PHT Public Trust Board Papers March 2011.pdf - Plymouth Hospitals

Trust Board 

Standing Items 

Friday 25 March 2011 

Board Room, Derriford Health & Leisure Centre 

Agenda 

1:30pm – Opportunity for Questions 

2:00pm – Trust Board Meeting 

Why we are here …. Learning from success 

1 Welcome and apologies Chairman Verbal 

2 Minutes of the meeting held on 25 February 2011 Chairman Paper 

3 Review of outstanding actions Chairman Paper 

4 Chairman’s introductory remarks Chairman Verbal 

5 Chief Executive’s Report Chief Executive Paper 

Safety and Quality 

6 The Development of Patient Pledges 

Agreement of patient pledges for 2011/12 and beyond. 

7 Quality Account – to follow 

Review of draft Quality Account for 2010/11. 

8 Standards with Patients with Dementia 

Recommended by the Safety & Quality Committee for noting 

by the Board. 

9 Safety & Quality Committee – to follow 

Report on the key activities of the Committee. 

Finance, Performance & Efficiency 

10 Performance Review 

Review of the Trust’s performance to the end of February 

2011. 

11 Finance, Performance & Investment Committee – to follow 

Report on the key activities of the Committee. 

Workforce and Organisational Development 

12 2010 Staff Survey 

Summary of the Trust’s performance from National Staff 

Survey. 

Governance, Regulatory and Compliance 

13 NIHR Research & Development Capability Statement 

Approval of operational capability statement required by NIHR. 

14 Trust Seal 

Quarterly report on the use of the Trust Seal. 

Chief Nurse 

Medical Director 

Chief Nurse 

Committee Chair 

Chief Operating 

Officer & Director 

of Finance 

Committee Chair 

Interim Director of 

Workforce 


Board Secretary 

Paper 

Paper 

Paper 

Paper 

Paper 

Paper 

Paper 

Paper 

Paper 

Date of next meeting – Friday 6 May 2011

Item 2 

Present: 

Apologies: 

Plymouth Hospitals NHS Trust 

Minutes of the Trust Board meeting Part 1 

held on Friday 25 February 2011 in the 


2.00 pm Questions 

Steven Jermy, Chairman 

Peter Burroughs, Non-Executive Director 

Alex Mayor, Medical Director 

Helen O’Shea, Chief Operating Officer 

Lee Paschalides, Non-Executive Director 

David Pond, Non-Executive Director 

Paul Roberts, Chief Executive 

Margaret Schwarz, Non-Executive Director 

D 

Sarah Watson-Fisher, Chief Nurse 

Ian Douglas, Non-Executive Director 

Joe Teape, Director of Finance 

R 

Sarah Brampton, Director of Financial Services & Performance 

In Attendance: Paul Beal, Interim Director of Workforce 

‘Governors’ In 

Attendance 

Lee Budge, Auditor 

Gill Hunt, FT Board Secretary 

Barry Lucas, LINk and Patient Representative, Public ‘Governor’, 

Plymouth Constituency 

A 

Amanda Nash, Head of Communications 

Brian Bird, Public ‘Governor’, Devon Constituency 

Vera Mitchell, Public ‘Governor’, Plymouth Constituency 

Ivor Vaughan, Public ‘Governor’, Cornwall Constituency 

F 

The Chairman welcomed ‘governors’, members of the public and press, and 

apologised for the late start to the public meeting. The Chairman invited questions. 

These primarily concerned recent media attention on six ‘never events’ and the 

issue, by the Care Quality Commission (CQC), of a warning notice on 22 February 

2011. 

T 

On behalf of Plymouth LINk, Mr Lucas asked why the Trust had not been proactive 

in alerting the CQC as each ‘never event’ had occurred. The Chief Executive 

updated Mr Lucas on his recent meeting with the CQC at which the warning notice 

had been issued. He assured Mr Lucas that the Board regularly received reports 

of all Serious Clinical Incidents (SUIs) and ‘never events’ had been discussed at the 

Board, both in private and in public. The Chief Executive offered to speak directly 

with LINk, if LINk felt this was appropriate. The Medical Director stated the Board’s 

desire to be as open and honest as possible, and although patient confidentiality 

did not permit discussion of specific cases, he stressed that no patient had come to 

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Item 2 

any long term harm. The Chairman affirmed that it was the Board’s absolute 

intention to be open and to promote a just culture where staff were held to account. 

Patient safety was the Board’s highest priority. 

Mr Lucas asked if the Trust intended to dismiss any staff in respect of the ‘never 

events’. The Chief Executive stated that there were policies and procedures in 

place for staff to follow. The Trust would be fair in its investigations but staff would 

be held to account. The Chairman stressed the importance of understanding the 

cause of ‘never events’; it may be a systematic failure but, if blame were 

attributable then, as the Chief Executive had stated, individuals would be held to 

account. 

Mr Lucas asked whether the ‘never events’ were the result of a systems failure. 

The Medical Director stated that a detailed investigation had been completed and 

where systems issues had 

D 

been identified, actions had been put into place to 

address them. Patient confidentiality prevented him from going into further detail. 

Mr Lucas asked whether the public would be advised when any disciplinary process 

had been finalised. The Interim Director of Workforce stated that this would be a 

matter for the Trust. 

R 

‘Governor’ Brian Bird stated that public confidence in the hospital had been 

seriously damaged by the ‘never events’ and that risk management appeared to 

have failed in these cases. Patient safety had been denied and he was concerned 

that the Trust had not been proactive in contacting the CQC. Mr Bird was 

concerned by the number of serious clinical incidents reported at the last meeting 

and urged the Trust to take 

A 

disciplinary action, where necessary. The Chief 

Executive stated that the Board had agreed at their meeting in January to contact 

the CQC and the Chairman assured Mr Bird that should negligence be identified, 

appropriate action would be taken. The Chief Executive stated that the CQC 

expected the Trust to make rapid improvements and he was confident that these 

would be achieved. Staff had worked hard to ensure incident reporting increased 

because this was absolutely crucial 

F 

for public safety. 

‘Governor’ Ivor Vaughan asked why the standard WHO checklist had not been in 

use. The Medical Director advised that Trust policies and procedures clearly stated 

that it should be. Audit had ascertained some variability to the standard checklist; 

this had been confirmed by the CQC and variability would be eliminated. The 

Board expected 100% compliance. 

T 

‘Governor’ Vera Mitchell expressed her disappointment at the issue of the CQC’s 

warning notice but was confident in the Trust’s intention, and in its ability, to put 

matters right. Mrs Mitchell was concerned by South West Water’s intention to 

increase water bills by 8.1% and asked what effect this would have on the Trust. 

The Director of Financial Services stated that utilities inflation costs were included 

in the Annual Business Plan for 2011/2012 and she would be pleased to pick this 

up further with Mrs Mitchell outside the meeting. 

A member of the public asked why the Trust appeared to discriminate against 

patients with medical phobias. She had made a formal complaint about her own 

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Item 2 

recent experiences, to which she did not expect a specific response at this forum, 

but sought a generic response from the Board. Her experiences had inspired her to 

become an advocate for patients with medical phobias. The Chief Executive 

welcomed her advocacy and agreed that her point was fair. He could not respond 

immediately but would be pleased to do so outside the meeting. 

‘Governor’ Ivor Vaughan stated that there was a lack of patient privacy and dignity 

caused by ambulance offloading arrangements adjacent to the Orthopaedic Clinic. 

The Medical Director stated that the current arrangements may result from the 

requirement to maintain a clear emergency pathway for patients arriving by 

helicopter, and for emergency resuscitation access, but he would consider what 

improvements could be made. 

There were no further questions. 

D 

R 

A 

F 

T 

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Item 2 


Minutes of the Trust Board meeting Part 1 

held at 2.30 pm on Friday 25 February 2011 in the 


Present: 

Apologies: 

Steven Jermy, Chairman 

Peter Burroughs, Non-Executive Director 

Alex Mayor, Medical Director 

Helen O’Shea, Chief Operating Officer 

Lee Paschalides, Non-Executive Director 

David Pond, Non-Executive Director 

Paul Roberts, Chief Executive 

Margaret Schwarz, Non-Executive Director 

Sarah Watson-Fisher, Chief Nurse 

D 

Ian Douglas, Non-Executive Director 

Joe Teape, Director of Finance 

In Attendance: Paul Beal, Interim Director of Workforce 

Sarah Brampton, Director of Financial Services & Performance 

Lee Budge, Auditor 

‘Governors’ In 

Attendance 

R 

Gill Hunt, FT Board Secretary 

Barry Lucas, LINk and Patient Representative, Public ‘Governor’, 

Plymouth Constituency 

Amanda Nash, Head of Communications 

A 

Vera Mitchell, Public ‘Governor’, Plymouth Constituency 

Brian Bird, Public ‘Governor’, Devon Constituency 

Ivor Vaughan, Public ‘Governor’, Cornwall Constituency 

F 

18/11 Welcome and apologies 

There were no apologies for absence. 

Action 

19/11 Minutes of the meeting held on 28 January 2011 

T 

The minutes were agreed as a true and accurate record of the 

meeting. 

20/11 Matters Arising 

There were no matters arising. 

21/11 Review of Outstanding Actions 

There were no outstanding actions and the Board noted the 

Action List. 

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Item 2 

22/11 Chairman’s Introductory Remarks 

The Chairman stated that the Board’s discussions during the 

morning had focused on issues of patient safety, business 

management and leadership. 

23/11 Chief Executive’s Overview 

The Chief Executive briefed the Board on issues of topical 

interest. 

Care Quality Commission (CQC) 

The Chief Executive updated the Board on the outcome of the 

meeting with the CQC 

D 

on 22 February, on the implications of the 

CQC’s regulatory response resulting from the Trust’s inadequate 

compliance with the WHO’s surgical safety checklist and the 

subsequent service of a warning notice requiring compliance 

within 28 days. The CQC would make public a full report on 

their visit and the Trust was required to produce a robust and 

comprehensive action plan to address their concerns. 

R 

The main points of the Board’s discussions were: 

• Assurance to the public that patient safety was the top 

priority for the Board. 

A 

• Ensuring that every member of staff understood their own 

responsibilities for patient safety and that in every 

operating theatre there was a single accountable person. 

• An observational audit across all theatres and a single, 

mandatory, 

F 

WHO checklist had been implemented. 

Identification of non-compliance may involve disciplinary 

action. Executive Board members were working closely 

with nursing and medical leads to support them in the 

delivery of this. 

T 

• The importance of positive and productive discussions 

with the CQC; the fostering of a good relationship 

between the Trust and its Regulator was crucial in 

assisting regulators to do their work. 

Health Service Ombudsman’s Report on Care of the Elderly 

This national report was disturbing and highlighted the 

responsibilities involved in the care of this large and vulnerable 

group. The Chief Executive had visited ward staff on the day of 

the report’s publication and there was a shared sense of 

personal responsibility – which extended through the Trust and 

included the Board – that all staff could learn from the case 

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Item 2 

studies described in the report. The CQC had stated their 

intention to visit 100 hospitals in England and Wales following 

the report’s publication and the Trust should expect to receive a 

visit. On behalf of older people, the Chief Executive welcomed 

this. 

There was NED challenge on: 

• Assurance on preparedness for a CQC visit. 1 The Chief 

Nurse stated that staff had been fully briefed on 

communication standards expected for CQC visits. The 

Associate Director of Nursing & Midwifery had revisited 

issues of nutrition, communication, and privacy and 

dignity. Junior medical staff had been briefed at a recent 

clinical leadership group meeting. 

D 

• Did the Trust do enough to support feeding? 

Nurse stated that wards practised protected mealtimes. 

The recent PEAT inspection team had observed a lunch 

serving, although compliance on that day had been 

variable. The 

R 

Healthcare of the Elderly clinical pathway 

was about to be rolled out by the Associate Director of 

Nursing & Midwifery; this would facilitate improved care 

for patients with multiple conditions. 

2 

The Chief 

24/11 

The Chairman thanked the Chief Executive for his update, 

which was noted by the Board. 

