1. Enc H1 Stewart Messer, Chief Operating Officer 1 Report to Board INTEGRATED PERFORMANCE REPORT June 2014

2. Enc H1 Pages 14 -17 Pages 8 - 13 Pages 4 - 7 Pages 18 -21 2 Key Headlines Workforce and Training Scorecard Sickness levels remain above target. Compared to other West Midlands Acute Trusts we are in the top 50%. Overall mandatory training completion rates are above target but performance is mixed across courses with below target performance on a number of key courses. E-rostering approval rate has reduced this month to 77% Performance & Efficiency Scorecard A&E 4 hours performance is holding steady at 94.3% YTD - High levels of emergencies and A&E attendances continuing to impact performance. Cancer 5 standards not achieved in month 18 weeks RTT admitted 84.35% YTD Quality and Outcomes Scorecard Decrease in C-Diff cases remaining within trajectory HSMR Serious Incidents – decrease in SIs open > 45days Reduction in falls but continuation of falls resulting in serious harm Pressure ulcer reduction for third successive quarter Friends and Family – improvement in return rate to meet Q1 CQUIN target of 25% Finance & Contractual Scorecard Q1 position - £5.2m deficit, £0.6m behind plan due predominantly to the premium costs of managing the excess demand which is then reimbursed at marginal tariff compounded by delivery of some elective activity at premium cost. CIP delivery on plan at Q1. Headroom planning target reached.

3. Enc H1 3 Trust Balance Scorecard

4. Enc H1 4 Quality & Outcomes - Overview HSMR – 108 for 2013/14. Serious Incidents – Decrease in SIs open > 45 days Control of Infection – C.Diff – 2 cases during June - on trajectory MRSA bacteraemia – 0 Falls - Reduction in falls with falls with serious harm continuing Pressure Ulcers - continued reduction in avoidable hospital acquired pressure ulcers/1,000 bed days Friends and Family – improved response rate and achievement of Q1 target. (25% for inpatients and 15% for A&E) Safety Thermometer – reduced score to below 95% target due to changes to data collection Complaints – a increase in numbers from previous month with response rates remaining a challenge Cleaning Scores are under review with an action plan to improve Actions to address adverse areas of performance are outlined in the CMO/CNO Quality report.

5. Enc H1 5 Quality & Outcomes Effectiveness – HSMR / SHMI Quality & Outcomes Effectiveness – HSMR / SHMI HSMR information has not been updated for May as the information is not available from HED. The chart is as per the May IPR. SHMI verbal update HSMR – Not updated for May as information not yet available

6. Enc H1 6 Quality & Outcomes Safety - Falls Quality & Outcomes Safety - Falls There has been an in-month reduction in the number of falls but an increase in falls with harm

7. Enc H1 7 Quality & Outcomes Experience – Friends & Family Quality & Outcomes Experience – Friends & Family Overall score for the Friends and Family Test within the Trust for June was 75% with a rise in response rate to 28.6% (the CQUIN target for 2014/15 Q1 is 25% for inpatients and 15% for A&E). In future months the data will be split to show inpatients and A&E separately.

8. Enc H1 8 Performance & Efficiency - Overview Performance against A&E, RTT and cancer standards continues to be compromised by high levels of referrals and high emergency demand exacerbated by high levels of delayed discharges. A&E 4 Hour Emergency Access Standard The Trust achieved an Emergency Access Standard (EAS) of 96% for June 2014, with continued high levels of emergency demand and delays in discharging patients, taking the YTD performance to 94.3%. A&E attendances were significantly higher than plan, exceeding last July’s peak. This continues the trend seen since last November which coincides with the reintroduction of the NHS111 triage service. 18 Weeks Referral to Treatment Whilst the challenges still remain on the admitted pathway and we achieved 83.6% for June it should be noted that the Trust achieved both the non admitted and incomplete standards. The backlog remains a challenge reducing in June, however there is an increase on the in patient waiting list due to an increase of the number of patients being referred into the Trust. Hitting the recovery trajectory is dependent on a reduction in both referrals and emergency demand which have not as yet materialised. National pressure is mounting to clear the backlog more quickly and additional resource may be made available to CCGs to enable them to fund additional capacity to support the recovery (Operational resilience and capacity planning 2014/15). The Trust has responded to numerous request with regards to data to make our position clearer with regard to the reduction of the projected backlog. The Trust is currently working with Checklist and IMAS to ensure a full understanding of further actions that are required. The Trust is reviewing these options to further support actions already in place which include extra waiting list sessions, private sector capacity for Endoscopy and Orthopaedics but take up is dependent on patient choice ( in line with the NHS constitution), selective ring-fencing of elective beds, communication strategy with CCGs and GPs around challenged specialties and further audit and validation resource in place. Currently GP’s are reviewing the over 18 week waiting list and it is estimated that 35% would accept treatment with in IS, and 10% no longer require treatment. Cancer Standards The Trust did not achieve the 31 day first treatment for all cancers nor the 62 day first treatment target in June. However having completed a deep dive into the breaches over the past 2 months, the vast majority of these patients were over the age of 80 with the added complications of multiple co morbidities meaning diagnosis and treatment became delayed. There is a significant rise in 2 www including the 20% increase in breast referrals. Analysis is taking place as to the reason for this surge in demand however first indications are that this is linked to a health awareness campaign.

