University Hospitals Plymouth NHS Trust

Transcription

1 University Hospitals Plymouth NHS Trust Use of Resources assessment report Derriford Road, Crownhill, Plymouth, PL6 8DH Tel: Date of publication: 15 August 2018 This report describes our judgement of the Use of Resources and our combined rating for quality and resources for the trust. Ratings Overall quality rating for this trust Are services safe? Are services effective? Are services caring? Are services responsive? Are services well-led? Requires improvement Requires improvement Requires improvement Outstanding Requires improvement Requires improvement Our overall quality rating combines our five trust-level quality ratings of safe, effective, caring, responsive and well-led. These ratings are based on what we found when we inspected, and other information available to us. You can find information about these ratings in our inspection report for this trust and in the related evidence appendix. ( Are resources used productively? Requires improvement Combined rating for quality and use of resources Requires improvement We award the Use of Resources rating based on an assessment carried out by NHS Improvement. Our combined rating for Quality and Use of Resources summarises the performance of the trust taking into account the quality of services as well as the trust s productivity and sustainability. This rating combines our five trust-level quality ratings of safe, effective, caring, responsive and well-led with the Use of Resources rating. Page 1 of 15

2 Use of Resources assessment and rating NHS Improvement are currently planning to assess all non-specialist acute NHS trusts and foundation trusts for their Use of Resources assessments. The aim of the assessment is to improve understanding of how productively trusts are using their resources to provide high quality and sustainable care for patients. The assessment includes an analysis of trust performance against a selection of initial metrics, using local intelligence, and other evidence. This analysis is followed by a qualitative assessment by a team from NHS Improvement during a one-day site visit to the trust. Combined rating for Quality and Use of Resources Our combined rating for Quality and Use of Resources is awarded by combining our five trust-level quality ratings of safe, effective, caring, responsive and well-led with the Use of Resources rating, using the ratings principles included in our guidance for NHS trusts. This is the first time that we have awarded a combined rating for Quality and Use of Resources at this trust. The combined rating for Quality and Use of Resources for this trust was requires improvement, because: we rated safe, effective, responsive, and well-led as requires improvement; and caring as outstanding; we took into account the current ratings of the three core services not inspected at this time. Hence, one core service is rated overall as inadequate, three are rated overall as requires improvement, and the remaining five services are rated good; the overall ratings for each of the trust s acute locations remained the same; and the trust was rated as Requires Improvement for Use of Resources. Page 2 of 15

3 University Hospitals Plymouth NHS Trust Use of Resources assessment report Derriford Road, Crownhill, Plymouth, PL6 8DH Tel: Date of site visit: 8 May 2018 Date of publication: 15 August 2018 This report describes NHS Improvement s assessment of how effectively this trust uses its resources. It is based on a combination of data on the trust s performance over the previous twelve months, our local intelligence and qualitative evidence collected during a site visit comprised of a series of structured conversations with the trust's leadership team. The Use of Resources rating for this trust is published by CQC alongside its other trust-level ratings. All six trust-level ratings for the trust s key questions (safe, effective, caring, responsive, well-led, use of resources) are aggregated to yield the trust s combined rating. A summary of the Use of Resources report is also included in CQC s inspection report for this trust. How effectively is the trust using its resources? Requires improvement How we carried out this assessment The aim of Use of Resources assessments is to understand how effectively providers are using their resources to provide high quality, efficient and sustainable care for patients. The assessment team has, according to the published framework, examined the trust s performance against a set of initial metrics alongside local intelligence from NHS Improvement s day-to-day interactions with the trust, and the trust s own commentary of its performance. The team conducted a dedicated site visit to engage with key staff using agreed key lines of enquiry (KLOEs) and prompts in the areas of clinical services; people; clinical support services; corporate services, procurement, estates and facilities; and finance. All KLOEs, initial metrics and prompts can be found in the Use of Resources assessment framework. We visited the trust on 8 May 2018 and met the trust s executive team (including the chief executive) and relevant senior management responsible for the areas under this assessment s KLOEs. Page 3 of 15