A 

Quality Account 2010/2011 Priorities 

The Medical Director advised that preparations for the 

publication of the Trust’s Quality Account were on target to meet 

the 30 June deadline. Healthcare governance focus had shifted 

from process to outcomes and it was important for patients that 

F 

the Trust could measure and demonstrate good outcomes from 

past areas of focus. This would be the case for the Quality 

Account priorities for 2010/2011 and the Board were now asked 

to agree the priorities for achievement in 2011/2012 for inclusion 

in this year’s Quality Account. In accordance with Department of 

Health recommendations, the paper suggested five priorities for 

the Board to consider. 

T 

The key point of the Board’s discussions was: 

• Agreement that the five priorities must be measurable. 

This was particularly pertinent to the priority to improve 

overall patient satisfaction, for which changes in 

1 Margaret Schwarz 

2 Margaret Schwarz 

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Item 2 

complaints management and reporting, and the collection 

of real time data on the patient experience at ward level, 

would be important factors. 

There was NED challenge on: 

• Effective communication with front line staff, particularly 

with regard to attitudes and behaviours. 3 The Chief Nurse 

stated that the answer lay in working with staff in a more 

formal setting on the importance of effective patient 

engagement. Simplicity was also important; simple 

measures, such as ward satisfaction levels, could have a 

big impact. 

The Board agreed 

D 

with the priorities recommended in the 

report and would expect to review the draft Quality 

Account, including measurable outcomes for last year’s 

priorities, at the March Board. 

MD 

25/11 Performance Report 

R 

The Director of Financial Services & Performance briefed the 

Board on the current financial position. The Trust was reporting 

a deficit of £3.8m, £4.1m adverse to budget but in line with the 

recovery plan agreed with NHS South West. Assuming the 

recovery plan remained 

A 

on track, the Trust continued to forecast 

the delivery of a break even position at the financial year end. 

The Chief Operating Officer reported good performance on 

infection control and Hospital Standardised Mortality Rates. The 

A&E 4 hour standard 

F 

improved in January, but was still under 

performing, with community performance at 94.64%, just below 

the 95% national target. Year to date performance remained 

above the national target. Referral to treatment targets were on 

trajectory to hit by March and the Chief Operating Officer drew 

the Board’s attention to new measuring standards from April 

2011. Reperfusion 

T 

waiting times were now measured by 

calendar year and clarification was required on whether this 

standard referred to all patients or only to those eligible for 

reperfusion. The drop in performance in Endoscopy should see 

improvement in February. 

Finance 

Performance 

Cancelled operations represented 1.9% of elective admissions, 

still below trajectory. The Trust had struggled with beds due to 

delayed discharges in January and there had been an increase 

in elective activity. 

3 Lee Paschalides 

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Item 2 

Performance against Monitor’s scorecard was amber/red but, 

with adjustment for the now validated performance against 

cancer standards, this had improved to amber/green. 

Workforce 

The Interim Director of Workforce reported that sickness 

absence was disappointing but improvement was expected 

following a review of the Sickness Absence policy and focused 

support from Occupational Health and HR Business Partners. 

The non-medical staff appraisal rate was 75.61% and it was 

probable that organisational change had affected appraisal takeup. 

Additional interventional work was required to further simplify 

the appraisal process and related paperwork. 

D 

The Board noted the Performance Report. 

The Chief Nurse’s paper briefed the Board on the requirements 

of the Public Sector 

R 

Equality Duty, effective 1 April 2011. As 

well as specific duties relating to the availability of equality data 

and the setting, by April 2012, of equality objectives, the paper 

reminded the Board of the three general equality duties: 

26/11 Equality and Diversity: the Public Sector Duty 

27/11 

• Eliminate unlawful discrimination, harassment and 

victimisation. 

• Advance equality of opportunity between different groups. 

A 

• Foster good relations between different groups. 

The strategic issue for the Trust was to mainstream the equality 

and diversity agenda. The Workforce Directorate would lead on 

this and a further report would come to the Board in April 2011. 

F 

The Board welcomed, and noted, the comprehensive report and 

did not underestimate the amount of work involved. The Board 

would receive a seminar to enable greater exploration of the 

issues involved and the Interim Director of Workforce would 

advise on timings. 

T 

Terms of Reference for Board Committees 

NEDs presented the Terms of Reference for the Finance, 

Performance & Investment Committee 

4 and the Safety & Quality 

Committee 5 for approval by the Board. As the new governance 

arrangements embedded, the Terms of Reference would be 

reviewed and refined to ensure the full scope of the Committees’ 

IDW 

IDW 

4 Peter Burroughs on behalf of the Committee Chairman, Ian Douglas 


8

Item 2 

responsibilities were covered. 

NED challenged on: 

• How the roles of the new Committees and issues arising 

from them would be communicated across the Trust. 6 

Lee Budge stated that updates had been included in the 

monthly Team Briefing, but more could be done, 

particularly around operational structures so staff would 

know where to go should they have concerns. The 

importance of clinical engagement through Committee 

membership was acknowledged. 

• The importance of good information flows and systematic 

D 

• Reflection on the benefits of more ‘face to face’ 

R 

The Board approved the Terms of Reference for the 

Finance, Performance 

A 

& Investment Committee and the 

Safety & Quality Committee. 

reporting. 

7 Clarification of the reporting and assurance 

structures below Board Committee level was ongoing and 

would be published when finalised. 

8 

communication. Lee Budge, the Interim Director of 

Workforce and the Head of Communications would 

consider this with regard to the leadership development 

programme and how to tap into existing meetings. NEDs 

offered their services to bring perspective. 

28/11 Appointment of Vice-Chairman 

The Board were asked to approve the appointment of Peter 

Burroughs as Vice-Chairman 

F 

of the Trust, effective 1 March 

2011. 

The Board approved this appointment and noted Margaret 

Schwarz’s continued chairmanship of the Audit Committee. 

29/11 Register of Board Members’ 

T 

Interests 

The Register of Board Members’ interests had been updated. 

Details would be published on the Trust’s website. 

The Board noted the report. 

6 Steven Jermy 


8 David Pond 

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Item 2 

30/11 Chairman’s report from Finance, Performance & Investment 

Committee meeting, 16 February 2011 

NED 9 presented this in the absence of the FPIC Chairman. The 

Committee had been pleased with the level of detail provided 

and the Committee Chairman’s report covered the main points 

of discussion. The Board’s attention was drawn to the improved 

presentation of the cash position. 

The Board noted the report and were pleased with progress 

and with the level of assurances provided. 

31/11 Any Other Business 

D 

The Chairman stated that good communications with colleagues 

in primary care had 

R 

resulted in a sense of positive movement; 

there was some clarity in the short to medium term strategy and 

momentum was important. In the longer term, health community 

interaction would be a key focus. 

There was no other business. 

32/11 Chairman’s closing remarks 

The meeting closed at 3.45 pm. 

A 

F 

------------------------------------------------------------------------------------ 

33/11 Date of next meeting 

Signed 

Friday 25 March 2011. 

Dated ------------------------------------------------------------------------------------ 

T 

9 Peter Burroughs 

10

Updated: prior to March Board Item 4 

Outstanding Actions 


Action List for Trust Board Part 1 

Date Ref Action Lead Comments 

25.02.11 24/11, 

page 7 

Draft Quality Account for review. AM Scheduled for 

March 2011 and 

included on 

agenda. 

25.02.11 25/11, 

page 8 

Equality & Diversity: the Public 

Sector Equality Duty – update 

following effective date of 1 April 

2011. 

IDW 

Scheduled for 

April 2011. 

Completed Actions 

All completed actions have been 

previously recorded. 

Completed actions will be shown for one month only. 1

Item 5 

SUMMARY REPORT 

Trust Board Meeting (Part 1) 25 March 2011 

Subject 

Prepared by 

Approved by 

Presented by 

Chief Executive’s Report 

Chief Executive 



Purpose 

To update the Board on important current issues. 

Corporate Objectives 

Decision 

Approval 

Information 

Other 

Safety Quality Efficiency Workforce Health Governance 

• • • 

Executive Summary 

This report contains a briefing on: 

1. Theatre Safety 

2. Review of the Human Resources Directorate 

Key Recommendations 

1. The Board is asked to note this report. 

Assurance Framework 

This regular update provides information on issues covering the full range of the assurance 

framework. 

Next Steps 

This report is provided for information, there are no specific next steps. 

• 

Corporate Impact Assessment 

CQC Regulations CQC outcomes 4, 9, 14 and 16 

Financial Implications None directly. 

Legal Implications Potential further enforcement action. 

Equality & Diversity None directly. 

1

Item 5 

DETAILED REPORT 

Trust Board (Part 1) 25 March 2011 

Subject 

Prepared by 

Approved by 

Presented by 

Chief Executive’s Report 




Purpose 

To update the Board on important current issues. 

Background 

In the last month the focus of the executive team has mainly been on two issues: ensuring 

that the Trust complies with the compliance action of the Care Quality Commission (CQC) in 

relation to theatre safety and the completion of the annual operational plan, budget and 

savings programme. The annual operating plan is covered elsewhere on this agenda. 

The focus has now moved to ensuring that the delivery arrangements are in place for 

implementing the Operating Plan; both the quality and the business improvement 

dimensions. The team will also be focusing on taking forward the leadership development 

programme discussed by the Board last month. 

The highlight of the month has been the success of the Infection Control Team winning the 

national Nursing Times/Health Service Journal Patient Safety Award in the Infection Control 

and Hygiene Category. This is a tremendous achievement and reflects the hard work of the 

team (led by Claire Haill and Peter Jenks) and the many staff involved in the surgical 

infection surveillance programme for which the award was won. 

Patient safety is the top priority of the Trust and it is good to be able to show this through a 

high profile result such as this. 

Theatre Safety 

Last month I reported on the compliance action taken by the Care Quality Commission. The 

warning issued to the Trust required the organisation to be able to demonstrate compliance 

with “Outcome 4” by 22 March. When the Board meets it is possible that the CQC will have 

revisited the Trust. If so, there will be a verbal update at the meeting. 

The CQC will also be providing a full report of the visit that took place on the 16 February. It 

is likely that they will require an action plan to address other concerns raised in this report 

which were not covered in the warning already issued. The Trust is in regular contact with 

the CQC and has a clear idea of the actions which are likely to be required and is also 

addressing these. 

There has been a significant focus on ensuring that the weaknesses identified by the CQC 

are addressed. The programme is being led by Paul McArdle (Assistant Medical Director). A 

comprehensive action plan has been drawn up and is being monitored by a task group 

chaired by the Chief Executive. The action plan includes the development and 

implementation of a new, more comprehensive version of the WHO checklist, and the 

communication of this new version to all relevant staff. This is supported by training and 

discussion with key staff. 

2

A second “Continuing Medical Education” session was devoted to this subject and was 

attended by 197 senior clinicians and theatre staff. An excellent discussion took place. The 

senior management team is visiting the theatres frequently to discuss safety concerns with 

staff and the safety team is providing excellent support to the theatre management team and 

staff. 

Review of the Human Resources Directorate 

The Board has asked for an update on the review and restructure of Human Resources and 

Workforce Development Directorate. 

The restructure of this service has been completed which including the following services: 

• Human resources 

• Recruitment and retention 

• Temporary staffing 

• Medical staffing 

• Workforce development and planning 

• Training and education 

• Workforce information and planning 

• HR systems and processes 

The process involved putting over 70 staff through an assessment process for new roles 

based on the “HR business partner model”. The new structure will be led by a Director of 

Workforce and Organisational Development supported by a Deputy Director of Workforce 

and an Associate Director of Organisational Development. 

The new HR service model will be supported by a “centre of excellence” which will give HR 

advice and support through a team of HR professionals in the HR Direct team. There will be 

a team of HR business partners who will support operational managers on transformational 

change to support the workforce productivity agenda. 

The OD team will support education and training, Organisational Development, leadership 

development, workforce development and planning. 

The interim HR Director is working with the new teams to develop an implementation plan 

and will be working with Directorates on the new service model to ensure a seamless 

transition with a suite of new HR policies and procedures. 

This is an exciting time for the service, developing a Workforce and OD service to support 

workforce morale and productivity across the Trust and to meet the financial challenges 

ahead. This transformation programme has saved the Trust £0.5 million recurrently. 