9. Enc H1 9 Performance & Efficiency 4 Hour Emergency Access Standard (EAS) Performance & Efficiency 4 Hour Emergency Access Standard (EAS) The Trust achieved an Emergency Access Standard (EAS) of 96% for June 2014 with continued levels of emergency demand and delays in discharging patients. Unlike many of its peers, the Trust does not manage all of the Minor Injury Units (MIUs) within the county. If the MIU performance is included, then at a health economy level the 95% standard has been achieved. A broader selection of A&E quality standards have been produced (below) which give a better overall view of performance than simply measuring the 4 hour standard. It can be seen that the Trust achieved 4 out of 5 standards in June.

10. Enc H1 10 Performance & Efficiency Factors Affecting 4 Hour EAS Performance & Efficiency Factors Affecting 4 Hour EAS Emergency admissions and delayed discharges are two of the main factors that influence the Trust’s ability to achieve the 95% standard. The first chart shows the overall trends in total emergency admissions over the last 3 years. Whilst the summer months of last year saw a reduction on the previous year, this trend has now reversed. From the last week of November through to mid May, the Trust has experienced a 4.2% increase in emergency admissions compared to the same period previously. This unplanned increased has left the Trust in a position where it has had to cancel elective work in order to prioritise patient safety. The second chart indicates that the Trust regularly has between 60-80 patients that are medically fit for discharge, equating to between 3 and 4 wards The use of Section 2 and Section 5 documentation commenced from early May. Consequently the Trust has notified Social Services that it reserves the right to impose fines in the event that significant delays continue.

11. Enc H1 11 Performance & Efficiency A&E Attendances Performance & Efficiency A&E Attendances There has been no change in A&E attendances and they continue to increase compared to the previous year. A&E attendances have historically been relatively static but since Nov 2013 attendances increased by 7% compared to the same period in the previous year. The graph shows that this trend is continuing in 2014 with May’s attendances exceeding last July’s peak. Weeks have been normalised to allow comparison of full weeks across years This year 31 Mar 2013 to 29 March 2015 Last Year 1 Apr 2013 to 30 Mar 2014

12. Enc H1 12 Performance & Efficiency Referral to Treatment Performance & Efficiency Referral to Treatment Encouragingly, the Trust has seen a higher than planned level of elective activity in June. However, this was not high enough to reduce the inpatient waiting list. For June, the performance stands at 83.6% a detoriation on the previous month but it is expected to get worse over the next few months, as the backlog is cleared, before recovering. The chart shows that the 18 week RTT Admitted performance will now take some months to recover to over the 90% standard due to the backlog that has accumulated over the last 18 months. The recovery plan assumes a reduction in both referrals and emergency demand. National pressure is mounting to clear the backlog more quickly and additional resource may be made available to CCGs to enable them to fund additional capacity to support the recovery (Operational resilience and capacity planning 2014/15). The Trust has responded to numerous request with regards to data to make our position clearer with regard to the reduction of the projected backlog. The Trust is currently working with Checklist and IMAS to ensure a full understanding of further actions that are required. Currently GP’s are reviewing the over 18 week waiting list and it is estimated that 35% would accept treatment with in IS, and 10% no longer require treatment. The 6 most challenged specialties which have been the key focus for recovery. Orthopaedics has in particular been hit by a 7.7% increase in referrals as being one of the first specialties to be impacted by cancellations due to trauma bed pressures. Consequently, the CCGs have been issued with a formal contractual notice to reduce referral demand, which requires a remedial action plan to be put in place to support the Trust during this period. The actions currently in place include extra waiting list sessions, private sector capacity for Endoscopy and Orthopaedics but take up is dependent on patient choice, selective ring-fencing of elective beds, communication strategy with CCGs and GPs around challenged specialties and further audit and validation resource in place.

13. Enc H1 13 4 cancer targets were not achieved in June: 31 days : wait for first treatment: all cancers 62 days: wait for first treatment from national screening referral 2 week wait for symptomatic breast patients 2 week waits The Trust did not achieve the 31 day first treatment for all cancers nor the 62 day first treatment target in June., however we maintained the screening referrals standard. However having completed a deep dive into the breaches over the past 2 months, the vast majority of these patients were over the age of 80 with the added complications of multiple co morbidities meaning diagnosis and treatment became delayed. There is a significant rise in 2 www including the 20% increase in breast referrals. Analysis is taking place as to the reason for this surge in demand however first indications are that this is linked to a health awareness campaign. Other drivers include patients choosing to delay their treatment due to Bank Holiday and Half- Term commitments and capacity constraints. Plans are being formulated to mitigate the impact. New tracking systems are about to be introduced and this area will continue to be reviewed by both Divisional and Executive teams, with assurance provided via the Quality Governance Committee. Performance & Efficiency Cancer Standards Performance & Efficiency Cancer Standards

14. Enc H1 14 Workforce & Training - Overview Sickness The Trust’s sickness rate as reported in June is 3.46%. This is a significant improvement on recent months resulting in a cumulative sickness rate of 3.89%. Medicine division in particular made a considerable improvement through effective sickness management. Mandatory Training The Trust is participating in the WM Streamlining project ensuring mandatory training requirements are consistently delivered across all organisations and records transferred with staff. It will require new ways of delivery and assessment to drive up compliance. Staff Turnover Staff turnover remains consistent with the last 3 months. Non Medical Staff Appraisals The Trusts non medical appraisals completed remains low at 67%. The Divisions have been asked to review this and ensure appraisals are completed for the relevant staff. Medical appraisal rates remain low with a drop in consultant compliance.