4 Findings Is the trust using its resources productively to maximise patient benefit? Requires improvement We rated the trust s use of resources as Requires Improvement. The trust s total cost per weighted unit of activity is 3,564 compared with a national median of 3,484. This means it spends marginally more on pay and other goods and services per weighted activity unit (WAU) than most other trusts nationally. The trust has an improving financial position, reporting a deficit of 39.9m in 2016/17, which has improved to a deficit of 13.5m in 2017/18 (figures exclude Sustainability and Transformation Funding (STF). This improvement was in part due to the delivery of 31m of savings in 2017/18, of which 25m were recurrent. However, despite this improvement the trust still had a high level of cumulative borrowings at 85m at the end of 2017/18. Whilst the trust has improved financially, operational performance has deteriorated, and the trust is not meeting any of its constitutional performance standards. The trust has made improvements in procurement, use of agency and supplies and services, but whilst the trust has adopted a strong approach to the identification of operational and clinical productivity opportunities, it has not yet consistently realised these opportunities. NHS Improvement s Model Hospital data identifies that there remain further productivity gains to be made and opportunities for improvement were identified in supplies and services, medicines, medical pay and healthcare science and other staff costs. The trust engages well with national programmes such as Getting It Right First Time (GIRFT) and Model Hospital, and has initiated a number of promising projects, including theatre productivity and outpatients. How well is the trust using its resources to provide clinical services that operate as productively as possible and thereby maximise patient benefit? The trust is not meeting NHS constitutional performance standards and its emergency readmission rates and pre-procedure bed days are above the national median. However, the trust has a good Did Not Attend (DNA) rate and an improving Delayed Transfers of Care (DTOC) position. The trust is fully engaged in the GIRFT programme and is a national leader in its use of Model Hospital. The trust has adopted a strong approach to the identification of operational and clinical productivity opportunities but has not yet consistently realised these. During the 12 months up to the assessment in May 2018, the trust did not meet any of the constitutional performance standards. Using the most recent data available (March 2018), Referral to Treatment (RTT) performance was 79.7%, (92% standard), A&E performance was 75.8% (95% target), Cancer 62 day performance was 82% (standard of 85%) and Diagnostics performance was 87.7% (99% standard). In addition, at March 2018, the trust had 108 patients waiting longer than 52 weeks for treatment; the fourth worst performer for long waiters in the South region. The trust s emergency re-admission rate within 30 days is 7.83%, slightly above the national median of 7%. Locally, the trust uses Healthcare Evaluation Data (HED) benchmarking and reports that this indicates that it is not an outlier. Non-elective pre-procedure bed days at the trust were 1.17 at December 2017; this puts the trust in the highest (worst) quartile against a national median of 0.78 days. The trust s local data reports that around 50% of patients do not have their operation or procedure Page 4 of 15

5 on the day of admission. The trust believes this to be due to waits for CT or MRI and is carrying out further analysis to understand how this can be improved and bed days reduced. Elective pre-procedure bed days at the trust were 0.27 (worst quartile) at December 2017 (national median of 0.13). The trust states that this is driven by its tertiary centre services for which patients often have to travel long distances requiring overnight stays. Many patients are admitted for pre-procedure checks on the day before surgery and are then discharged to a local charitable facility to spend the night close to the hospital. The trust s own local data reports admissions on the day of surgery for elective patients at 80%. The trust has begun working on service integration projects with the local provider of community, children s and mental health services including a review aimed at improving clinical productivity in hospital and community therapy and pharmacy. Overall, the trust s rate of DTOCs shows a reducing trend between December 2016 and March 2018 with performance at March 2018 of 5.65% against a target of 3.5%. Whilst this rate is still high, the trust has made good progress in this area. The trust s DNA rate is 6% compared with a national median of 7%. The trust reports improvements have been made through implementing an automatic telephone reminder service as well as more flexible booking options for patients. The trust is fully engaged in the GIRFT and Model Hospital programmes. The trust has a 5 metric programme and is undertaking a quarterly review of every speciality from the first phase, led by the Medical Director, to assess performance. Demonstrations of Model Hospital and GIRFT have been given by the trust at Board meetings and during meetings with staff and hospital committees evidencing that clinicians have bought into the methodology. The trust has a dedicated Model Hospital post supporting the delivery of value for money and discussions at service line level are based on costing data and Model Hospital analysis. The trust s GIRFT tracker has been adopted for use across the South West and the national team has shared the trust s GIRFT tracker with local hubs for wider distribution to trusts. How effectively is the trust using its workforce to maximise patient benefit and provide high quality care? Overall the trust s pay cost per WAU is broadly comparable to most other trusts, but medical costs are comparatively very high. The trust has reduced its use of agency staff and consistently operates within the agency ceiling. Staff retention benchmarks well, levels of sickness and absence are in line with the median and staff turnover is reducing. The trust uses e-rostering for nursing including use of a safe staffing module. The trust is currently reviewing consultant job plans. The trust s overall pay cost per WAU is 2,113, slightly lower than both the peer median of 2,123 and the national median of 2,157 meaning that it spends marginally less on staff per unit of activity than most trusts. Within this, the trust benchmarks well against both its peers and nationally for nursing ( 641 against national median of 718) allied health professionals (AHP) ( 116 against national median of 127) and corporate, admin and estates staff costs ( 302 against national median of 352). In addition, the trust s non-substantive and agency costs per WAU ( 203, 95 respectively) are both below the national median ( 260, 137 respectively) although higher than peers ( 187, 87 respectively). Against this, the trust has a substantive pay cost per WAU of 1,910 against a national median of 1,886 and the highest medical staff costs per WAU in the country ( 657 against a national median of 526 and a peer median of 500). The trust recognises this position and has a number of projects which are aiming to improve this. Page 5 of 15