The next stage will be to undertake a thorough review of Occupational Health and Payroll 

Services over the next few months. 

Recommendation 

1 The Board is asked to note this report 

3

Item 6 



Subject 

Prepared by 

Approved by 

Presented by 

The Development of Patient Pledges 

Jayne Davies, Service Planner 

Chief Nurse 

Chief Nurse 

Purpose 

To provide Board members with an update on the development of Patient 

Pledges as outlined in the Patient Experience Strategy which the Board 

approved in December 2010. This strategy was written in response to the 

NHS Constitution (2010) and to support the delivery of the Trust’s Quality 

Strategy. 


Decision 

Approval 

Information 

Other 


• • 


The paper provides an update on the Patient Pledges which were outlined as a key 

deliverable within the Trust’s Patient Experience Strategy (Dec 2010). It provides a summary 

of the consultation which took place, the pledges or promises themselves and highlights the 

work that is still outstanding. Additionally, it provides a summary of our compliance with the 

NHS Patient Pledges contained within the NHS Constitution as at March 2011. 


The key recommendation is that we now further engage with our staff in the implementation 

of the pledges or promises and seek to embed them within the organisation and the 

community, via a series of engagement sessions and communication activity. 


There are clear links between the NHS Constitution, PHNT and PCT performance. There are 

also links with CQC evaluations e.g. patient & staff surveys. Patient and Public Involvement 

and patient experience in general. 

Next Steps 

Sense check the pledges/promises with staff and engage staff in the development of a 

framework which will describe the behaviours and competencies which staff will need to 

demonstrate for each pledges. This will be done via a series of engagement sessions with 

staff. 

• 


CQC Regulations 9, 10, 11, 12,15,17, 21, 23 & 24. 

Financial Implications 

Legal Implications 

Equality & Diversity 

None. 

The NHS Constitution is now backed by law which means that NHS organisations 

are legally obliged to take account of the rights and pledges set out in the NHS 

Constitution. 

There are no direct implications for health inequalities in this paper. The NHS 

Constitution takes account of health inequalities and access to services for all 

groups, which is enshrined within the Constitution. 

1

Item 6 



Subject 

Prepared by 

Approved by 

Presented by 

The Development of Patient Pledges 

Jayne Davies – Service Planner 

Chief Nurse 

Chief Nurse 

Purpose 

To provide Board members with an update on the development of Patient Pledges as 

outlined in the Patient Experience Strategy which the Board approved in December 2010. 

This strategy was written in response to the NHS Constitution (2010) and to support the 

delivery of the Trust’s Quality Strategy). 

Background 

From January 2010, all NHS organisations are legally obliged to take account of the rights 

and pledges set out in the NHS Constitution. The pledges, although not legally binding, 

represent a commitment to provide high quality of services and a high quality workforce. 

The publication of the Patient Experience Strategy 2010 – 2013 clearly sets out our response 

to the requirements of the national and strategic guidance around providing the best possible 

patient experience, to which both NHS and Plymouth Hospitals NHS Trust is committed. 

The Patient Experience Strategy approved by the Trust Board in December 2010 describes 

our approach to supporting the delivery of the “Personal Care” element of the Trust’s Quality 

Strategy (Dec 2010) and sets out a three year programme of work that will see the Trust 

continuously listening to patients, evaluating feedback and acting upon it in a systematic 

way. 

As part of this programme, work has been undertaken specifically around developing a set of 

patient pledges or promises, or short statements of service standards that epitomise what 

‘good’ patient experience should mean and which all staff can sign up to. 

The promises have been developed through consultation with patients and staff about what 

good quality patient care should look like at the Trust. Consultation activity has been 

undertaken as follows: 

• A postal questionnaire to 800c Foundation Trust ‘members’ about what aspects of 

care were most important to them (October 2010). 

• Face to face interviews with 100 members of the public at the Healthy Plymouth 

event about what good quality care looks like (October 2010). 

• Interactive session with Foundation Trust ‘members’ to define key dimensions of 

good quality care (November 2010). 

• Feedback sessions with Trust ‘Governors’ (October 2010 and March 2011). 

• Three staff forum sessions focusing on quality of patient care (June to September 

2010). 

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Item 6 

These engagement sessions have enabled us to simplify the pledges set out in the NHS 

Constitution and to put them into context for our patients, community and organisation as a 

set of ‘Patient Promises’. 

Our challenge now is to ensure that every member of staff makes a commitment to the 

following promises: 

1. I will… care for you compassionately and respectfully 

2. I will… give you clear information and involve you in your care 

3. I will… give you the best treatment I can when you need it 

4. I will… make sure you are treated in a clean and safe environment 

Next Steps 

The plan is now to sense check these promises with staff and engage them in the 

development of a framework which will describe the behaviours and competencies which 

staff will need to demonstrate for each pledge. 

These promises will then be communicated and embedded into the organisation, supported 

by the Organisational Development Programme to ensure they become part of our culture 

both now and in the future. 

Engagement sessions will shortly be held with key groups e.g. Clinical Directors, Directorate 

Managers, Medical Secretaries Forum and some open breakfast meetings with staff. 

Staff will be asked to prioritise a series of suggestions on the top five behaviours, which will 

demonstrate their commitment to meeting each of our promises. When these behaviours 

have been determined, staff will be asked to make a commitment to them and acknowledge 

their integration into their own personal performance management and responsibility. 

It is envisaged that these promises will become central to our organisation and widely used, 

with objectives, work programmes and measureable outcomes and targets mapped to each 

promise. 

It is recognised that improving the patient experience requires the continued support and 

involvement of staff. These patient promises provide a driving force and visual vehicle which 

will help staff to develop the behaviours required to promote a quality focused culture in 

which they can be justly proud. 

The NHS Constitution also outlines pledges to staff. Consideration needs to be given as to 

whether staff pledges need to be launched at the same time as those for patients or should 

be managed as a separate matter and tied into the Organisational Development Programme. 

The current compliance to the NHS Constitution Patient Pledges and work that has been 

completed, alongside work outstanding is set out in (Annex 1) for information. 

Conclusion and recommendations 

The Board is asked to note the work carried out to date and the next steps. 

3

Item 6 

NHS Constitution Patient Pledges Annex 1 

Patient Pledge March 2011 Declaration Working outstanding Compliance 

The NHS commits to provide 

convenient, easy access to services 

within waiting times set out in the 

Handbook to the NHS Constitution 

To make decisions in a clear and 

transparent way so that patients and the 

public can understand how services are 

planned and delivered 

To make the transition as smooth as 

possible when you are referred between 

services and to include you in relevant 

discussions. 

To ensure that services are provided in 

a clean and safe environment that is fit 

for purpose on national best practice. 

To provide continuous improvement in 

the quality of services you receive 

identifying and sharing best practice in 

quality of care and treatments. 

To share with you any letters sent 

between clinicians about your care 

Compliance with all waiting list targets Fully 

complaint 

Patient engagement and consultation 

undertaken to define promise No. 2 


undertaken to define promise No. 1 & 2 

Adherence to referral criteria’s and 

compliance to referral pathways. 


undertaken to promise No. 4 

External audit by the CQC 



Letters available if requested and clinically 

appropriate 

Communicate promises to staff across the 

organisation and gain their engagement 

and ownership of this promise. 

Public Relations strategy required to 

determine how the message is both given 

and received by patients 

The NHS constitution and what it means 

to staff needs to be incorporated into the 

Trust Induction programme. 

As above 

Continue to adhere to referral criteria’s 

and comply with pathway referral. 

Full Implementation of the Patient 

Experience Strategy 

As above 



As above 



Partially 

complaint 

Partially 

compliant 

Partially 

compliant 

Partially 

compliant 

Fully 

compliant 

4

Item 6 

Patient Pledge March 2011 Declaration Working outstanding Compliance 

To inform you about the healthcare 

services available to you and offer easily 

accessible, reliable and relevant 

information 

To provide you with the information you 

need to influence and scrutinise the 

planning and delivery of NHS services 

and to work in partnership with you, your 

family, carers and representatives 

To ensure you are treated with courtesy 

and you receive appropriate support 

when making a complaint 

When mistakes happen, to acknowledge 

them, apologise, explain what went 

wrong and put things right quickly and 

effectively 

To ensure that the organisation learns 

lessons from complaints and claims and 

uses these to improve NHS services 





Meet all mandatory information 

requirements 



New policy and procedures to deal with 

complaints 


undertaken to promise No. 1, 3 and 4 


complaints 


undertaken to promise No. 1, 3 and 4 


complaints 

As above 



Review of patient information planned for 

2011-12 

As above 



As above 



New complaint’s policy, procedures and 

targets to be further embedded 

As above 





As above 





Partially 

compliant 

Partially 

compliant 

Partially 

compliant 

Partially 

compliant 

Partially 

compliant 

5

Item 7 




Subject Quality Account 2010/2011 

Prepared by 

Approved by 

Presented by 




Purpose 

To update the Board on progress with the completion of the Quality Account 

and to seek the Board’s views on the draft document. 

Trust Objectives 

Decision 

Approval 

Information 

Other 


• 


The Trust is required to publish an annual Quality Account and to agree priorities for inclusion 

in the Quality Account 2010/2011. In February, the Board approved the priorities for inclusion 

in the document. The purpose of a Quality Account is threefold: firstly, as an important 

document that will enable the public to hold NHS Trusts to account for the quality of the NHS 

healthcare services they provide; secondly, to enable Trust Boards to focus on quality 

improvement as a core function; and finally, to assist patients and their carers to make fully 

informed choices about their healthcare. The production of this document is an iterative 

process and the Board is presented with a draft for review. 


1. The Board is asked to note progress on the draft Quality Account, to review it and to 

comment. 

• 


Links to the Quality objectives in the Assurance Framework. 

Next Steps 

Feedback on the draft Quality Account is required from external stakeholders (Plymouth 

Overview & Scrutiny Committee, Cornwall Overview & Scrutiny Committee, Local 

Involvement Network and NHS Plymouth) in a consultation process and the final Quality 

Account will come to the April Trust Board for approval. 


CQC Regulations N/A 

Financial Implications To be determined as part of routine performance review. 

Legal Implications The Trust has a statutory duty to publish a Quality Account. 

Equality & Diversity To be considered in the discharge of the priorities identified. 

1

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Draft Quality Account 2010-11 

Part 1 - Introduction to Our Service 

1.1 Welcome and Message from Chief Executive 

Welcome to our Quality Account for 2010-11, another year of real challenge and 

achievement, characterised by a commitment from our teams to deliver high quality patient 

care. 

The quality and safety of the patient experience is central to all that we do. We do not always 

get it right, but there are many indications that we continue to improve. These Quality 

Accounts reflect our achievement against our goals for 2010-11 and show areas where we 

know we still need to improve. 

We are particularly proud that we continue to be one of the best performers nationally on 

infection control with dramatically falling rates of MRSA and C.Diff. The Trust is among the 

best hospitals in the country for patient outcomes, according to a report by the independent 

body, Dr Fosters. We have unconditional registration with the Care Quality Commission 

which assesses us on over fifty patient related features – including cleanliness with which we 

have struggled in the past. 

Waiting times continue to fall. We achieved the Emergency Department 4 hour target, the 18 

week maximum wait for inpatient treatment, the six week diagnostic wait, and the range of 

cancer targets. 

The independent patient survey shows that almost 80% of our patients rate their treatment 

as excellent or good. Mums-to-be and their families can be confident that maternity care in 

Plymouth is good and, in parts among the best in the country according to the patients who 

use them. 

A Care Quality Commission report has rated Plymouth stroke services amongst the best in 

the Country. The Trust has a direct admission for patients to a dedicated stroke unit at 

Derriford Hospital where they are cared for by a specialist team of staff. 

In placing quality patient services at the centre of what we do we have developed four patient 

promises, drawn up with the help of patients and staff. These provide a driving force behind 

our efforts to establish our hospital as the first choice for care. The promises focus on what 

matters most to patients like providing clean and safe environments and providing clear 

information to patients. 

This level of continued progress represents a significant achievement by all staff of the Trust 

during 2010-11 and provides us with a strong platform from which to address the challenges 

that we face in the year ahead. 

