female (42.9% male) in comparison to our internal data collection (section
9) of 57% female to 43% male, showing that our survey is comparable. This compares favourably to the 52%
females and 48% males making up the local population according to the 2011 Census results.
12.2 Age (Question 31)
Similarly to last year’s results, the largest age group surveyed were the 75-84 year olds, followed by the 65-74
year olds and then 85 years +. This is reflected in our actual patient data in section 9 and by the demography
of the local community as per the census data shown in section 1.1
12.3 Disability (Question 32)
41% of those surveyed declare they had a disability which is just .59% less than the figure for last year. This
compares to 17% considering themselves to be disabled from the 2011 Census results. However this should
be expected when it is conducted within a hospital environment. The question also details the types of
disability and again this year mobility is the highest scoring at 23.3%, followed by deaf or hearing impairment
and then blind or vision impaired.
12.4 Ethnic origin (Question 33)
97.27% of our surveyed patients were British which compares to 88.9% of the local population. From this
1.29% of our patients were from a non-British or Irish white background compared to 8.33% last year. This
result is surprising as the white non-British population appears to have increased overall.
49
The maternity survey was conducted in the same time period and had 309 responses. An increase from
180 responses last year:
50
12.5 Age
The largest proportion of maternity patients were aged between 25 and 34 (55.99%. , followed by 28.21% for
35-44 year olds and then. There has been a fairly significant change for the older and younger age brackets
since the last survey with 15.86% of our surveyed patients being16-24 year olds compared to 21.11% last
year and 28.21% 35-44 year olds, an increase from the 21.11% last year. This is reflective of the changing
society but appears a fairly large jump in the space of a year.
12.6 Disability
From the maternity patients surveyed, 3.99% consider themselves to have a disability and of these
1% had mobility difficulties and 1% other, followed by 0.66% deaf/hearing impaired and 0.66% with mental
health and 0.33% blind/partially sighted and 0.33% with learning difficulties.
12.7 Ethnicity
92.88% of our maternity patients were white in the last year compared to 95% last year.
51
52
Children’s Survey – There were 279 respondents in total over the same time period
12.8 Gender
There were slightly more female children as patients compared to male within the last year.
12.9 Age
The age split has changed since the last year with now 51.9% of patients being 0-5 year olds compared to
33.33% last year. Then 28.67% were 6-10 year olds compared to 33.33%, 13.26% were 11-15 which was
18.8% last year and 4.66% were over 16 (1.71% last year)
Next Steps
Whilst every area has the opportunity for using the survey and in the majority of cases it is at the
bedside, there is great variation in the uptake. Further work to be carried out in making this survey
less random and more standardised.
53
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language other than English, please contact the Communications Office by: email:
[email protected] or by calling 01903 205 111 ext 4038.
54
13) APPENDIX
The tables below show any (non-identifiable) raw data used but not already quoted in this report.
HEADCOUNTS
Characteristic Category
Census
Heads 2011
ESR Heads
Sep-12
RECRUITMENT DATA
ESR Heads
Sep-13
Applicants
Shortlisted
LEAVERS
Leavers
01/10/12 30/09/13
Appointed
TRAINING
Courses
01/10/12 30/09/13
ALL STAFF
806892
6350
6486
24554
6591
1206
524
Under 20
36410
17
24
1037
320
83
4
72
20 - 24
41088
333
340
4333
1063
197
50
1639
25 - 29
44020
701
762
5198
1066
191
51
2812
30 - 34
46098
741
719
3643
910
176
57
2834
35 - 39
50890
868
834
2953
821
137
67
3479
40 - 44
59503
854
880
2483
788
137
54
3363
45 - 49
60793
873
892
1990
647
137
52
3477
50 - 54
53986
826
831
1657
541
85
50
2912
55 - 59
48229
655
693
928
314
45
55
1959
60 - 64
54345
362
360
240
93
14
69
839
65 - 69
44859
97
128
71
13
1
11
188
70 - 74
37003
20
20
7
2
0
4
28
75 - 79
31993
3
Female
416325
4956
5068
15920
Male
390567
1394
1418
8615
2472
2516 n/a
Female - Full Time n/a
3 n/a
n/a
n/a
4800
1781
n/a
23605
0
3
943
408
20250
260
116
3355
n/a
190
11003
Female - Part Time n/a
2484
2552 n/a
n/a
n/a
218
9247
Male - Full Time n/a
1163
1193 n/a
n/a
n/a
81
2833
Male - Part Time n/a
231
225 n/a
n/a
n/a
35
522
Disabled
60156
133
132
793
259
31
21
462
Not Disabled
746736
3110
3252
23632
6293
1166
278
11816
White British
717551
4888
4886
12774
4464
916
407
18014
White (Non British)
38948
396
446
3180
683
106
36
1620
Mixed
12155
64
58
518
69
11
11
159
Asian Or Asian British
25374
531
526
5293
878
105
34
1805
Black Or Black British
7146
105
105
1595
272
31
13
300
Chinese
2960
29
32
114
23
2
1
130
Any Other Ethnic Group
2758
98
116
774
132
22
5
392
Christianity
498367
3139
3186
12733
3745
699
274
11952
1739
Atheism
216844
471
504
2770
860
182
34
Buddhism