6 In addition, healthcare science and other staff costs per WAU are 194 against a national median of 153. The trust reports this is in part due to being a regional provider for pathology and that this figure includes operating theatre practitioners and sterilisation unit staff that may be recorded elsewhere in other organisations. The trust met its agency ceiling of 8.79m as set by NHS Improvement for 2017/18, with actual spend of 7.98m, a significant reduction from an agency spend of 12.99m in 2016/17. The trust plans to reduce agency use again in 2018/19 and is one of 12 Flexible Working Pilot sites approved by the Department of Health. Directors meet care groups on a weekly basis to review agency usage and look for alternatives. The trust uses an e-rostering system for nursing, including safe staffing modules and has recently been Highly Commended by the system provider for its application. Work is on-going to roll this out to medical and AHP staff. Information from Model Hospital reports that 84.9% of consultants have an active job plan against the national median of 89.7%. Following NHS Improvement Guidance, the trust established a Medical Job Plan Consistency Committee in June 2017 which is reviewing all consultant job plans and making required amendments in real time. Assumptions around benefits have been included in the trust s 2018/19 plan. This piece of work is on-going. Staff retention at the trust is good being 89% against a national median of 86%. The trust s staff survey reported that 81.5% of staff are proud to work for the trust and 91% feeling proud of working in their team. Sickness rates are in line with the national median. The trust reports a reducing staff turnover of 10.2% as at February 2018 from a high of 11.3% in April Professional and Technical and AHP staff groups continue to have the highest turnover rates of any staff group at 11.7% and 13.0% respectively. How effectively is the trust using its clinical support services to deliver high quality, sustainable services for patients? The trust performs well for pathology costs. However, medicines costs are relatively high when benchmarked but the trust performs well for the Top Ten medicines. The trust is using technology to improve access and efficiency. The overall cost per test for Pathology is reducing from 2.14 in 2016/17 to 1.82 in quarter 2 of 2017/18 against a national median of We note that higher costs might be expected in a specialist centre. The trust s cost per WAU for direct access pathology is 2,743 for 2016/17 which is below the national average of 3,669 and puts it in the lowest (best) quartile. The trust is discussing ways of increasing imaging reporting capacity with the other trusts within the South West Peninsula although this work has not yet reported results. The trust is leading the South West Peninsula Radiology Network (one of four national NHSI pilots). As part of this, the trust is developing projects to improve skill mix, for example, through radiographer reporting and home working. As this point, however, results are not available. The trust s medicines cost per WAU is high when compared nationally at 427 compared with the national median of 320. The trust reported that it has a high volume of high cost drugs, which are pass through costs to commissioners, being at comparable levels to trust with a high level of specialist activity. It is not possible to say at this time if the variation is warranted by the specialist services provided by the trust. The trust has invested in an electronic prescribing system which commenced as a pilot across two wards in July A full roll out is planned by January Page 6 of 15