We are proud of all our staff and volunteers for the great contribution they have made to the 

delivery of high quality patient care over the past year. 

Sarah Widnell / Jayne Glynn V7 21.03.11 1

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1.2 Statement by Chief Executive 

The content of this Quality Account was approved by the Board of Directors on 25 March 

2011 and to the best of my knowledge the information contained within is accurate. 

Signed by Paul Roberts, Chief Executive 


Item 7 

Part 2 - Information Required by Regulation 

2.1 Priorities for improvement 2011-12 

We are committed to continually driving up the quality of our services and have carefully 

considered where we need to improve this year. These areas have been identified through 

reviewing our performance in 2010-11 and considering national and local priorities. 

The Trust has developed goals based around the three important aspects of quality care 

which it has defined as: 

• Safe Care 

• Effective Care 

• Personal Care 

High level quality ambitions for the Trust based around these three areas have been 

developed through the Trust’s Quality Strategy developed during 2010-11. The Trust will 

review this strategy annually and achievements and one year priorities will be published 

within this document annually. 

The key priorities for 2011-12 have been developed to support the delivery of our patient 

promises which are: 

• Caring for you compassionately and respectfully 

• Giving you clear information and involving you in your care 

• Giving you the best treatment we can when you need it 

• Making sure you are treated in a clean and safe environment 

We have set five key priorities areas for improvement in 2011/12: 

Domain Priority Rationale 

Safe Care 

Effective Care 

Personal Care 

• Reduce avoidable harm through 

improved levels of learning from 

incidents and complaints 

• Appropriate handover and escalation 

during patient management 

• Ensure effective pathways of patient 

care across the health community – 

appropriate follow up, continuity of 

clinical care, reducing length of stay, 

reducing delayed discharges 

• Ensure optimal outcomes of care 

through delivery of evidence based 

best practice 

• Improve overall patient satisfaction, 

based on results of inpatient survey, 

and aim for the upper quartile for all 

NHS Hospitals. 

To continuously improve 

services to ensure when 

things go wrong lessons are 

learnt and changes are 

made. 

To ensure early detection 

and appropriate escalation of 

unwell patients. 

Every aspect of patient care 

contributes to a minimum 

time for recovery and length 

of stay in hospital 

Adopting best practice 

provides the maximum 

opportunity to provide the 

best outcome for patients. 

Listening to patients and 

acting on their concern to 

make improvements. 


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The five priorities were developed following discussions with various groups within the Trust, 

including the Safety & Quality Committee, before agreement at the Trust Board. The Trust’s 

‘governors in waiting’, recruited in preparation for our Foundation Trust application, were also 

consulted. 

Priority 1 – Reduce avoidable harm through improved levels of learning from incidents 

and complaints 

It is acknowledged nationwide that despite our best efforts patients suffer harm in hospital 

and many other patient narrowly avoid a similar experience, a ‘near miss’. Our first priority is 

aimed at reducing overall levels of harm and continuous improvement of services to ensure 

when things go wrong lessons are learnt and changes are made. 

How will we do it? 

We will collect information when things go wrong. Through reporting and analysis of adverse 

events using the root cause analysis tool, which allows us to identify the core issues and to 

learn lessons we will aim to preventing a reoccurrence. To support this approach root cause 

analysis training will be introduced for staff groups to identify true causes of harm. 

The Trust would encourage increased reporting of no harm or near miss incidents to enable 

to learning, a large proportion of near miss reflects a strong organisational reporting culture 

where potential problems are identified and action taken to prevent harm. 

The standard approach to reporting of adverse events, relies on voluntary, self reporting of 

incidents and is known to only identify 10 to 20% of adverse occurrences. In order to 

supplement this process the Trust has adopted the global trigger tool (GTT) to measure and 

identify events that cause harm to patients. It is a casenote review tool that enables the 

Trust to understand and measure adverse events and rates of harm, whereby a severity 

rating is assigned to each adverse event. 

A multi-disciplinary clinical team have been trained in how to conduct the GTT casenote 

review according to a pre-defined template. Members of this team meet fortnightly to ‘double 

review’ 20 sets of randomly selected noted each month. 

How will we measure it? 

GTT monthly data will be reviewed on a monthly basis alongside regular mortality data 

through the Clinical Governance Steering Group. 

Monitor Trust performance using Dr Foster data and incident reporting trends from the 

National Reporting and Learning System (NRLS). 

% reduction in the number of grade 3 pressure ulcers 

% reduction in the number of patient falls 

% reduction in surgical site infection 

% reduction of infections secondary to urinary catheters 

% reduction in the incidence of VTE 

% to be confirmed 

How will we report it? 

Regular monthly incident and complaints reports will be submitted to the Trust’s Safety & 

Quality Committee. Additional quarterly reports on progress against the global trigger tool 

will be submitted to the Clinical Governance Steering Group. 


Item 7 

Priority 2 - Appropriate handover and escalation during patient management 

Identification of the deteriorating patient and ensuring appropriate escalation and response is 

an essential aspect of patient care. The Trust has developed an action plan to improve the 

care of deteriorating patients and reduce the number of cardiac arrests, which includes a 

colour banded observation chart for the early detection and appropriate escalation of unwell 

patients. 


The Trust has developed an action plan to improve the care of deteriorating patients and 

reduce the number of cardiac arrests, which includes a colour banded observation chart for 

the early detection and appropriate escalation of unwell patients. Patients that trigger on the 

observation chart will be added to the ward whiteboard and discussed at the daily safety 

briefing which have been introduced to ensure structured handover of key patient information 

including key principles Situation, Background, Assessment and Recommendation (SBAR). 

All cardiac arrests calls will be investigated to identify aspects of care which may have 

attributed to preventable deterioration. 

We will ensure that patient observations are carried out in a timely manner and that all 

deteriorating patients are appropriately escalated to ensure action is taken. 


The percentage of patient who trigger on the Early Warning System and receive an 

appropriate response will be monitored monthly, alongside the number of rapid response 

calls made per month. These figures will provide assurance that when a patient deteriorates 

appropriate escalation has taken place. 

We will monitor the frequency and percentage of wards using daily safety briefings, to assess 

the communication methods used to handover patient information. 

The number of cardiac arrest calls will be monitored monthly to ascertain how many were 

avoidable. In addition the Trust subscribes to the Dr Foster mortality database, which 

predicts the Hospital Standardised Mortality Ratio (HSMR) which is an indicator of healthcare 

quality that measures whether the death rate at a hospital is higher or lower than you would 

expect. 

% reduction in the number of cardiac arrest calls 

% increase in the number of rapid response calls 

Increase the % of patients who trigged on the EWS and receive an appropriate response 

Increase the frequency and percentage of wards using daily safety briefings 



Regular monthly reports will be submitted to the Clinical Governance Steering Group and 

quarterly reports submitted to the Trust’s Safety & Quality Committee. Additional monthly 

reports on progress will be submitted to the SHA. 

Priority 3 - Ensure effective pathways of patient care across the health community, 

appropriate follow up, continuity of clinical care, reducing length of stay and reducing 

delayed discharges 

As a Health Community there is a requirement to make efficiencies throughout elective care, 

in order to improve both the patient experience and to reduce costs. 


Item 7 


The Enhanced Recovery Programme is currently being implemented in the four main 

specialties, Colorectal, Orthopaedics, Urology and Gynaecology, across the Trust. In 

addition to this the Quality, Innovation, Productivity and Prevention (QIPP) Programme 

identifies Enhanced Recovery as a key area through which quality improvement and savings 

can be delivered. 

It is important to implement best practice because: 

• The patient will be in the best possible condition for surgery i.e. managing pre existing comorbidities 

in Primary Care 

• The patient has the best possible management during and after the operation i.e. 

minimally invasive surgery, reduced starvation and fluid management 

• The patient has the best post-operative rehabilitation i.e. planned mobilisation, improved 

pain relief 

The Trust has introduced the Outpatient Efficiency Work Programme to improve and 

streamline the administration process and provide a better experience for patients. 


% reduction in patient average length of stay 

% reduction in the number of delayed discharges 

% reduction of the follow up waiting list backlog 

% reduction in the number of patient waiting for repatriation 



Progress will be reported through the Trust Board performance databook on a monthly basis. 

In addition monthly progress reports will be submitted for review at the Enhanced Recovery 

Steering Group (ERSG). 

Priority 4 - Ensure optimal outcomes of care through delivery of evidence based 

practice 

The Trust recognises that adopting best practice provides the maximum opportunity to 

ensure optimal outcomes for patients. There are a number of key healthcare organisations 

who are responsible for identifying best practice, which is shared through a variety of reports 

and guidance. 

We will ensure that all information is assessed and key recommendations identified for 

implementation at Plymouth Hospitals NHS Trust. 


The Trust will ensure all national guidance is effectively assessed and implemented 

throughout the organisation with the full engagement of clinical staff. 

National Guidance including: 

• NICE Clinical Guidelines, Interventional Procedure Guidance, Technology Appraisal 

Guidance and Public Health Guidance 

• National Confidential Enquiries in Peri-Operative Deaths (NCEPOD) – ‘Age Old Problem’ 

and ‘Mixed Bag’ 

• National Patient Safety Agency (NPSA) Alerts and Reports 

• Royal College and Professional Society Guidance and Reports 


Item 7 


Implementation will be measured through clinical audit, focusing on NICE Guidance and new 

interventional procedures and continuous assessment of key clinical outcomes. The Trust 

has an approved Annual Clinical Audit Plan to be delivered for the period 2011-12. 

Compliance rates will be monitored through the Healthcare Governance Team for all NICE 

guidance and NPSA reports. 

Increased level of compliance for NICE Guidance 

% reduction in the incidence of VTE 



Regular quarterly reports submitted to the Trust’s Safety & Quality Committee. Additional 

quarterly reports detailing progress against the overall NICE Guidance submitted to the 

Clinical Governance Steering Group and NHS Plymouth. 

Priority 5 - Improve overall patient satisfaction, based on results of inpatient surveys, 

and aim for the upper quartile for all NHS Hospitals 

We believe that patients have the right to be treated in an environment that makes them feel 

safe and cared for. We will listen to patients and act on their concerns to make 

improvements, with the aim that patients will leave us having had a positive experience and 

will recommend us to people they know. 


Every month we will ask patients if they are happy with the care they received through a 

programme of continuous local inpatient surveys. Survey results will be shared with the 

relevant teams who will be asked to develop action plans addressing the key issues raised. 

The National Inpatient Survey provides an annual view of patient experience and our goal for 

2011/12 will be to improve the percentage of patients who rated the care received as 

excellent in the National Inpatient survey. 

We will deliver the Nursing High Impact Actions which consist of the following key elements: 

• Staying Safe – preventing falls 

• Your Skin Matters 

• Keeping Nourished – getting better 

• Promoting Normal Birth 

• Where to die when the time comes 

• Fit and Well to Care 

• Ready to Go – no delays 

• Protection from Infection 

The Trust is working with the Strategic Health Authority to implement the Equality Delivery 

System, a new Department of Health initiative. 


Local and national inpatient survey findings are compiled into our patient experience action 

plan which is monitored to ensure effective changes are being made. 


Item 7 

Nursing dashboards are currently being developed and will be used to monitor activity 

against a number of set criteria during 2011-12. 

We will aim to improve our response rate for ‘excellent’ in the National Inpatient Survey by 

10% 

2009 2010 

Overall, how would you rate the care you have received 51% 48% 

Threshold for highest scoring 20% of NHS Trust 44% 44% 

Improved overall % in the national inpatient survey 

Improved provision of single sex accommodation 

Improved engagement with patients in decision about their care 



Regular update reports will be submitted to the Trust’s Improving Through Listening Steering 

Group and quarterly reports will be submitted to the Safety & Quality Committee. 

2.2 Statements relating to quality of NHS services provided 

During 2010-11 Plymouth Hospitals NHS Trust provided and/or sub contracted 64 NHS 

services. 

The Trust has reviewed all data available to us on quality of care in all these NHS services. 

The income generated by the NHS services reviewed in 2010-11 represents 100% of the 

total income generated from the provision of NHS services by Plymouth Hospitals NHS Trust 

for 2010-11. 

