Board meeting - 19 March, NHS Trust Service and Financial Performance Report for the period ending 31 December 2014

Transcription

1 Board meeting - 19 March, 2015 Paper D: NHS Trust Service and Financial Performance Report for the period ending 31 December 2014

2 NHS Trust Service and Financial Performance Report for the period ending 31 December 2014 Table of Contents Page No. Section 1 Introduction... 1 Section 2 Summary Scorecard... 3 Section 3 Indicator Overviews... 4 Section 4 Financial Performance Section 5 Oversight and Escalation Section 6 Recommendations Appendix 1 Appendix 2 Financial performance of NHS Trusts for the period to December Oversight and Escalation scores of NHS Trusts from April to 28 December

3 1. Introduction 1.1 This report presents a summary of the service and financial performance of the NHS Trust sector for the period ending 31 December The non-financial indicators presented are: Accident and Emergency 4 hour standard (All Types); Referral to Treatment (18 Weeks); Admitted Pathways; Non Admitted Pathways; Incomplete Pathways; 52 Week Waits; Diagnostic Waits; Cancer; Two week waits from GP referral; Two week waits from GP referral (breast symptoms); 31 day wait from diagnosis to treatment; 31 day wait for second or subsequent treatment; Radiotherapy; Drugs; Surgery; 62 day wait from urgent GP referral; 62 day wait from screen detection referral; Ambulance Category A 8 minute response Red 1; Ambulance Category A 8 minute response Red 2; Ambulance Category A 19 minute response; MRSA(b) Infections; Clostridium Difficile Infections; f Mental Health; 1

4 Care Programme Approach (CPA) review within the last 12 months; Health of the Nation Outcome Scales (HoNOS) assessment in the last 12 months; Care Programme Approach patients discharged from inpatient care who are followed up within 7 days; Admissions to inpatient services who had access to Crisis Resolution/Home Treatment teams; Mental health delayed transfers of care; Improving Access to Psychological Therapies (IAPT) The proportion of people who complete treatment who are moving to recovery; Admissions to adult facilities who are under 16 years of age; Meeting commitment to serve new psychosis cases by early intervention teams; name; Summary Hospital Mortality Indicator; Hospital Standardised Mortality Ratio; Friends and Family Test. 1.3 Financial performance explained in Section 4 focuses on the revenue performance of the NHS Trust sector and analyses the key operational drivers of that performance. 1.4 Oversight and Escalation Scores for the sector are summarised in Section 5 as assessed under the Accountability Framework for 2014/15. 2

5 2. Summary Service Performance Scorecard 2.1 The following scorecard presents an aggregated service performance position of NHS Trusts against key indicators listed in Section 3 of this report. NHS Trusts Performance Summary - December 2014 Metric Period Standard Performance Direction of Travel Referral to Treatment 18 Weeks Admitted Pathways (%) Weeks Non Admitted Pathways (%) December Weeks Incomplete (%) Week Waits (Number) Diagnostics Number of diagnostic tests waiting longer than 6 weeks (%) December Accident and Emergency All Types Performance (%) Type 1 Performance (%) December 2014 A&E Attendances - 706,948 - Emergency Admissions - 144,039 - Cancer Two week wait referral to date first seen 2 week GP referral to 1st outpatient, cancer (%) week GP referral to 1st outpatient breast symptoms (%) day wait for second or subsequent treatment 31 day wait from diagnosis to first treatment (%) day second or subsequent treatment (surgery) (%) day second or subsequent treatment (drug) (%) December day second or subsequent treatment (radiotherapy) (%) day wait for first treatment 62 day urgent GP referral to treatment for all cancers (%) day urgent GP referral to treatment from screening (%) Ambulance Category A call emergency response within 8 minutes, comprising Red 1 calls (%) December 2014 Red 2 calls (%) Category A call ambulance vehicle arrives within 19 minutes (%) Infection Control MRSA (b) 0 19 December 2014 Clostridium difficile Eliminating Mixed Sex Accommodation Mixed-Sex Accommodation December Mental Health Having formal review within 12 months/proportion of users on new Care Programme Approach who have had a HoNOS assessment in last 12 months CPA patients for at least 12 months who had a CPA review in the last 12 months Under 16 bed days on Adult wards Proportion of patients on Care Programme Approach discharged from inpatient care followed up within 7 days Proportion of admissions to inpatient services who had access to Crisis Resolution/Home Treatment Teams November 2014 Q3 2014/ NB: Mortality is not presented as it is not appropriate to aggregate these indicators 3