7 Expected outputs are improved governance, reduced waste (from minimising overprescribing by volume), and use of alternative and cheaper drugs. The trust performs very well against the Top Ten Medicines with savings of 2.77m against a target of 2m (130% of target). This has been driven in particular by the Medicines Utilisation Committee with the use of biosimilars. The trust reports that it has started to use a number of alternatives to face to face hospital appointments including running a significant number of telephone clinics. In 2017/18 9.4% of follow up appointments were conducted over the telephone. Virtual clinics are being used in Ophthalmology and, in addition, the trust has been running a pilot Skype clinic where Ear, Nose and Throat clinicians work with a local GP Practice group to discuss pre-arranged patients with the aim of maximising care in a GP setting. The trust reports that early indications from this work suggest referrals to secondary care could be reduced by 12%. The trust s central booking team has recently implemented an automatic partial booking process where patients are given the option to select and book an appointment directly. In addition, the trust is currently working on a project to implement e-communications with patients which will enable patients to log into a web portal and manage their care remotely. How effectively is the trust managing its corporate services, procurement, estates and facilities to maximise productivity to the benefit of patients? The trust reports high levels of backlog maintenance. However, the trust performs very well in procurement where it is engaged at a national level and has invested in its internal capacity and capability. For 2016/17 the trust had an overall non-pay cost per WAU of 1,451 (ranked 105 out of 135 trusts), compared with a national median of 1,301, placing it in the second highest cost quartile nationally. This represents a marginal improvement on 2015/16 ( 1,485) where it was ranked 115 out of 136 trusts, suggesting that the trust is reducing its spending on supplies and services. For 2016/17, the cost of running the trust s Finance department is lower than the national median and in the lowest (best) quartile at 559,540 per 100m turnover and payroll costs are also below the national median at 74,276 per 100m turnover. Human Resources costs are in the second lowest (best) cost quartile at 1,000,000 per 100m turnover. The trust makes use of shared services in finance and hosts payroll services for the Ambulance service. The trust undertook a Corporate Services Review as part of its 2017/18 Financial Improvement Programme and the resulting projects delivered 2.3m of savings in year. The trust is also part of the STP s focused review of corporate services aimed at looking at potential opportunities from sharing services across Devon. A number of best practice sessions have been held to progress this agenda with pilot areas in HR, procurement and legal services identified. The trust s supplies and services costs per WAU are 526 (worst quartile) against the national median of 375. Drivers for this performance (from the trust s non-pay deep dive) are pass-through costs to commissioners; pay elements within contracted services ( 15m) and external contracts (for example, the provision of 2.3m of drugs to third parties). As at quarter /18, the trust was performing well against the expanded Top 500 products metric, ranking 14th best nationally out of 135 trusts with 24.6% of products that are achieving best price from the Top 500 product lines. The trust has made investments in procurement including staffing, investment in software and technology to improve efficiency and governance, a warehouse to Page 7 of 15

8 reduce cost and inventory freeing up clinical space and adoption and implementation of GS1 standards to improve efficiency. The trust s Chief Procurement Officer leads the Nationally Contracted Products programme and the Purchase Price Index and Benchmarking tool (PPIB) on behalf of NHS Improvement and is also currently the Senior Reporting Officer for the Peninsula Purchasing and Supply Alliance. The trust ranks 6th best out of 136 trusts in the procurement league tables and is above the required thresholds for core Carter metrics. The trust is ranked in quartile 4 (lowest) for procurement with a cost of 418k per 100m turnover for 2016/17; it reports that it expects to improve this performance further in 2017/18. The trust is reporting 47.9m of backlog maintenance, with 99% belonging to the Derriford Hospital site. Total backlog is 334/m2 placing it in the worst quartile) compared to peer median of ( 226/m2). The high backlog levels are linked to the age of the estate and are included in the long term estates strategy. The trust has good processes in place to ensure critical backlog maintenance is prioritised and clinical services are not at risk. Although the trust is at benchmark at 0.05/kWh, opportunities still exist within energy. The trust is a pilot site for Scan4Safety (a barcode technology used to improve patient safety by tracing patients and treatments), managing supplies and monitoring the effectiveness of equipment. How effectively is the trust managing its financial resources to deliver high quality, sustainable services for patients? The trust has an improving financial position, reporting a deficit of 39.9m in 2016/17 and a deficit of 13.5m in 2017/18 (figures exclude Sustainability and Transformation Funding (STF). This improvement was due, in part, to the delivery of 31m of savings in 2017/18, of which 25m were recurrent. Despite this improvement the trust still had a high level of borrowings at around 85m at the end of 2017/18. It has good processes in place to control and monitor expenditure and clinical engagement is used to scrutinise and challenge savings plans. The trust has an improving financial position, moving from a reported deficit of 39.9m in 2016/17 (when the trust was unable to accept the financial target it was given by NHS Improvement) to a 13.9m deficit not including STF in 2017/18. The trust s underlying 2017/18 deficit was 30.5m against a turnover of 504m (representing just over 6% of turnover). Savings delivery in 2017/18 was 31.1m against a plan of 40m. Of this, 25m was delivered recurrently and 11.1m was delivered through income improvements. This is an increase from savings delivery of 14m in 2016/17. In 2018/19, the trust has an ambitious cost improvement programme of 33m of which 16m was categorised by the trust as high risk at the time of our review. The trust s Finance and Investment Group (FIG) and Business Support Units support staff to understand budgets and engage and deliver on savings plans. Robust processes, with clinical input, are in place to review recruitment and additional investment requests. The trust has liquidity and capital service metric scores (the ability of the trust to meet its financial obligations) of 4 and 3 respectively, recognising the challenging environment for the trust. At the end of 2017/18, the trust had a significant 85m of borrowing. The trust produces a quarterly costing report and reviews this against Model Hospital data to identify variations. The trust uses service line reporting and has designated business advisors for each service, responsible for business development and improvement. During 2017/18, the trust appointed an external consultancy firm to review its sub-scale services and medical workforce productivity, via deep dive analysis. The review identified Page 8 of 15