2.3 Review of data on quality care 

Participation in Clinical Audit and National Confidential Enquiries 

During 2010-11 Plymouth Hospitals NHS Trust participated in 106 Trust wide and local 

clinical audits, this is an increase in coverage from the previous year. The results of all 

clinical audits were presented to and reviewed by the appropriate staff within the Trust over 

the course of the year. The table below summarises the high level reporting arrangements 

for key aspects of Clinical Audit results. 

The results of Trust-wide audits are reported and reviewed to the following groups: 

• 12 audits were reviewed and discussed at the Trust’s Health Records Committee 

• 3 audits were reviewed and discussed at the Trust’s Medical Devices Steering Group 

• 3 audits were reviewed and discussed at the Clinical Governance Steering Group 

• ? audits were reviewed and discussed at the Trust’s Audit Committee 

• All local audits are reviewed and discussed at the relevant directorate meeting 

The results of all local audits are reviewed and discussed at the relevant directorate meeting. 

The Clinical Audit Support Team is further developing its processes during 2011/12 and has 

developed, with the support of the Medical Director, a corporate trust wide plan for the 

coming year. The current Clinical Audit Policy is also in the process of being reviewed to 

reflect current practice. 


Item 7 

In addition the national clinical audits and national confidential enquiries that Plymouth 

Hospitals NHS Trust participated in, and for which data collection was completed during 

2010-11 are listed below. 

National Clinical Audits 

Plymouth Hospitals NHS Trust participated in and reported on 24 national audits, the reports 

of which were reviewed by the provider in 2010-11, full details of National Audits can be 

found at www.nao.org.uk. The Clinical Audit Support Team is developing improved links with 

clinical directorates and the Healthcare Governance Team to ensure participation in National 

clinical audits is recorded and resulting learning opportunities disseminated. 

National Audit Title 

Peri and Neonatal 

Perinatal Mortality (CMACE) 

Neonatal Intensive and Special Care (NNAP) 

Paediatrics 

Paediatric Fever 

Childhood Epilepsy 

Paediatric Diabetes 

Acute Care 

Adult Non-invasive Ventilation (NIV) 

Pneumonia 

Cardiac Arrest 

Long Term Conditions 

Diabetes – Adult 

Heavy Menstrual Bleeding (HMB) 

Adult Asthma 

Ulcerative Colitis and Crohn’s Disease 

COPD 

Inflammatory Bowel Disease (IBD) 

Cystic Fibrosis 

Elective Procedures 

Hip, Knee and Ankle Replacements (National Joint Registry) 

Cartoid Interventions 

Elective Surgery (PROMS) 

Abdominal Aortic Aneurysm 

Cardiovascular Disease 

Stroke Care 

Acute Stroke? 

Renal Disease 

Acute Kidney Injury 

Vascular Access 

Renal Transport Survey 

Cancer 

Lung Cancer 

Bowel Cancer 

Mastectomy and Breast Reconstruction 

Trauma 

Falls and Non Hip Fractures – National Audit of falls and 

bone health in older people 

Hip Fracture 

Status 

Completed 

Completed 

In Progress 

In Progress 

On going 

Completed 

In progress 

In progress 

In progress 

In progress 

Completed 

In progress 

In progress 

In progress 

In progress 

Completed 

Completed 

In progress 

In progress 

Completed 

In progress 

In progress 

In progress 

In progress 

In progress 

In progress 

Completed 

In progress 

Completed 


Item 7 

Severe Trauma ( TARN) 

Psychological Conditions 

Dementia 

Blood Transfusions 

O Neg Blood Use 

Platelet Use 

In progress 

In progress 

In progress 

In progress 

National Confidential Enquiries 

During 2010/11, 6 national confidential enquiries covered NHS services that Plymouth 

Hospitals NHS Trust provides. Full details of national confidential enquiries can be found at 

www.ncepod.org.uk. 

The national confidential enquiries that Plymouth Hospitals Trust participated in and reported 

during 2010/11 are as follows: 

NCEPOD studies – reported in year 

Title of study 

An Age Old Problem - Emergency 

Surgery in the Elderly 

A Mixed Bag - Parental Nutrition 

Action taken 

Report recommendations and implications for 

the Trust considered by lead clinicians for 

further action. 

Report and recommendations considered by 

the Trust’s Nutritional Team. 

The national confidential enquiries that Plymouth Hospitals NHS Trust participated in, and for 

which data collection was completed or commenced during the 2010/11, are listed below 

alongside the number of cases submitted to each audit or enquiry as a percentage of the 

number of registered cases required by the terms of that audit or enquiry 

NCEPOD studies – data collection (100% participation in relevant studies) 

Title of study 

No. of cases 

submitted 

Percentage required by 

enquiry 

Cardiac Arrest Procedures 8 100% 

Surgery In Children 18 100% 

2.4 Participation in Clinical Research 

The number of patients receiving NHS services provided by Plymouth Hospitals NHS Trust in 

2010-11 that were recruited during that period to participate in research approved by a 

research ethics committee was 3300. 

Participation in clinical research demonstrates Plymouth Hospitals NHS Trust’s commitment 

to improving the quality of care we offer and to making our contribution to wider health 

improvement. Our clinical staff stay abreast of the latest possible treatment possibilities and 

active participation in research leads to successful patient outcomes. 


Item 7 

2.5 Goals agreed with commissioners 

Plymouth Hospitals NHS Trust income in 2010-11 was not conditional on achieving quality 

improvement and innovation goals through the Commissioning for Quality and Innovation 

payment framework. 

2.6 Statements from the CQC 

Plymouth Hospitals NHS Trust is required to register with the Care Quality Commission and 

its current registration status is ‘registered’ and therefore licensed to provide services. 

Plymouth Hospitals NHS Trust no conditions on its registration. 

The Care Quality Commission has however taken enforcement action against Plymouth 

Hospitals NHS Trust. A Warning Notice was issued on 22 February 2011 for concerns raised 

about the number of Never Events in our operating department. 

Plymouth Hospitals NHS Trusts has not participated in special reviews or investigations by 

the Care Quality Commission as at 31 March 2011. 

2.7 Data Quality 

We recognise that good quality information underpins effective delivery of quality patient care. 

Having robust data enable us to make meaningful decisions to improve care and overall 

patient safety. 

Plymouth Hospitals NHS Trust submitted records during April to December 2010 to the 

Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in 

the latest published data. The percentage of records in the published data: 

Which included the patient’s 

valid NHS number was: 

Percentage for admitted patient 

care 

% Which included the patient’s 

valid general medical practice 

was: 

98.3% Percentage for admitted patient 

care 

% 

99.9% 

Percentage for outpatient care 98.8% Percentage for out patient care 100% 

Percentage for accident and 

emergency care 

93.3% Percentage for accident and 

emergency care 

99.5% 

2.8 Information Governance 

Plymouth Hospitals NHS Trust Information Governance Assessment Report score overall 

score for 2010-11 was 71% and was graded as green, which equates to satisfactory using 

the IGT Grading Scheme. 

2.9 Clinical Coding 

Plymouth Hospitals NHS Trust was subject to the Payment by Results clinical coding audit 

during 2009/10 by the Audit Commission and the error rates reported in the latest published 

audit for that period for diagnoses and treatment coding (clinical coding) were: 


Item 7 

Criteria Measured 2009/10 % 

Primary diagnoses incorrect 12% 

Secondary diagnoses incorrect 9.2% 

Primary procedures incorrect 11.7% 

Secondary procedures incorrect 5.5% 

The Trust was not subject to a Payment Results audit in 2010/11 however, Plymouth 

Hospitals NHS Trust completed an Information Governance Audit completed by D & A 

Consultancy in June 2010 and error rates had improved as detailed below : 

Criteria Measured 2010/11 % 

Primary diagnoses incorrect 2.5% 

Secondary diagnoses incorrect 1.25% 

Primary procedures incorrect 3.19% 

Secondary procedures incorrect 1.25% 


Item 7 

Part 3 Review of Services 

3.1 How the Trust identifies local improvement priorities 

A Quality Strategy for Patients for the Trust was approved by the Trust Board in 

December 2010. This provides a renewed focus and momentum on addressing current 

and future quality improvement challenges and ensures that all staff share the same 

understanding of what quality care should look like. It reflects the shared ambitions of 

everyone working for the Trust to provide high quality person-centred, clinically effective 

and safe healthcare services and to be recognised as a leader in our approach. 

Our approach to quality is based upon the three aspects of quality set out within the 

NHS Next Stage Review 1 led by Lord Darzi, and have been defined as: 

provided 

patient- 

• the effectiveness and access of the treatment and care 

to patients – measured by both clinical outcomes and 

reported outcomes; 

• the safety of the treatment and care provided to 

patients; and 

• the broader experience patients have of the 

treatment and care they receive. 

In short, effective, safe and personal are 

the three aspects required to deliver a 

quality service. Effective care being 

the foundation of high quality care, 

but it must then be delivered 

safely and in a personal way. 

Personal Care 

“Be nice to me” 

Safe Care 

“Don’t harm me” 

Effective Care 

“Treat me right, the first time” 

High-level quality ambitions for the Trust have been set for each of the quality 

dimensions. Improvement priorities will be identified annually working towards achieving 

these high level ambitions. 

Additionally to inform this process the Trust is committed to understanding and 

responding to the views of patients, staff and the public in determining priorities for 

quality. 

Consultation with staff, patients and members of the public have taken place during 

2010 to determine priority areas. This has led to the development of four patient 

promises. These promises will shape the business strategy and objectives and are an 

ongoing commitment to the Trust’s patients. These are the promises that every member 

of staff makes to patients: 

I will…… 

I will …... 

I will ….. 

I will ….. 

care for you compassionately and respectfully 

give you clear information and involve you in your care 

give you the best treatment I can when you need it 

make sure you are treated in a clean and safe environment 

1 Darzi, Lord A. (2009), High Quality Care for All, DOH, London 


Item 7 

3.2 Performance against key national priorities 

2010-11 has been a successful year in relation to safety, quality and patient experience. 

This section describes the Trust’s performances against key quality performance targets 

as well as progress against quality indicators highlighted as priorities for 2010/11. 

(To be updated post 31 March 2011) 

Target Standard Performance Achieved 

Incidence of C-Diff 101 (max) 26 

Incidence of MRSA 8 (max) 3 

18 week maximum wait for admitted 90% 95.9% 

patients from point of referral to 

treatment 

18 week maximum wait for non 95% 97.0% 

admitted patients from point of referral 

to treatment 

Maximum time in ED of four hours from 95% 97.8% 

arrival to admission, transfer or 

discharge 

All cancer two week wait 93% 95.3% 

Two week wait for symptomatic breast 93% 97.9% 

patients (cancer not initially suspected) 

31 day (diagnosis to treatment) wait for 96% 98.1% 

first treatment: all cancers 

31 day wait for second or subsequent 94% 96.8% 

treatment: surgery 


treatment: anti cancer drug treatments 


treatment: radiotherapy treatments 

62 day (urgent GP referral to 85% 86.7% 

treatment) wait for first treatment: all 

cancers 

62 day consultant upgrade wait for first 90% 90.1% 

treatment: all cancers 

62 day wait for first treatment from 90% 92.1% 

consultant screening service referral: 

all cancers 

Access to genitor-urinary medicine 100% 100.00% 

clinics (48 hours) 

Access to rapid access chest pain >=98% 100.00% 

clinics within two weeks from referral 

from GP 

Cancelled operations by the hospital

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3.3 Patient Safety 

Keeping patients safe is central to providing high quality care and we have continued our 

efforts to do all we can to continuously improve patient safety. Plymouth Hospitals NHS 

Trust has adopted key principles of the SHA Patient Safety Improvement Programme, 

which commenced in October 2009 and will run for a period of 5 years. The Programme 

aims to reduce the hospital standardised mortality rate by 15% and adverse events by 

30% by 2014. These aims will be achieved through the implementation of evidence 

based initiatives in five core work streams: Leadership; Critical Care; General Ward; 

Medicines Management and Peri-Operative. Each work stream has an executive, 

clinical and nursing lead. 