6 Performance (%) 2.2 The scorecard shows the period to which the data relates, the national performance standard that applies to each indicator along with the NHS Trust Development Authority aggregate actual performance. 2.3 The direction of travel column shows whether performance has improved or deteriorated since the last period. A downwards arrow means it has deteriorated and an upwards arrow shows the position has improved. Sideways arrows mean that there has been no change. 2.4 A green arrow indicates that the aggregated performance position has achieved the national standard whilst a red arrow means that the national standard has not been met during the period reported. 3. Indicator overviews Accident and Emergency 3.1 Performance against the 95% standard for patients to wait less than 4 hours between arrival, and discharge, treatment or admission is proving to be increasingly challenging across all sectors of the NHS. Graph 1: Accident and Emergency performance against the 4-hour standard by month for the period 1 April 2013 to 31 December Achieving Not achieving Standard Quarter Month 3.2 The quarter /2015 position for the NHS Trust Development Authority (NHS TDA) was 90.82%. 3.3 For quarter 3, 19 of the 71 acute and other NHS Trusts which provide A&E services achieved the standard. 3.4 Performance during December 2014 was 88.07%, and therefore the 95% standard was not achieved. 4

7 Performance (%) Referral to Treatment (RTT) Admitted Pathways 3.5 The NHS Constitution enshrines the right of patients to be treated within 18 weeks of referral to a consultant- led service. Performance is assessed against four primary performance standards; Admitted Pathways (90%); Non Admitted Pathways (95%); Incomplete Pathways (92%); Number of over 52 week waits (zero tolerance). Graph 2: Referral to Treatment Admitted Pathways for the period 1 April 2014 to 31 December Achieving Not achieving Standard Month 3.6 During December 2014, 19 NHS Trusts failed the target compared with 33 in November Performance was 88.6%, therefore the national standard of 90% was not achieved. The reduction in performance over the last few months is as a result of NHS Trusts treating backlog patients which have built up over the winter period. 5

8 Performance (%) Performance (%) Non Admitted Pathways Graph 3: Referral to Treatment Non Admitted Pathways for the period 1 April 2014 to 31 December Achieving Not achieving Standard Month 3.7 Performance this month against the non- admitted standard has been achieved for the month after failing the previous four months. 3.8 In December 2014, 13 NHS Trusts failed to achieve the target. Performance was 95.05% therefore the national standard of 95% was achieved. Incomplete Pathways Graph 4: Referral to Treatment Incomplete Pathways by month for the period 1 April 2014 to 31 December Achieving Not achieving Standard Month 6

9 Breaches 3.9 Performance this month against the incomplete pathways standard has fallen below the national standard, the only other month failing to achieve this year was in August Performance in December 2014 was 91.86% therefore the 92% standard was not achieved. Over 52 Week Waits 3.11 There is a zero tolerance approach across the NHS to patients waiting longer than 52 weeks for treatment. Graph 5: Referral to Treatment over 52 Week Waiters by month for the period 1 April 2014 to 31 December Week Breaches Month 3.12 In December 2014 there were 249 patients waiting longer than 52 weeks at NHS Trusts, a decrease of two from November Diagnostic Waits 3.13 Diagnostic waiting times are a key part of the delivery of the RTT target as the majority of patients will need a diagnostic test. Therefore, ensuring patients receive their diagnostic test within six weeks is vital to ensuring the delivery of the RTT waiting times standard of 18 weeks National waiting time targets for diagnostic services are that no more than 1% of total patients waiting should wait in excess of six weeks to be seen. 7

10 Performance (%) Patients Graph 6: Percentage of patients waiting over 6 weeks for a diagnostic test by month for the period 1 April 2014 to 31 December Total Waiters Standard Performance (%) 360, , , , , , , , ,000 Month 3.15 In December 2014, 300,183 patients were waiting for diagnostic tests. With 4,777 waiting over 6 weeks for treatment performance was 1.59%. Performance is improving, but the national standard was not achieved. Table 1: Diagnostic waiting times for the period 1 December 2014 to 31 December 2014 Diagnostic Test 6+ Weeks Total Performance (%) Audiology - Audiology Assessments , Barium Enema Cardiology - echocardiography , Cardiology - electrophysiology Colonoscopy , Computed Tomography , Cystoscopy 237 5, DEXA Scan 135 7, Flexi sigmoidoscopy 125 6, Gastroscopy , Magnetic Resonance Imaging , Neurophysiology - peripheral 91 6, neurophysiology Non-obstetric ultrasound 1, , Respiratory physiology - sleep studies 110 2, Urodynamics - pressures & flows 107 1, TOTAL 4, ,