9 16.1m of opportunities across job planning, theatre productivity, outpatients and subscale activities. As an alternative to retaining consultancy support to further develop these opportunities, the trust took this work in-house, using the results in 2018/19 savings plans. The trust s commercial income in 2015/16 was in the top quartile at 14m (national median was 7.3m) or 3.26% of total income. It earned private patient income in quarter 3 of 2016/17 of 647k (top quartile), representing 0.24% of total income (2nd highest quartile). Outstanding practice The trust is fully engaged in GIRFT at operational, clinical and executive level, developing an approach which is considered excellent practice by the NHS Improvement Operational Productivity team. The trust s GIRFT tracker was adopted across the South West and the national team has shared the trust s GIRFT tracker with local hubs for wider distribution to trusts. The trust has a dedicated Model Hospital post delivering value for money and ensuring service line conversations are based on costing data and Model Hospital analysis. The trust ranks 6th out of 136 trusts in the procurement league tables and is engaged nationally via its Chief Procurement Officer. The trust is a pilot site for the national Scan4Safety project. Areas for improvement The trust is not meeting its constitutional performance targets. Investigating trends and themes of re-admissions at a specialty level in order to reduce re-admissions where possible is an on-going work stream. Reviewing the drivers of non-elective pre-procedure bed days and reducing these where possible, is an on-going piece of work for the trust. The trust is part of an NHS Improvement deep dive review of its high Medical Costs. The trust in the process of embedding the results of a number of internal and external reviews of efficiency opportunities. There is scope to review the trust s medicines cost to establish if the high costs are warranted by the tertiary level services it provides. Opportunities exist to recurrently reduce the trust s energy costs. Page 9 of 15

10 Ratings tables Ratings Inadequate Key to tables Requires improvement Good Outstanding Rating change since last inspection Same Up one rating Up two ratings Down one rating Down two ratings Symbol * Month Year = date key question inspected * Where there is no symbol showing how a rating has changed, it means either that: we have not inspected this aspect of the service before or we have not inspected it this time or changes to how we inspect make comparisons with a previous inspection unreliable. Ratings for the whole trust Page 10 of 15