This is a comprehensive improvement programme striving to deliver safe care for every 

patient every time. Reliability and standardisation are central to this work. Progress 

within each work stream is continuously measured for improvement purposes and 

reported to the SHA monthly. Four of the priorities identified in 2009/10 were aligned to 

the Patient Safety Improvement Programme and have delivered consistent results. 

Executive Patient Safety Walkround was introduced in 2010 and provides an opportunity 

for front line staff to meet and discuss safety issues with directors. Safety briefings and 

safety bulletins have also been introduced as a means of spreading good practice, 

providing feedback and learning from adverse events across the Trust as a whole. 

Serious Incidents and Never Events 

The Trust has a process for managing all incidents and serious incidents, which includes 

those classified as ‘Never Events’ by the National Patient Safety Agency. Since 1 April 

2010 six Never Events have occurred at Plymouth Hospitals NHS Trust in the following 

categories: 

• Wrong site nerve block performed in April 2010 

• Swab retained in August 2010 

• Wrong site surgery performed in August 2010 

• Swab retained in November 2010 

• Swab retained in December 2010 

• Throat pack retained in January 2011 

In line with Trust policy each incident was investigated to establish the root cause and 

immediate actions taken in response to the investigation findings. To address the issues 

raised a comprehensive Theatre Patient Safety Strategy has been introduced which 

focuses on 10 key domains which are essential to provide permanent improvement in 

patient safety: 

• Leadership 

• Safety culture 

• Implementing best practice 

• Standardising Trust policy 

• Implementing standard operating procedures 

• Documentation 

• Education and training 

• Communication with staff 

• Communication with patients and families 

• External expertise 


Item 7 

Target 

Performance Performance Target 

09/10 10/11 11/12 

Incidence of C-diff 77 26 tbc 43 

Incidence of MRSA 15 3 tbc 5 

Hand hygiene completion rates 100% 100% 100% 

Hand hygiene compliance rates 98% tbc 95% 

Patient falls resulting in harm or death 89 103 90 

Incident reporting rate – per 100 

admissions 

3.5 3.86 

(Sept 10) 

4.25 

Number of Never events 2 6 0 

% of observation charts completed 

accurately 

60% 89% 95% 

Deaths from cardiac arrests 474 255 TBC 

Ulcer prevalence (% of patients with 

pressure ulcers) 

Total Patients: 

Hospital Acquired: 

% patients receiving appropriate VTE 

risk assessment (started recording 

from July 2010) 

% patients receiving appropriate 

thromboprophylaxis 

Infection Control 

N/A 

N/A 

5.3% 

2.3% 

N/A 56% 

93% 95% 

TBC 

The Infection Prevention and Control Team (IPCT) at Plymouth Hospitals NHS Trust 

has made significant progress towards modernising the service it provides and meeting 

the challenging new agenda being set at both local and national levels. This has led to 

improvements in clinical practice, with reductions in healthcare-associated infections. 

During 2010/11, we reinforced our efforts to control and reduce MRSA and Clostridium 

difficile infections. How: consistent approach to three important areas: environmental 

cleanliness, appropriate antibiotic prescribing and strict hygiene at the point of care have 

all been vigorously pursued. 

Key achievements for the year April 2010-March 2011 were as follows: 

• MRSA bacteraemias – to reduce cases of MRSA bacteraemias in line with the 

national target of 9 and local target of 6. For the period April to December 2010 

there were 3 cases. 

• Clostridium difficile – to reduce cases of post 72 hour clostridium difficile in line 

with the national target of 128 and local target of 117. For the period April to 

December 2010 there were 24 cases. 


Item 7 

• To achieve a 10% reduction in all cases of MRSA. For the period April to 

December 2010 there were 31 new cases, compared to 53 in the same period 

last year which equates to 42% 

• Epidemic gastroenteritis – to maintain the average ward closure time due to 

epidemic gastroenteritis below 7 days. For the period April to December 2010 

there were 4 ward closures with an average ward closure period of 5.5 days. 

• Hand hygiene compliance – for all wards to perform at least 1 monthly hand 

hygiene audit with a compliance rate of 95%. For the period April to December 

2010 overall compliance was 99%. 

• Alcohol hand gel - for the availability of alcohol hand gel in clinical areas to be 

maintained as close to 100% as possible. For the period April to December 2010 

availability was 98%. 

• Surgical site surveillance – to continue surgical site surveillance on all major 

procedures. Majority of procedures now covered. 

• Delivery of a Postgraduate Certificate in Infection Prevention and Control in 

collaboration with the Peninsular School of Medicine and Dentistry. Two module 

PGCert to run in spring and summer 2011. 

• Infection Control Website developed and updated. 

• Saving Lives High Impact Interventions – all wards to perform at least 1 audit for 

in use medial devices, compliance monitored through the dashboard. 

C. Difficile Reporting 


Item 7 

MRSA Reporting 

Medicines Management 

Patient Information Following Discharge 

Pharmacy launched the Patient helpline last year with poster advertising the service put 

up in the Outpatient Department and Accident & Emergency Department with business 

cards issued with all outpatient and discharge medication. The service and phone 

number are also printed on the medication bag labels. In addition all medicines are 

dispensed with a patient information leaflet. 

At the point of discharge nursing staff will explain the discharge medication with the 

patient. For those patients who collect their outpatient medication from Pharmacy, they 

will have the opportunity to ask Pharmacists for advice and guidance. 

The Trust has developed a Self Administration Policy, will be underpinned by better 

engagement with patients about their medication, medication reminder cards will be 

made available for patients to help improve their understanding. To support the new 

service a patient information leaflet has also been designed. 

E-discharge has now been rolled out Trust wide in the last 12 months with patients being 

given a comprehensive list of their medicines on discharge with a copy of the clinical 

information. Patients are also given a list of medicines to give to their community 

Pharmacy to improve the seamless transfer of care on discharge 

3.4 Clinical Effectiveness 

Stroke Pathway 

The Care Quality Commission (CQC) carried out a review of services, ranking health 

trusts and social care services on a number of areas. These included acute care, 

discharge from hospital, access to rehabilitation and continuing care and support. 

Plymouth was ranked as "best performing". Plymouth Hospitals NHS Trust has one of 

the lowest mortality ratios following stroke within England and performance against 

direct admission to an Acute Stroke Unit is in the upper quartile within the region. 

In addition the SHA commended Plymouth Hospitals NHS Trust and NHS Plymouth on 

the reconfiguration of services that followed a review in 2008. The impression was that 

the stroke services are now delivered by a cohesive and joined up team who have 

clearly worked hard to develop a high quality stroke service. 


Item 7 

TIA Service 

This is a good example of joint working for the prevention of stroke as the service is 

provided by neurologists, health care of the elderly consultants, acute GP service with 

support from other departments providing rapid access diagnostics. This means that 

patient only have one visit to hospital and reduces the need for repeated follow up. 

Hospital Standardised Mortality Ratio (HSMR) 

The hospital standardised mortality ratio continues to fall, which can be attributed to the 

attention given to the patient pathway and the introduction of a number of programmes 

to improve safety including infection control and ward cleanliness. 

The ongoing Patient Safety Improvement Programme which consists of a number of 

various elements which focus on delivering improvements in patient safety. The five key 

domains of care are: 

• Leadership 

• General Ward Care 

• Perioperative Care 

• Critical Care 

• Medicines Management 

A wide range of Trust initiatives contribute to overall improvement of the Trust’s HSMR 

in conjunction with external guidance available from a variety of sources including NICE 

and National Patient Safety Agency. 

Target 

Performance 

09/10 

Performance 

10/11 

Mortality (HMSR) 

84.3 Relative 77.3 Relative 

Risk* 

Risk* 

Stroke mortality rate 101.9 95.9 Relative 

Relative Risk* Risk* 

% stroke patients spending 90% of 46% 68% 

their stay on ASU 

Target 

11/12 (tba) 

Fractured NOF – delays to surgery 

< 48hrs 

52% 24% 

Fractured NOF- readmission rates 4.0% 1.4% 

Heart failure readmission rates 13.1% 10.7% 


Item 7 

Cancelled operations by the hospital 

for non-clinical reasons on the day of 

or after admission 

Cancelled operations by the hospital 

for non-clinical reasons on the day of 

or after admission, who were not 

treated within 28 days 

* National Average = 100 

1.9% (1100) 1.6% (779) 

14.1% (155) 3.5% (27) 

Patient Experience 

Patient experience is the term used to describe those aspects of healthcare that, though 

they do not relate directly to the treatment of illness or injury, can make all the difference 

to whether patients feel that they have been looked after properly. 

A Patient Experience Strategy for the Trust was approved by the Trust Board in 

December 2010. This strategy outlined our plans to develop the patient experience. 

During 2010-11 we implemented a programme of local patient experience surveys on 

our wards to gather regular feedback from patients. Patients are asked about cleanliness, 

quality of food, how they are communicated with and involved, and about how respectful 

and kind staff are. A total of 26 inpatient adult wards have been surveyed and 760 

patients involved between October and March 2011. 

As part of this programme real-time feedback is collected at ward level to allow instant 

reporting of patient satisfaction scores. All feedback is collated and fed back directly to 

the ward management teams to allow action planning and improvement activity to take 

place. 

In addition to this programme the Trust obtains feedback from patients through a variety 

of channels: complaints, PALS, local media and websites, national patient and staff 

surveys. Key themes from all this activity are drawn together to form a more rounded 

views of the patient experience. 

A new steering group, the Improving Through Listening Steering Group, has been set up 

dedicated to monitoring and driving forward improvement actions, the group meets 

regularly and includes a patient representative. 

(D/N Will need to be updated once new Peat Scores are released, CQC publishes 

standardised National Inpatient Survey results and March 31 st local survey 

recommended scores) 

Target 

PEAT Scores Food & Hydration 

Environment 

Privacy & Dignity 

Recommender scores (would definitely 

recommend) 

Overall satisfaction scores (excellent 

and very good) 

Performance 

09/10 

Performance 

10/11 

Target 

11/12 

Good Excellent Excellent 

Good Good Excellent 

Good Good Good 

Not available 86% * 88% 

84% 79% 84% 


Item 7 

Overall Dignity and respect (always) 83% 79% 84% 

% patients receiving care in single sex 

setting 

% patients given a choice of admission 

date 

% patient rating cleanliness as very or 

fairly clean 

80% 82% 85% 

22% 21% 25% 

95% 97% 97% 

% involved as much as wanted to be in 57% 54% 57% 

decision about their care 

% experiencing delayed discharge 53% 56% 57% 

from hospital 

Complaints and concerns 529 666* 600 

Complaints and concerns responded to 

within target time 

18.9% 39.7%* 100% 

* up to February 2011 

Satisfied Patients 

The majority of our patients feel the care they received is excellent or very good, 

according to a survey by the Care Quality Commission taken in the summer of 2010. 

Respondents to the National Inpatient Survey reported improvements in a number of 

areas when compared with last year’s survey, these were: 

• The hospital did not change their admission date 

• Less patients shared same sex sleeping areas 

• Further cleanliness improvements 

• Greater confidence and trust in nursing staff 

• More patients feeling involved in decisions their discharge from the 

hospital. 

Privacy and dignity 

Our Trust is committed to delivering the highest standards of privacy and dignity for its 

patients. We have been striving to create better same-sex accommodation to ensure 

that the privacy and dignity of our patients is respected. We are working wherever 

clinically possible, to provide men and women with separate sleeping areas, bathrooms 

and toilets. This programme of work has included many upgrades, including to our toilets 

and washing facilities to give better segregation for men and women. 

Patient Promises 

During 2010 we have developed four patient promises after consulting with patients and 

staff. These promises, described earlier, will be the promises that every member of staff 

makes to each and every patient. During 2011-12 these promises will be developed in 

detail to ensure that every member of staff is clear about the commitment they are 

making to delivering excellent patient care. 


Item 7 

Complaints and Compliments 

The Trust has worked hard on improving its response and learning from feedback from 

patients, relatives and carers. Where possible the Trust will resolve complaints locally 

and recognises that further work is required in this area during 2011/12. 

Each inquiry and complaint received by the Trust is acknowledged within 48 hours and 

an investigated with the objective of replying to the complainant undertaken within 25 

working days. Each clinical service which was subject to a complaint is required to 

include the improvements they have made or plan to take within the response. The 

Patient Services Team collates and monitors trends to identify further opportunities for 

improvement. 