11 3.16 Of the 15 diagnostic tests measured, 13 were above the 1% standard, of which Urodynamics - pressures & flows was the largest at 7.58% The largest diagnostic waiting lists are for Non-obstetric ultrasound, where 102,360 patients were waiting for treatment, of which 1,115 (1.09%) were waiting over 6 weeks. Magnetic Resonance Imaging had 62,096 patients waiting for treatment, of which 887 (1.43%) were waiting over 6 weeks. Cancer 3.18 Patients should have timely access to diagnosis and treatment and be seen by the right person with the appropriate expertise. National targets for cancer waiting times have been set for the groups of patients who will have waiting times monitored Table 2 provides a summary of performance in December 2014 against each of the national cancer standards. Table 2: Performance against national cancer standards for the period 1 December 2014 to 31 December 2014 Indicator Standard (%) December 2014 (%) Q3 2014/2015 (%) Percentage of patients referred urgently by their general practitioner seen within 14 days Percentage of patients with breast symptoms referred to a specialist seen within 14 days Percentage of patients treated within 31 days of diagnosis for first treatment Percentage of patients treated within 31 days with surgery for second or subsequent treatment Percentage of patients treated within 31 days with drugs for second or subsequent treatment Percentage of patients treated within 31 days with radiotherapy for second or subsequent treatment Percentage of patients receive treatment within 62 days of urgent general practitioner referral Percentage of patients with suspected cancer detected through national screening programmes waiting no more than 62 days

12 MSA Breaches 3.20 As shown in table 2 performance against percentage of patients receiving treatment within 62 days of urgent general practitioner referral was 84.3% for December, therefore the national standard was not achieved and also for Quarter 3 as a whole. Mixed Sex Accommodation 3.21 Being in mixed-sex hospital accommodation can be difficult for patients for a variety of personal and cultural reasons. Therefore all providers of NHSfunded care are expected to eliminate mixed-sex accommodation, except where it is in the overall best interest of the patient or reflects their personal choice In December 2014 there were 146 breaches of the mixed sex accommodation standard across 15 NHS Trusts, 41 more breaches than in November Graph 7: Mixed Sex Accommodation breaches by month for the period 1 April 2014 to 31 December Mixed Sex Accomodation Breaches Month MRSA (b) Rates 3.23 In recent years, rates of MRSA (b) have fallen because of increased awareness of the infection by both medical staff and the public. However, MRSA (b) still places a considerable strain on healthcare services. The NHS has a zero tolerance approach to MRSA (b) infections. 10

13 Infections Graph 8: Number of MRSA(b) infections by month for the period 1 April 2014 to 31 December Since April 2014, 40 NHS Trusts have reported at least one case of MRSA(b) There have been 112 MRSA(b) cases reported year to date. Nineteen of these cases were reported in December Clostridium Difficile Rates 3.26 A Clostridium Difficile infection (CDI) is a type of bacterial infection that can affect the digestive system, it causes disease when the normal bacteria in the gut, with which CDI competes, are disadvantaged, usually by someone taking antibiotics, allowing the CDI to grow to unusually high levels. Graph 9: Number of Clostridium Difficile infections above cumulative plan by month for the period 1 April 2014 to 31 December C Diff Infections Reported Plan Month 11

14 Performance (%) 3.27 During December 2014 there were 21 NHS Trusts that were above their plan for the month compared to 19 during November For the period between 1 April 2014 to 31 December 2014 there have been 1,576 infections against an agreed trajectory of 1,572, four above the plan. Ambulance Response Times 3.29 The national targets for ambulance response times are; 75% of Red 1 and Red 2 Category A calls are responded to within 8 minutes; 95% of Category A calls are responded to within 19 minutes. Graph 10: Percentage of Category A Red 1 calls responded to within 8 minutes by month for the period 1 April 2014 to 31 December Category A Red 1 Standard Year to date Month 12