11 Use of Resources report glossary Term 18-week referral to treatment target 4-hour A&E target Agency spend Allied health professional (AHP) AHP cost per WAU Biosimilar medicine Cancer 62-day wait target Capital service capacity Care hours per patient day (CHPPD) Cost improvement programme (CIP) Control total Diagnostic 6- week wait target Definition According to this national target, over 92% of patients should wait no longer than 18 weeks from GP referral to treatment. According to this national target, over 95% of patients should spend four hours or less in A&E from arrival to transfer, admission or discharge. Over reliance on agency staff can significantly increase costs without increasing productivity. Organisations should aim to reduce the proportion of their pay bill spent on agency staff. The term allied health professional encompasses practitioners from 12 diverse groups, including podiatrists, dietitians, osteopaths, physiotherapists, diagnostic radiographers, and speech and language therapists. This is an AHP specific version of the pay cost per WAU metric. This allows trusts to query why their AHP pay is higher or lower than national peers. Consideration should be given to clinical staff mix and clinical staff skill mix when using this metric. A biosimilar medicine is a biological medicine which has been shown not to have any clinically meaningful differences from the originator medicine in terms of quality, safety and efficacy. According to this national target, 85% of patients should begin their first definitive treatment for cancer within 62 days following an urgent GP referral for suspected cancer. The target is 90% for NHS cancer screening service referrals. This metric assesses the degree to which the organisation s generated income covers its financing obligations. CHPPD measures the combined number of hours of care provided to a patient over a 24 hour period by both nurses and healthcare support workers. It can be used to identify unwarranted variation in productivity between wards that have similar speciality, length of stay, layout and patient acuity and dependency. CIPs are identified schemes to increase efficiency or reduce expenditure. These can include recurrent (year on year) and non-recurrent (one-off) savings. CIPs are integral to all trusts financial planning and require good, sustained performance to be achieved. Control totals represent the minimum level of financial performance required for the year, against which trust boards, governing bodies and chief executives of trusts are held accountable. According to this national target, at least 99% of patients should wait no longer than 6 weeks for a diagnostic procedure. Page 11 of 15

12 Did not attend (DNA) rate Distance from financial plan Doctors cost per WAU Delayed transfers of care (DTOC) EBITDA Emergency readmissions Electronic staff record (ESR) Estates cost per square metre Finance cost per 100 million turnover Getting It Right First Time (GIRFT) programme Human Resources (HR) cost per 100 million turnover A high level of DNAs indicates a system that might be making unnecessary outpatient appointments or failing to communicate clearly with patients. It also might mean the hospital has made appointments at inappropriate times, eg school closing hour. Patients might not be clear how to rearrange an appointment. Lowering this rate would help the trust save costs on unconfirmed appointments and increase system efficiency. This metric measures the variance between the trust s annual financial plan and its actual performance. Trusts are expected to be on, or ahead, of financial plan, to ensure the sector achieves, or exceeds, its annual forecast. Being behind plan may be the result of poor financial management, poor financial planning or both. This is a doctor specific version of the pay cost per WAU metric. This allows trusts to query why their doctor pay is higher or lower than national peers. Consideration should be given to clinical staff mix and clinical staff skill mix when using this metric. A DTOC from acute or non-acute care occurs when a patient is ready to depart from such care is still occupying a bed. This happens for a number of reasons, such as awaiting completion of assessment, public funding, further non-acute NHS care, residential home placement or availability, or care package in own home, or due to patient or family choice. Earnings Before Interest, Tax, Depreciation and Amortisation divided by total revenue. This is a measurement of an organisation s operating profitability as a percentage of its total revenue. This metric looks at the number of emergency readmissions within 30 days of the original procedure/stay, and the associated financial opportunity of reducing this number. The percentage of patients readmitted to hospital within 30 days of discharge can be an indicator of the quality of care received during the first admission and how appropriate the original decision made to discharge was. ESR is an electronic human resources and payroll database system used by the NHS to manage its staff. This metric examines the overall cost-effectiveness of the trust s estates, looking at the cost per square metre. The aim is to reduce property costs relative to those paid by peers over time. This metric shows the annual cost of the finance department for each 100 million of trust turnover. A low value is preferable to a high value but the quality and efficiency of the department s services should also be considered. GIRFT is a national programme designed to improve medical care within the NHS by reducing unwarranted variations. This metric shows the annual cost of the trust s HR department for each 100 million of trust turnover. A low value is preferable to a high value but the quality and efficiency of the department s services should also be considered. Page 12 of 15