15. Enc H1 15 The Trust’s sickness rate as reported in June is 3.46%. This is a significant improvement on recent months resulting in a cumulative sickness rate of 3.89%. The year to date cumulative rate is 3.63%. Most notable reductions in absence are noted in the Medicine Division where considerable improvement through effective sickness management resulting in a reduction of absence since April 14 of in excess of 1.50% and in Asset Management and IT a reduction of 1.25%. Since April 14 In line with the reduction in levels across the Trust there has also been favourable movement in the absence rates for the staff groups - Additional Clinical Services of 1.50% and Nursing and Midwifery approx. 1%. Further actions taken to improve absence rates and support the wellbeing agenda are as follows: In addition to the support provided to managers by the HR Consultancy Team, plans are well advanced to hold a series of staff engagement/ listening events targeting initially those areas where sickness amongst the HCA staff group has been high. The aim is to explore issues that affect staff’s attendance at work and to develop an action plan that supports improved attendance and increased engagement. It is planned that these will take place during July. There will be a fortnightly item on the daily brief commencing 18 June 14, called Wellbeing Wednesday, promoting an aspect of the well -being agenda for managers and staff. Plans to re- introduce a first day of absence approach within the OH department for staff suffering from back problems/Muscular skeletal issues and stress/anxiety will be supported and endorsed via the Divisions. Workforce & Training Sickness and Absence Workforce & Training Sickness and Absence

16. Enc H1 16 The Trust is participating in the WM Streamlining project ensuring mandatory training requirements are consistently delivered across all organisations and records transferred with staff. It will require new ways of delivery and assessment to drive up compliance. Workforce & Training Statutory and Mandatory Training Workforce & Training Statutory and Mandatory Training Areas where we have not achieved compliance are Fire, Resuscitation and Safeguarding. Execs have individual responsibilities to ensure their teams training monitor compliance. Commissioners require the Trust to put into place a Remedial Action Plan (RAP) to deliver a minimum of 70% in all areas of mandatory training by 31st October 2014, with the exception of Information Governance, Safeguarding Children and Safeguarding Adults which need be a minimum of 95% by 31st October 2014.

17. Enc H1 17 Staff turnover remain consistent with April, qualified nursing staff turnover is 10.9% for May and unqualified 11.25%. National challenges in sourcing additional nurses are growing. Overseas recruitment and assessment centres remain in place. Open days planned and the first baseline assessment to look at safer staffing levels being established to ensure we achieve compliance. Introducing higher apprenticeships to existing and new HCAs is aimed at improving retention. Workforce & Training Turnover Workforce & Training Turnover

18. Enc H1 18 Finance & Contractual - Overview Based on a set of assumptions regarding activity levels and QIPP delivery, the Trust is planning on a £9.8m deficit in 2014/15. Once adjusted for the impact of non recurrent funding rebates, the Trust’s underlying deficit stands at £3.8m (circa 1% of turnover). The run rate has been maintained at the similar levels as April and May giving a YTD deficit of £5.2m after 3 months, an adverse variance of £0.6m. At 5% above plan June has been the highest month for elective work bringing the total activity for Q1 back into line with plan. However, this level of activity has not been sufficient to make significant inroads into the inpatient waiting list in light of the increased referrals. Some of this activity has been delivered at premium cost through external providers (£0.25m), additional temporary staff and WLIs thereby eroding margins on what would normally be relatively high margin activity. A&E activity remains high, although emergency demand has dropped to planned levels. Consequently the impact of the emergency threshold has held at £0.25m year to date. The pay overspends reflect the retention of the additional capacity to safely manage the excess emergency demand and high levels of medics vacancies. This is being incurred at a premium rate which is not recompensed when funded at the 30% marginal rate. QIPP actuals are in line with plans, which continue to be developed with plans and developing PIDs identified now in line with the headroom target at £20.2m. This is an increase of £1.7m on Month 2, with plans continuing to be developed to give headroom against slippage of schemes. The Trust has had a temporary cash injection of £9.25m this year to enable it to maintain payments to suppliers but this will continue to deteriorate until the permanent cash solution is in place. The Trust is in the process of submitting an application for a permanent cash injection of £26.5m.

19. Enc H1 19 Finance & Contractual Income & Expenditure Position Finance & Contractual Income & Expenditure Position

20. Enc H1 20 Finance & Contractual CIP Delivery Finance & Contractual CIP Delivery

21. Enc H1 21 Finance & Contractual Activity Finance & Contractual Activity