15 Performance (%) Performance (%) Graph 11: Percentage of Category A Red 2 calls responded to within 8 minutes by month for the period 1 April 2014 to 31 December Category A Red 2 Standard Year to date Month 3.30 Year-to-date, only one of the six ambulance trust is achieving the 75% standard for Category A (Red 1) and one trust is achieving the Category A (Red 2) standard In aggregate for the year to date Red 1 performance is 69.7% and Red 2 performance is 65.7%. Graph 12: Percentage of Category A calls responded to within 19 minutes by month for the period 1 April 2014 to 31 December Category A 19 Standard Year to date Month 13

16 3.32 Year-to-date two of the Ambulance NHS Trusts are achieving the 95% standard for Category A calls responded to within 19 minutes. Aggregate performance for the year to date is 92.9%. Mental Health 3.33 There are several standards used to monitor the performance of trusts providing mental health services Table 3 shows the latest performance of Mental Health services in the NHS Trust sector. Table 3: Mental Health Indicators Indicator Proportion on Care Programme Approach (CPA) for at least 12 months had a CPA review within the last 12 months (%) Proportion on CPA have had a HoNOS assessment in the last 12 months (%) Proportion on CPA discharged from inpatient care were followed up within 7 days (%) Proportion admitted to inpatient services had access to Crisis Resolution/Home Treatment teams (%) Proportion with a delayed transfers of care (%) Proportion of Improving Access to Psychological Therapies (IAPT) patients completing treatment moved to recovery (%) Number of admissions to adult facilities for patients under 16 years of age Number meeting commitment to serve new psychosis cases by early intervention teams Period November 2014 November 2014 Q3 2014/15 Q3 2014/15 December 2014 Q2 2014/15 November 2014 Q3 2014/15 Standard (%) Actual (%) , At an aggregate NHS TDA level, five of the seven mental health standards were achieved The standard for the indicator, which requires that 95% of clients, who have been on the Care Programme Approach for at least 12 months and have had a review within the last 12 months, has not been achieved during the lifetime of the Trust Development Authority. Only four out of the 16 NHS TDA trusts exceeded the standard in November. 14

17 3.37 The standard for the Proportion on CPA have had a HoNOS assessment in the last 12 months was also failed during November The TDA delivered 89.19% against a target of 90%. There were 7 trusts out of 17 that achieved over 90% The aggregate performance of NHS trusts which measures the proportion of clients who are moving to recovery following completion of treatment was 44.94% in quarter two 2014/15. This was below the 50% standard, and was not achieved in the previous two quarters of the financial year. Four of the 19 NHS Trusts included in this measure achieved the standard The other standards continue to be delivered at a NHS TDA aggregate level. Patient Experience 3.40 Graphs 13 and 14 contain the Friends and Family percentage of patients that would not recommend care as an Inpatient or in an A&E department during December Graph 13: Friends and Family Score for Inpatients for the period 1 December 2014 to 31 December

18 Graph 14: Friends and Family Score for Accident and Emergency for the period 1 December 2014 to 31 December Revised national guidance published by NHS England no longer recommends the use of the net promoter score to report the results of the Friends and Family Test, instead results should be displayed as percentage of patients recommending care, and percentage of patients not recommending care. Guidance also documents the removal of the national CQUIN attached to response rates. The NHS TDA is incorporating these recommendations into the revision of its Patient Experience Headlines tool The Graphs show NHS Trusts are in general maintaining favourable results in inpatient Friends and Family Test scores with variation between 0.2% and 8.2% of patients not recommending care; however this still means in the worst performing of trusts around one in 12 of patients receiving inpatient care would not recommend the NHS Trust. These NHS Trusts continue to be the focus of the NHS TDAs development work to improve quality Friends and Family Test results for A&E show greater divergence of percentage of patients not recommending the NHS Trust between 1% and 32%. This means in one NHS Trust around one in three people world not recommend the care they received. NHS Trusts with the worst results tend to be those with challenged waiting times. As with inpatient Friends and Family Test, the NHS TDA is focussed on supporting those NHS Trusts with the greatest need for improvement. Mortality 3.44 An update of the Summary Hospital-level Mortality Indicator (SHMI) was published in October 2014 covering the period April 2013 to March In this publication, three NHS Trusts were shown to be high outliers. Table 4, below, illustrates NHS Trusts shown to be high outliers in the last four SHMI publications. Cells highlighted in red show when the NHS Trust was a high outlier, cells in white when it was not. 16