3057
48
45
351
46
6
8
140
Hinduism
7368
89
90
1297
209
18
8
169
179
Islam
12668
67
66
2639
198
12
7
Judaism
1434
7
10
66
7
1
0
26
Sikhism
1137
11
15
80
13
1
0
45
Other
4121
324
345
2214
679
126
17
1304
Heterosexual n/a
4237
4349
22037
5868
1094
348
16173
Bisexual n/a
19
26
293
81
7
2
65
Gay n/a
31
32
241
69
8
2
86
Lesbian n/a
18
23
130
39
8
2
57
1676
Divorced
44859
464
467 n/a
n/a
n/a
48
Legally Seperated
12597
81
79 n/a
n/a
n/a
10
327
Married or Civil Partnership
337734
3581
3643 n/a
n/a
n/a
264
13061
Single
206314
1835
1928 n/a
n/a
n/a
165
7334
Widow ed
46772
94
87 n/a
n/a
n/a
13
285
Census data restricted to ages betw een 16 to 80 as this is the date range of our staff
Day-to-day activities limited a lot: 60156, Day-to-day activities limited a little: 78724, Day-to-day activities not limited: 668012
One person declared Jainism in 2012 and 2 in 2013 but since this category is not included in the census they are in the "Other" category
Recruitment data stops at 70+, all of those in this group have been put in 70-74 category, hence n/as for recruitment data for 75-79
55
HEADCOUNTS
Characteristic Category
Census
Heads 2011
ESR Heads
Sep-12
LEAVERS
Leavers
01/10/12 30/09/13
RECRUITMENT DATA
ESR Heads
Sep-13
Applicants
Shortlisted
Appointed
TRAINING
Courses
01/10/12 30/09/13
Age Undisclosed
0
0
0
14
13
3
0
0
Gender Undisclosed
0
0
0
19
10
3
0
0
Disability Undisclosed
0
3107
3102
129
39
9
225
11327
Ethnicity Undisclosed
0
239
317
306
70
13
17
1185
Religion Undisclosed
61896
2194
2225
2404
834
161
176
8051
2045
2056
1853
89
170
7224
24
922
Sexuality Undisclosed
n/a
Marital Status Undisclosed
0
295
282 n/a
534
n/a
n/a
The following tables display the raw data behind the Equality & Diversity training %s.
Division
OK
Core Services
Corporate
Facilities & Estates
Out Of Date
1199
46
770
56
581
30
Medicine
1474
192
Surgery
1209
144
Women & Children
Grand Total
Staff Group
682
93
5915
561
OK
Add Prof Scientific and Technic
Out Of Date
251
17
Additional Clinical Services
1048
111
Administrative and Clerical
1147
48
Allied Health Professionals
390
15
Estates and Ancillary
624
36
Healthcare Scientists
Medical and Dental
Nursing and Midw ifery Registered
Students
Grand Total
Payscale Description
89
2
576
169
1787
160
3
3
5915
561
OK
Out Of Date
Band 1
388
24
Band 2
1328
120
Band 3
425
23
Band 4
376
25
Band 5
1269
112
Band 6
831
52
Band 7
504
23
Band 8 - Range A
119
8
Band 8 - Range B
46
Band 8 - Range C
19
Band 8 - Range D
11
2
Band 9
4
2
Medical
576
169
Other
Grand Total
19
1
5915
561
56
The adult inpatient survey was conducted between 1st November 2011 and 2nd November 2012.
In total there were 3801 responses and it was undertaken randomly at the inpatients bed side.
The Maternity Survey was conducted in the same time period and had 180 responses:
57
Children’s Survey –
58
59
COMPLAINTS BY PROTECTED CHARACTERISTIC
All complaints are logged onto the DATIX system under the patient’s name. The Trust is required to
complete some data for the Department of Health, including ethnicity of the patient, however the
team do not currently ask the patient’s ethnicity and therefore our return is ‘not stated’ which is an
option. The Trust is not required by the Department of Health to report complaints by any other
protected characteristic, however there are fields on DATIX which can be completed relating to sex
and age. There is no field for marital status, sexual orientation, disability or religion/belief. In total
there were 502 formal complaints received between 1.10.2012 and 30.9.2013.
11.1 Gender
From the number of complaints received where gender is recorded, 65% were female, 35% were
male. Included in the above figure, there were 23 complaints about maternity services of these:
• 17 were clinical treatment
• 4 were about communication
• 2 were about staff attitude/behaviour
11.2 Age
Out of the 502 complaints received, age was not disclosed by the complainant in 439 cases. From
the number of complaints received where age is disclosed the following spread can be seen:
0-20 years: 1
21-39 years: 12
40-64 years: 31
0ver 65: 19
11.3 Ethnic Origin
Out of the 502 complaints received, ethnic origin was recorded against the patient in 213 cases as
follows:
White British: 204
White Irish: 1
White Other White: 4
Indian: 1
Other Asian: 1
Black African: 1
Other: 1
Not stated: 289
The trust is taking part in a survey from February 2014 organised by the Patients Association, an
independent, national charity which campaigns for improvements in patient care. The survey will
ask questions about each complainant’s experience of how their complaint was handled and will
seek to obtain background information to ensure certain people are not disadvantaged or
discriminated against. This information will include gender, age, disability and ethnic background.
The Patient Experience & Feedback Committee will be using this data collection exercise as a way
of obtaining equality & diversity information and there will be national comparative data with other
trusts who have joined this scheme.
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