13 Income and expenditure (I&E) margin Key line of enquiry (KLOE) Liquidity (days) Model Hospital Non-pay cost per WAU Nurses cost per WAU Overall cost per test Pay cost per WAU Peer group Private Finance Initiative (PFI) Patient-level costs Pre-procedure elective bed days This metric measures the degree to which an organisation is operating at a surplus or deficit. Operating at a sustained deficit indicates that a provider may not be financially viable or sustainable. KLOEs are high-level questions around which the Use of Resources assessment framework is based and the lens through which trust performance on Use of Resources should be seen. This metric measures the days of operating costs held in cash or cash equivalent forms. This reflects the provider s ability to pay staff and suppliers in the immediate term. Providers should maintain a positive number of days of liquidity. The Model Hospital is a digital tool designed to help NHS providers improve their productivity and efficiency. It gives trusts information on key performance metrics, from board to ward, advises them on the most efficient allocation of resources and allows them to measure performance against one another using data, benchmarks and good practice to identify what good looks like. This metric shows the non-staff element of trust cost to produce one WAU across all areas of clinical activity. A lower than average figure is preferable as it suggests the trust spends less per standardised unit of activity than other trusts. This allows trusts to investigate why their non-pay spend is higher or lower than national peers. This is a nurse specific version of the pay cost per WAU metric. This allows trusts to query why their nurse pay is higher or lower than national peers. Consideration should be given to clinical staff mix and clinical staff skill mix when using this metric. The cost per test is the average cost of undertaking one pathology test across all disciplines, taking into account all pay and non-pay cost items. Low value is preferable to a high value but the mix of tests across disciplines and the specialist nature of work undertaken should be considered. This should be done by selecting the appropriate peer group ( Pathology ) on the Model Hospital. Other metrics to consider are discipline level cost per test. This metric shows the staff element of trust cost to produce one WAU across all areas of clinical activity. A lower than average figure is preferable as it suggests the trust spends less on staff per standardised unit of activity than other trusts. This allows trusts to investigate why their pay is higher or lower than national peers. Peer group is defined by the trust s size according to spend for benchmarking purposes. PFI is a procurement method which uses private sector investment in order to deliver infrastructure and/or services for the public sector. Patient-level costs are calculated by tracing resources actually used by a patient and associated costs This metric looks at the length of stay between admission and an elective procedure being carried out the aim being to minimise it and the Page 13 of 15

14 associated financial productivity opportunity of reducing this. Better performers will have a lower number of bed days. Pre-procedure non-elective bed days Procurement Process Efficiency and Price Performance Score Sickness absence Single Oversight Framework (SOF) Service line reporting (SLR) Supporting Professional Activities (SPA) Sustainability and Transformation Fund (STF) Staff retention rate Top Ten Medicines This metric looks at the length of stay between admission and an emergency procedure being carried out the aim being to minimise it and the associated financial productivity opportunity of reducing this. Better performers will have a lower number of bed days. This metric provides an indication of the operational efficiency and price performance of the trust s procurement process. It provides a combined score of 5 individual metrics which assess both engagement with price benchmarking (the process element) and the prices secured for the goods purchased compared to other trusts (the performance element). A high score indicates that the procurement function of the trust is efficient and is performing well in securing the best prices. High levels of staff sickness absence can have a negative impact on organisational performance and productivity. Organisations should aim to reduce the number of days lost through sickness absence over time. The Single Oversight Framework (SOF) sets out how NHS Improvement oversees NHS trusts and NHS foundation trusts, using a consistent approach. It helps NHS Improvement to determine the type and level of support that trusts need to meet the requirements in the Framework. SLR brings together the income generated by services and the costs associated with providing that service to patients for each operational unit. Management of service lines enables trusts to better understand the combined view of resources, costs and income, and hence profit and loss, by service line or speciality rather than at trust or directorate level. Activities that underpin direct clinical care, such as training, medical education, continuing professional development, formal teaching, audit, job planning, appraisal, research, clinical management and local clinical governance activities. The Sustainability and Transformation Fund provides funding to support and incentivise the sustainable provision of efficient, effective and economic NHS services based on financial and operational performance. This metric considers the stability of the workforce. Some turnover in an organisation is acceptable and healthy, but a high level can have a negative impact on organisational performance (eg through loss of capacity, skills and knowledge). In most circumstances organisations should seek to reduce the percentage of leavers over time. Top Ten Medicines, linked with the Medicines Value Programme, sets trusts specific monthly savings targets related to their choice of medicines. This includes the uptake of biosimilar medicines, the use of new generic medicines and choice of product for clinical reasons. These metrics report trusts % achievement against these targets. Trusts can assess their success in pursuing these savings (relative to national peers). Page 14 of 15

15 Weighted activity unit (WAU) The weighted activity unit is a measure of activity where one WAU is a unit of hospital activity equivalent to an average elective inpatient stay. Page 15 of 15