19 Table 4: SHMI outliers April 2012 to March 2013 and January 2013 to December 2013 NHS Trust Jul Jun 2013 Oct Sep 2013 Jan Dec 2013 Apr Mar 2014 East and North Herefordshire NHS Trust East Lancashire Hospitals NHS Trust East Sussex Healthcare NHS Trust Northampton General Hospital NHS Trust Southport and Ormskirk Hospital NHS Trust Wye Valley NHS Trust The only published source for Dr Foster HSMR data remains the Good Hospital guide and the next scheduled publication is in Spring As reported previously, the Hospital Standardised Mortality Ratio (HSMR) for April 2012 to March 2013 was released on 6 December 2013 with the publication of the Good Hospital Guide Table 5, below, illustrates the elevated HSMRs for 2011/12 and 2012/13, red boxes showing those with elevated HSMR. Table 5: HSMR outliers 2011/12 and 2012/13 NHS Trust HMSR 2011/12 HSMR 2012/13 George Eliot Hospital NHS Trust The Princess Alexandra Hospital NHS Trust United Lincolnshire Hospitals NHS Trust Walsall Healthcare NHS Trust Mid Yorkshire Hospitals NHS Trust North Cumbria University Hospitals NHS Trust Buckinghamshire Healthcare NHS Trust Northern Devon Healthcare NHS Trust West Hertfordshire Hospital NHS Trust

20 4. NHS Trust Financial Performance for the nine month period ending 31 December This section of the report sets out the financial performance of all NHS Trusts in England for the period to 31 December 2014 and compares performance to the original operating plans submitted by NHS Trusts at the start of the year. 4.2 The NHS Trust sector is forecasting a net deficit of million, compared to a planned net deficit of million, a negative variance of 42.8 million. 4.3 At the start of the financial year the planned net deficit was million, this has been adjusted by 19 million to reflect those NHS Trusts that have been authorised as Foundation Trusts or dissolved Trusts part way through the year. 4.4 The net deficit position is despite the NHS Trust sector forecasting that they will deliver 1.3 billion of efficiencies during 2014/15. The key generic cost drivers affecting the NHS Trust sector in the first nine months of 2014/15 are listed below and described further later in this report: an unplanned growth in demand for care in a hospital setting particularly in urgent and emergency care; a significant increase in the use of agency and contract staff; failure to deliver the levels of cost improvement schemes planned at the start of the financial year. 4.5 Within the net deficit forecast of 448 million, there are currently 64 NHS Trusts (65%) forecasting break-even or a surplus of a combined value of 123 million in 2014/15. This position includes the part year surpluses reported by three NHS Trusts (listed below) prior to Foundation Trust (FT) authorisation on the 1 November 2014: Bridgewater Community Healthcare NHS Trust; Derbyshire Community Health Services NHS Trust; Royal United Hospital Bath NHS Trust. 4.6 At the same time, there are 35 NHS Trusts, including three NHS Trusts that ceased to exist and one newly merged NHS Trust, forecasting a combined deficit of million at the year-end. 4.7 Within the deficit figures reported there are three NHS Trusts that ceased to exist as stand alone NHS Trusts and a new Trust that has been established during the financial year: Barnet and Chase Farm Hospitals NHS Trust were acquired by the Royal Free London NHS Foundation Trust on the 1 July 2014; 18

21 Ealing Hospital NHS Trust and North West London Hospitals NHS Trust were dissolved on the 1 October 2014; London North West Healthcare NHS Trust was established on the 1 October At the end of December (Month 9) the NHS TDA remains accountable for the financial performance of 93 NHS Trusts and consolidates the financial results of six NHS Trusts for the period in 2014/15 that they were NHS Trusts. Non Recurrent Provider Deficit Funding 4.9 Non-recurrent provider deficit funding has been made available to a cohort of NHS Trusts. This funding is not a substitute for commissioning resources for patient services. It is being directed at particular NHS Trusts that: exhibit particular financial challenges which we consider are exceptional and affect the overall sustainability of the Trust, such as evidence of a structural deficit component to the overall financial position and /or; are in a position to use this funding to accelerate their agreed recovery trajectory and return to financial balance To qualify for this funding the NHS Trust must be on track to delivering their agreed financial plan for 2014/15 having delivering the required level of productivity savings and have a clear plan to manage their resources in the future This funding is made available with conditions that range from explicit engagement in and adoption of shared back office services/national procurement and commercial initiatives, to controls on the remuneration of Trust senior management. In-year Revenue Performance 4.12 For the nine month period to December 2014, the year-to-date aggregate financial position of the NHS Trust sector is a deficit of million, compared to a planned year-to-date deficit of million, an adverse variance of million Table 6 below exemplifies the regional financial performance of the NHS Trust sector. The London and Midlands and East regions currently have 52% and 39% of NHS Trusts forecasting a deficit compared to 26% in the North and 22% in the South. 19