The Trust has established the Improving Through Listening Steering group to consider 

all patient related comments and concerns, including surveys, complaints, comments 

and compliments. The primary aim of the group is to develop strategies for the ongoing 

development of services to patients. One of the priorities for the coming year is to deliver 

customer care awareness training to all staff, so that staff can respond effectively to 

patient needs at the earliest opportunity. 

The Improving Through Listening Steering Group also has responsibility for assessing 

how the Trust gathers and uses information so that the patient’s voice is heard. 

In order to improve existing response rates for complainants, the Trust has 

commissioned several pieces of work which are expected to deliver results in the first 

half of 2011. Work includes better utilisation of IT technologies to distribute 

documentation, flexible approach to methods used to expedite resolutions of issues, 

simplify the existing arrangements with clinical areas to support the investigation and 

earliest possible response. 

An example of learning outcomes following a number of complaints, has been a review 

of the management of follow up waiting lists and the reduction in the backlog of 

neurology clinic letters. 

The Trust received 39 compliments during the period 2010-11 which are fed back to staff 

and used as part of local staff training as examples of good practice and team building. 

An extract from one of these compliments is shown below: 

“I would like to place on record my grateful thanks to all the staff with whom I came in 

contact during my brief stay. From the reception in Fal Ward, the theatre staff, to the 

staff in Postbridge Ward during my recovery I was treated throughout with courtesy, 

kindness and total professionalism” 

“I must commend to you the Audiology and ENT departments at Derriford, who after a 

somewhat delayed start of getting into the system (no fault of theirs) dealt with me most 

efficiently. My doctor was particularly kind, informative, helpful and reassuring” 

3.5 Quality and the Business Strategy 

A commitment to quality is at the heart of what we do as an organisation. The Trust’s 

Quality Strategy outlined the many quality improvement projects currently underway in 

the Trust. In addition each clinical directorate has as part of their business plan for the 

2011-12 financial year completed a quality plan. These quality plans describe each 

services quality programme of work with clear targets and performance monitoring. 


Item 7 

3.6 Leadership 

During 2011-12 we will launch an Organisational Development Programme for all our 

staff. The aim of the programme is to help create a culture to ensure that patients are put 

at the heart of everything and that staff feel valued, supported, involved, engaged and 

empowered. 

3.7 Innovation 

The Trust recognises that in order to improve we must be innovative in our solutions to 

solve quality issues. Below are two examples of work that has taken place and 

improved the quality of care our patients receive: 

Infection Prevention and Control - Surgical Site Infection monitoring 

The Trust’s infection control team were awarded top prize at the National Patient Safety 

Awards 2011, in the Infection Control and Hygiene category. The team won the award 

for their surgical site infection surveillance service, which has driven down the incidence 

of infections in surgical procedures for which surveillance has been established for some 

time, notably cardiac and vascular surgery. This is important for patients for whom an 

infection after surgery can delay a good timely recovery. 

The service assesses procedure specific surgical site infections on a quarterly basis and 

is exceptional because it includes areas outside of the Health Protection Agency range 

and performs surveillance post-discharge by undertaking patient questionnaires on all 

major surgical procedures. Reports are fed back to individual surgeons and directorates 

on a quarterly basis. 

Stroke Care 

Plymouth health and social care was rated as Best Performing for stroke because, out of 

15 indicators measured, the area scored amongst the best in the country by the Care 

Quality Commission, 

Consideration was given to the care experienced by people who have had a stroke and 

their carers. It starts from the point people prepare to leave hospital, to the long-term 

care and support that people may need to cope with stroke-related disabilities. It looks at 

both health and adult social care, as well as links to other relevant services, such as 

local support groups and services to help people participate in community life. 

Health organisations, Plymouth Hospitals NHS Trust and NHS Plymouth, and Plymouth 

City Council have focused considerable effort on improving care for stroke patients in the 

last two years and this is demonstrated in the rating given to the area. 

Plymouth scored very well in terms of the outcomes for patients one year after their 

stroke and had one of the lowest mortality ratio of all areas in the country. Measures 

taken within Derriford Hospital to help achieve this include setting up direct admission for 

patients to a dedicated stroke unit where they are cared for by a specialist team of 

doctors, nurses, physiotherapists, speech and language and occupational therapists. 

Direct access to a TIA clinic – any patient who has had a mini or warning stroke (a TIA) 

can be referred in and seen within 24 hours if they are high-risk and seven days if not 

assessed as high risk and access to thrombolysis (clot-busting drugs) for all eligible 

patients whose stroke is caused by a clot rather than a bleed, is now available 24 hours 

seven days per week. 


Item 7 

3.8 Our Environment 

Providing patients with modern, accessible and well designed facilities is important to the 

Trust. We will continue to refurbish and improve our hospital building where appropriate. 

During 2010-11 we have installed a series of images and artwork around the building to 

improve healthcare environments across the Trust. 

Zest, based in the Estates Department, work on the design of new and refurbished 

healthcare buildings as well as projects within the day to day provision of healthcare. 

The aim with all of their work is to transform the healthcare experience, at key moments 

in people's lives, into a positive one. Nearly nine out of ten people say that better quality 

buildings and public spaces improve their quality of life, according to MORI research 

published by the Commission for Architecture and the Built Environment (CABE) 

September 2009. Good healthcare environments have been found to lead to: 

• faster patient recoveries 

• reduced pain 

• fewer cases of infection 

• greater patient satisfaction 

• reduced stress levels among staff 

• easier recruitment and retention of quality staff 

One example of Zest’s work in 2010 was a project where the team worked with 

designers Neil Tinson and Chris Haughton to create bright and colourful images that are 

now installed in both the main and pharmacy stairwells at Derriford Hospital, an example 

is shown below. They were commissioned to help make the stairwells more attractive 

and encourage, patients, staff and visitors to use the stairs more frequently. 

Stairwell between level 3 and 4 

3.9 Partner Organisations 

The Trust is committed to working with its partner organisations to meet the continuing 

care needs of patients in an efficient and effective way, across the whole patient 

pathway. The Plymouth Health Community has a Health and Social Care Improvement 

Plan (2010/11 to 2013/14) which outlines how Plymouth’s Health and Social Care 

organisations are increasingly working together to plan services and service changes; 


Item 7 

deliver them together where this adds value and identify areas where expertise, 

functions and facilities could be shared or aligned. 

There is regular contact between the Trust and its main Health and Adult Social Care 

Overview and Scrutiny panel at Plymouth City Council. In 2010/11 the Chief Executive of 

the Trust continued to hold quarterly meetings with the panel Chair and the Trust gave 

presentations at six of the panel’s meetings. This regular contact ensured that 

information was shared and the panel gave feedback to the Trust on issues such as 

quality and performance. In the last quarter of 2011, the Trust has strengthened relations 

with Cornwall Health and Adults Overview and Scrutiny Committee, attending panel 

meetings and ensuring the free flow of two-way communication. 

In addition the Trust works with a huge range of patient and voluntary organisations to 

ensure we involve and work with them to understand other people’s views and how we 

are doing. 

Close working relationships have been forged with Plymouth Local Involvement Network 

(LINk), established to enable people in Plymouth to have their say on their local health 

and social care services. The group is run by local people and independently supported 

with a primary aim of finding out people’s views about health and social care and 

monitoring local services. 

Members of Plymouth LINk are members of the newly formed Improving Through 

Listening Steering Group, which aims to ensure that the views of patients and carers are 

actively solicited and used by the Trust to make demonstrable improvements to patient 

experience. In addition a member of the Plymouth LINk sits as a representative on the 

public part of the Trust Board. 

Plymouth Hospitals NHS Trust worked in conjunction with Plymouth LINk to produce a 

survey aimed at establishing how patients leaving the hospital have found the 

experience of hospital discharge. Throughout January and February 2011 all inpatients 

were given a LINk Discharge Survey at the point of discharge with the aim of gathering 

views on the patients experience to ultimately improve the process. 

Annex 1: Statement from Key Stakeholders 

We have invited comments from our key stakeholders. These are outlined below 


Item 8 



Subject 

Prepared by 

Approved by 

Presented by 

Standards for Patients with Dementia 

Associate Director of Nursing / Nurse Consultant Older People 

Chief Nurse 

Chief Nurse 

Purpose 

The purpose of this report is to inform the Board on the requirement to 

undertake and report to its commissioners, a self assessment against the 

South West Standards for People with Dementia in General Hospitals and to 

publish this by the end of March 2011. 


Decision 

Approval 

Information 

Other 


• • • 


The self-assessment against the standards has begun – with the formation of a multi-agency 

working group, including stakeholders and carers. The initial self-assessment has been 

reported to the Safety & Quality Committee and is being developed further. An improvement 

plan will be finalised by June 2011. 


The Board is asked to note the standards and the plan to publish a self-assessment by 31 

March 2011. 


This pertains to the care of vulnerable patients and takes into account existing national and 

local expectations, performance measures and standards – including the National Dementia 

Strategy, NICE NICE Quality standards, CQC Essential Standards for Quality & Safety; 

National Audit of Dementia in Hospitals and South West SHA performance framework for 

delivery of the National Dementia Strategy. 

Next Steps 

The self-assessment will be published by 31 March 2011. The development and 

implementation of an improvement plan will be monitored by the Safety & Quality Committee. 

• 

CQC Regulations 





Regulation 9 (care and welfare of service users) and 

Regulation 10 ( assessing and monitoring the quality of service provision) 

Failure to meet national and local recommendations could lead to reduced 

commissioning of services for patients with dementia. 

This work informs part of the Trust’s ongoing registration with the CQC 

essential standards. 

Access to services for patients with dementia. 

1

Item 8 



Subject 

Prepared by 

Approved by 

Presented by 

Standards for Patients with Dementia 

Associate Director of Nursing/Nurse Consultant Older People 

Chief Nurse 

Chief Nurse 

Purpose 

The purpose of this report is to inform the Board on the requirement to undertake and report to 

its commissioners, a self assessment against the South West Standards for People with 

Dementia in General Hospitals and to publish this by the end of March 2011. 

Background 

The Trust is required to undertake and report to its commissioners, a self assessment against 

the South West Standards for People with Dementia in General Hospitals (Annex 1). This 

assessment should be published by the end of March 2011, with an improvement plan 

approved by end of June 2011. A peer review process to monitor progress against the 

standards across general hospitals in the South West will commence in September 2011. 

The self-assessment against the standards has begun – with the formation of a multi-agency 

working group, including stakeholders and carers. The initial self-assessment has been 

reported to the Safety & Quality Committee and is being developed further. An improvement 

plan will be finalised by June 2011. 

It is important to ensure that work towards improving standards of care for patients with 

Dementia in hospital, links with other work towards the quality agenda and improving patient 

experiences such as Essences of Care, Delivering Excellence and High Impact Actions. An 

important element of improving standards for patients with Dementia in hospital will be the 

awareness and training of all staff. 

People with Dementia will access services in the majority of Trust specialities - they are 

admitted to hospital with a wide range of clinical issues and will access services both 

electively and through urgent care pathways. The South West Dementia Partnership 

Standards for Patients with Dementia in General hospitals, aim to incrementally improve all 

aspects of care for patients with dementia. The standards will be used to: 

• benchmark hospital services; 

• identify gaps in services; and 

• drive improvements in care, facilities and services for people with dementia. 

The standards take account of existing national and local expectations, performance 

measures and standards – such as the National Dementia Strategy, NICE Quality standards, 

CQC Essential Standards for Quality & Safety; National Audit of Dementia in hospitals, South 

West SHA performance framework for delivery of the National Dementia Strategy. 

Recent reports and research have highlighted the shortcomings in the current provision of 

dementia services in the UK. Dementia presents a huge challenge to society, both now and 

increasingly in the future. There are currently 700,000 people in the UK with dementia; up to 

70% of acute hospital beds are currently occupied by older people and up to a half of these 

may be people with cognitive impairment, including those with dementia and delirium. 

2

Item 8 

Dementia costs the UK economy £17 billion a year and, in the next 30 years, the number of 

people with dementia in the UK will double to 1.4 million, with the costs trebling to over £50 

billion. General hospitals are particularly challenging environments for people with memory 

and communication problems, with cluttered ward layouts, poor signage and other hazards. 