22 Table 6: Financial performance of the NHS Trust sector as at 31 December 2014 by region Region Months /15 Forecast 2014/15 Plan m Actual m Var. m Plan m Forecast m Var. m No. of Trusts No of Trusts forecasting a deficit % of Trust Region London (105) (207) (102) (126) (226) (101) % Midlands and East (135) (190) (55) (163) (185) (23) % North (57) (33) 24 (78) (29) % South (44) (37) 7 (39) (7) % TOTAL (341) (467) (127) (406) (448) (43) % 4.14 At an aggregate sector level the community, mental health and ambulance NHS Trusts continue to deliver a solid financial performance. Of these 39 NHS Trusts, 35 are planning to deliver a surplus or breakeven in 2014/15. There is however further pressure building in the non-acute sector which has resulted in a reduction in margins and 4 non-acute NHS Trusts are reporting a deficit for the first time As at the 31 December 2014 the aggregate surplus for the non-acute NHS Trust sector is 46 million compared to a planned surplus for the year of 65 million, an adverse variance of 19 million. The following NHS Trusts are forecasting a deficit: Barnet, Enfield and Haringey Mental Health NHS Trust planned deficit; Manchester Health and Social Care NHS Trust unplanned deficit. Solent NHS Trust unplanned deficit, Staffordshire and Stoke on Trent Partnership NHS Trust unplanned deficit Acute NHS Trusts continue to experience significant levels of financial pressure. Table 7 below clearly identifies the extent of financial challenge that acute NHS Trusts are facing At the 31 December 2014, 52% of Acute NHS Trusts are forecasting a deficit in 2014/15 with many signalling operational pressures in urgent and emergency care and the financial impact of the heightened focus on service quality and safety manifest as increased permanent and non-permanent clinical staffing expenditure. 20

23 Table 7: Financial performance as at 31 December 2014 by NHS Trust sector NHS Trust Sector Months /15 Forecast 2014/15 Plan m Actual m Var. m Plan m Forecast m No. of Trusts No of Trusts forecasting a deficit % of Trust Region Acute (385) (492) (107) (471) (494) (23) % Ambulance 4 1 (3) 7 5 (2) 5 0 0% Community 20 5 (15) (16) % Mental Health (1) (1) % TOTAL (341) (467) (127) (406) (448) (43) % Var. m 4.18 There is a wide span of financial positions planned by NHS Trusts across England that range from a surplus of 11.5 million at Oxford University Hospitals NHS Trust (1.3% of turnover) to a deficit of 93 million at Barts Health NHS Trust (7.2% of turnover). Appendix 1 confirms the financial performance of individual NHS Trusts as at 31 December The aggregate forecast deficit for NHS Trusts is 1.47% of operating revenue for the sector as a whole. The NHS TDA measures the financial performance of all NHS Trusts against their individual plans for the 2014/15 financial year. Key Drivers of Operational Financial Pressure 4.20 The NHS TDA has been working with the NHS Trust sector to establish the key drivers of operational financial pressures in 2014/15. The review has established that there are predominantly two key themes Firstly, rising unplanned demand for care in a hospital setting often paid for at a premium cost has detrimentally impacted on the financial positions of a number of NHS Trusts. It is estimated this impact is in excess of 258m. Where the activity increase is in urgent and emergency care it is often paid for at a marginal rate and displaces elective activity paid for at full cost. The Marginal Rate Emergency Tariff (MRET) deduction in the acute sector is worth approximately 174 million This is further compounded by the various contract sanctions applied against providers for not managing activity totalling approximately 145 million Table 8 below summarise the position by sector. 92% of these external cost pressures impacts acute trusts which continue to be the most financially challenged in the NHS Trust sector. 21

24 Table 8: Impact of premium costs of unplanned activity, contract sanctions and the 30% Marginal Rate Emergency Tariff Operational Financial Pressures Mental Acute Ambulance Community Total Health '000 '000 '000 '000 '000 Unplanned Activity Cost Pressures (Premium Costs of unplanned activity) - Non Elective 104, ,861 - Cancelled Ops 27, ,169 - A&E 42,199 6, ,287 - Other activity 43,585 24,929 3,912 5,604 78,029 Sub Total 217,813 31,017 3,912 5, ,346 Business Rules /Contract MRET - 70% not reinvested in the Trust 173, ,616 Fines applied 143, ,119 - A&E 23, ,655 - RTT 38, ,030 - Other Fines 81, ,434 Sub Total 317, ,735 Total 535,193 31,312 4,509 6, , Secondly, the increase in the level of agency and contract spend is contributing to the decline in the financial position. Table 9 shows the increase in agency and consultancy spend from 2013/14 levels and also the significant variance to plan in 2014/ A high number of NHS Trusts are finding it difficult to fill vacancies on a substantive basis and there has been an increase in the number of nursing posts required in response to unplanned activity pressures and a heightened focus on service quality and safety. Table 9: NHS Trusts Agency / Contract staff costs at Month 9 Agency / Contract Agency/Contract staff costs 2013/14 Full Year Accounts 000s Plan 000s Current Year-to-Date Actual 000s Variance 000s Plan 000s Forecast Outturn Forecast 000s Variance 000s 1,150, ,171 1,107, , ,115 1,435, , However, the NHS Trust sector is also failing to deliver the levels of cost improvement schemes planned at the start of the financial year. A summary of financial efficiency performance (cost improvement plans) by sector is shown in table 10 below. At Month 9 the forecast adverse variance against plan is 169 million There are also a larger proportion of cost improvement schemes being delivered non-recurrently, the forecast adverse variance is 303 million in 2014/15 and this slippage will carry forward recurrently into 2015/16. 22

25 Table 10: Summary of Financial Efficiencies by Sector Sector YTD Plan 000s YTD Actual 000s YTD Variance 000s FOT Plan 000s FOT Actual 000s FOT Variance 000s Acute 826, ,385 (152,004) 1,195,844 1,046,770 (149,074) Ambulance 39,835 36,792 (3,043) 54,367 54, Community 99,921 81,397 (18,524) 142, ,793 (13,631) Mental Health 83,636 80,149 (3,485) 119, ,355 (6,723) TOTAL 1,049, ,723 (177,056) 1,511,713 1,342,795 (168,918) Actions 4.28 The NHS TDA is currently working closely with those NHS Trusts in deficit. This ranges from ensuring each NHS Trust has sufficient cash available to support operational services so enabling the Trust to focus on service delivery and improvement, to supporting those organisations through a transaction process where their unsustainability has been determined Other interventional activity with NHS Trusts in deficit involve: scrutinising cost improvement plans to ensure there are robust processes in place for tracking delivery and identifying substitute schemes where necessary with subsequent focused service performance management; supporting the NHS Trust to gain a thorough understanding of the key risks and mitigations of the financial position, including an assessment of the quality impact of making in year changes to cost improvement plans; the regional quality teams support NHS Trusts to ensure robust quality impact assessments of all cost improvement plans has been undertaken to protect services; sharing good practice on savings schemes from other organisations and from our own experience of working in provider organisations; supporting the development, including targeted challenge of turnaround/recovery plans with tracking through our mainstream oversight and escalation processes; facilitating discussions with commissioners on business management issues, including transformation support and local restructuring arrangements; providing leadership and active engagement in the strategic review of specific health economies to help identify longer-term viable options for those NHS Trusts in distress. 23

26 5. Oversight and Escalation 5.1 Graph 15 below shows the number of organisations in each escalation level for the month of December compared to November. Graph 15: Comparison of overall Oversight and Escalation for the months of November and December 2014 Escalation score changes 5.2 There has been no movement between categories between November and December A summary of escalation scores from April to December 2014 can be found at Appendix Recommendations 6.1 The Board is asked to note: Service Performance for the NHS Trust sector to 31 December 2014 as set out in Sections 2 and 3. Financial Performance for the NHS Trust sector for the period to 31 December 2014 as set out in Section 4. Oversight and Escalation scores in the NHS Trust Sector in Section 5. 24