People with dementia in general hospitals have worse outcomes in terms of length of stay, 

mortality and institutionalisation. This results in an estimated cost of care to patients with 

dementia to be more than £6 million per year in an average general hospital. 

The National Dementia Strategy (2010) has identified improvements to the care of people with 

dementia in general hospitals as one of its key objectives. General hospitals need to have the 

following in place: 

• An identified senior clinician to take the lead for quality improvement in dementia care in 

the hospital; 

• An explicit care pathway for the management and care of people with dementia in hospital; 

• Specialist liaison older people’s mental health teams to work in general hospitals. 

The South West Dementia Partnership has used the National Dementia Strategy, NICE 

guidelines (2010) and recommendations from the Alzheimers’ society, to define specific 

standards of care for people with Dementia in general hospitals to improve care of people with 

Dementia in hospital, reduce delays in discharge and vastly improve patient experiences. 

Monitoring 

The Trust will continue its monitoring of progress towards the Standards for People with 

Dementia in General Hospitals, through the multi-agency working group. An Improvement 

Plan will be developed to be published by June 2011 – this will be reviewed by the Safety & 

Quality Committee on a quarterly basis. 

Recommendation 

The Board is asked to note the standards and the plan to publish a self-assessment by 31 

March 2011. 

3

Item 8 

South West Dementia Partnership – Summary Standards Annex 1 

For each standard listed there are measures or indicators described to inform the monitoring 

of the implementation of the standard. Audit processes will be need to be integrated within 

hospital governance arrangements to provide evidence of compliance of the standards. 

Dementia leads will be required to ensure there is a process for measuring the standards; 

achievement and compliance will be reported to the SW Dementia Partnership and the 

Strategic Health Authority via commissioners. 

Feedback from patients, relatives, carers and volunteers as well as staff delivering care will be 

vital in ensuring these standards are being delivered. A process of peer review across the 

South West will be implemented in Autumn 2011/12. 

Standard 1: People with a dementia are assured respect, dignity and appropriate care 

• A Ward Champion for dementia is appointed to provide leadership for delivery and 

monitoring (where applicable), as well as training. 

• There is accessible literature on the ward for patients, carers and staff. 

• The care plan is person-centred for each patient. 

• There is individualised and appropriate risk assessment. 

• Patient care is person centred, informed by Dementia Care Mapping or similar. 

• The trust Board regularly reviews serious and untoward incidents, falls, delayed 

discharges, and complaints associated with patients with dementia. 

Standard 2: Agreed assessment, admission and discharge processes are in place, with 

care plans specific to meet the individual needs of people with a dementia and their 

carer 

• The lead carer is identified and provided with information about how they can support 

the patient. 

• A booklet ‘This is me’ about each patient is completed to inform care plans. 

• All patients with suspected dementia receive a comprehensive assessment with further 

referral to memory service if required. 

• Carers receive information about the assessment. 

• Carers understand that an assessment of their needs can be arranged. 

• There is a system so that all staff are aware of the patients with dementia. 

• Discharge is actively managed from 24 hours of admission. 

• Information on discharge /support available on admission. 

• There is a named person who takes responsibility for discharge coordination. 

• Discharge plans summarise assessment and treatment and support plan. 

• There is access to intermediate care. 

Standard 3: People with a dementia or suspected cognitive impairment who are 

admitted to hospital, and their carers/families have access to a specialist mental health 

liaison service 

• There is access to a full multi disciplinary, specialist mental health liaison service. The 

level of service is based on assessed need. 

• Appropriate referrals are made for further assessment. 

• Training provided by liaison teams is incorporated into local training strategies. 

4

Item 8 

Standard 4: The hospital and ward environment is dementia-friendly, minimising the 

number of ward and unit moves within the hospital setting and between hospitals 

• The hospital Clinical Champion determines appropriate signage and sensory 

environments across the hospital and reviews quality of environment during peak 

activity so that standards do not slip. 

• Patients with a dementia should not be moved between wards (or hospital) unless 

required for their care and treatment. 

• If a move is necessary it should be at least disruptive time and carers informed and 

involved if appropriate. 

• ‘This is me’ profile must accompany the patient is moved. 

• Daily therapeutic and recreational activities are available where appropriate. 

Standard 5: The nutrition and hydration needs of people with a dementia are well met 

• All patients have a weight assessment and are assessed via malnutrition screening. 

• Patient preferences are recorded in ‘This is me’. 

• Protected mealtimes with carers or volunteers actively encouraged to assist. 

• Flexibility in provision and timing of food and appropriate utensils / crockery. 

• Access to specialist assessment in 12 hours if swallowing difficulties. 

Standard 6: The hospital and wards promote the contribution of volunteers to the wellbeing 

of people with a dementia in hospital 

• There is designated leader within hospital to promote volunteering for people with a 

dementia. 

• The Ward Champion identifies ways to improve patient experience by greater 

involvement of volunteers. 

• Support, feedback and training provided to volunteers. 

• Regular review of recruitment and retention of volunteers. 

Standard 7: The hospital and wards ensure quality of care at the end of life 

• GPs are informed of patients identified as approaching end of life. 

• Patients who remain in hospital to die are cared for using an integrated care pathway. 

• All clinical and support staff receive appropriate training. 

Standard 8: Appropriate training and workforce development are in place to promote 

and enhance the care of people with dementia in general and community hospitals, and 

their carers/families 

• All new staff receive mandatory training. 

• The hospital has a training and knowledge framework in place which is being 

implemented and reviewed. 

5

Item 9 



Subject 

Prepared by 

Approved by 

Presented by 

Chair’s Report of key issues arising from February and March Safety & 

Quality Committee meetings 

Healthcare Governance Manager 

Chief Nurse 

Chair, Safety & Quality Committee 

Purpose 

To provide an update on key issues discussed at the Safety & Quality 

Committee (formerly known as the Healthcare Governance Committee) 

meeting held on 14 February 2011 and the Safety & Quality Committee 

meeting on 14 March 2011. 


Decision 

Approval 

Information • 

Other 


• • 


Key issues considered:- 

• Care Qulaity Commission inspection visit of theatres 

• Theatre Strategy/action plan (incorporating WHO Checklist actions) 

• Review and update of Never Events 

• Medicines Management 

• National Inpatient Survey 

• Dementia Strategy Standards 

• Safeguarding 


Board Members are asked to consider the contents of the report. 


The Committee reviewed a number of key areas of governance and associated action plans 

to ensure compliance with the Care Quality Commission (CQC) and Strategic Health 

Authority requirements, including the Theatre Patient Safety Strategy, actions plans and CQC 

compliance reports. 

Next Steps 

The Committee will meet on a monthly basis and ensure that all actions agreed at the 

previous meetings are implemented. 

Progress the agreed Safety & Quality Committee Forward Plan. 


Financial 

Implications 




Relevant to all essential standards and outcomes 

Potential loss of income if the Trust does not have robust 

governance processes in place 

CQC registration may be affected 

Ensure all patients have equal access to treatment 

1

Item 9 



Subject Chair’s Report of key issues arising from February 2011 and March 2011 

Safety and Quality Committee meetings 

Prepared by 

Approved by 

Presented by 

Healthcare Governance Manager 

Chief Nurse 

Chair, Safety & Quality Committee 

Purpose 

To provide a report on key issues discussed at Safety & Quality Committee (formerly 

Healthcare Governance Committee) meetings held on 14 February 2011 and 21 March 

2011. 

Terms of Reference and Forward Plan 

Following the review of committee structures, the revised terms of reference and associated 

forward plan were considered and updated for approval by the Board. It was agreed that the 

Committee would be renamed as the Safety & Quality Committee. Further work was 

required to consider the sub-committee structure which supports the Safety & Quality 

Committee. 

14 February 2011 

Key issues discussed included:- 

Never Events 

Update of progress with actions arising from Never Events. 

Update of progress with action plan developed following Never Events in theatres (including 

WHO checklist). 

Medicines Management 

The Medicines Management report was received for information and following detailed 

discussion, the Committee requested a more detailed paper regarding actions and 

assurances be produced for the March meeting. 

National Inpatient Survey for 2010 

The National Inpatient Survey for 2010 was presented; the overall response rate was slightly 

down from 58% in 2009 to 54%. Of the 62 indicators, results showed declining performance 

in 35 areas, improvement in 19 areas and static for the remaining 8. Further work is planned 

to develop the action plan addressing the recommendations raised within the report. 

14 March 2011 

Key issues discussed included:- 

Updated Medicines Management Report 

The updated report was discussed in detail, and the Committee requested that further work 

be undertaken to identify and analyse the outcome data available, against the requirements 

of Outcome 9 (Management of Medicines). 

Theatre Patient Safety Strategy 

A summary of follow up information was received detailing progress with the new theatre 

Patient Safety Strategy and action plan which had been put in place to improve overall 

theatre safety following from the Never Events. Particular focus was given to the actions 

surrounding compliance with the WHO Safer Surgery Checklist. 

2

Item 9 

Patient safety Initiative 

A review of key workstreams and key issues was presented, eg: falls, pressure ulcers and 

recognition of the deteriorating patient, with a request that plans be developed to roll-out the 

workstreams across the Trust. 

Dementia Strategy Standards Report, 

A paper outlining the Trust’s current position against the Dementia Standards and an outline 

action plan was discussed. 

Safeguarding Report 

A Safeguarding Report providing an overview on safeguarding activity for both children and 

adults was considered and also demonstrated the work towards compliance of the 

safeguarding standards for the CQC Outcome 7 (Safeguarding People who use Services). 

Conclusion and recommendations 

The Board are asked to note the report 

3

Item 10 



Subject 

Prepared by 

Approved by 

Presented by 

Performance Report 

Senior Assurance and Performance Manager 

Head of Performance and Management Information 

Director of Finance / Chief Operating Officer 

Purpose 

This paper summarises performance across the full range of NHS Performance 

Standards for the year to 28 th February 2011. 


Decision 

Approval 

Information 

Other 


• • • • • 


The Trust is reporting a deficit of £3.5m at the end of February 2011. In order to achieve a break 

even position for the financial year a surplus of £3.5m needs to be generated in March. 

Whilst the Trust has actions identified to achieve this position there are some assumptions that 

will need active management to realise the position. 

Operational performance remains above target in the majority of areas and previous areas of 

underperformance due to winter pressures, e.g Accident & Emergency waits, have now fully 

recovered to levels observed before December 2010. 

Action plans are in place at either Trust-wide or specialty level for those areas where performance 

is below target. 


N/A 


Covers Safety, Quality, Efficiency, Health and Workforce objectives in the Assurance Framework. 

• 

Next Steps 

Active management of mitigating actions and emerging pressures required to maintain levels of 

performance and achieve breakeven target. 



Potential impact on all of the core outcomes. 

Financial Implications Assessment of the Trust breakeven target and year to date position. 



N/A 

Performance metrics include some data relating to equality and 

diversity. 

1

Item 10 

Introduction 

1. This paper summarises performance across the full range of NHS 

Performance Standards for the year to 28 February 2011. 

Finance 

Purpose 

2. The focus of this narrative is to update the Board on the financial results 

for the first 11 months of the financial year 2010/11, as detailed in the 

Trust Data Book and on providing an update to the Board in securing 

the breakeven target. 

Key Issues 

3. In the original budget the Trust planned a deficit of £0.2m at the end of 

February 2010, the Trust is reporting a deficit of £3.5m, an adverse 

variance of £3.3m. 

4. Despite the overall position being still off plan by £3.3m there has been 

an improvement in month on the income and expenditure of the Trust of 

£0.3m due to additional contract and non-recurrent income. 

5. This year to date position is in line with the Trust’s recovery plan that 

was agreed with NHS South West. 

6. The Trust continues to forecast the delivery of a break even position by 

the end of the financial year and has plans to recover the £3.5m deficit 

in March. 

7. There are a number of expenditure budget variances that have equal 

and opposite income variances in the Trust’s performance report. 

These variances have been adjusted for in this report to allow focus on 

budget pressures not offset by income. 

8. The key areas of variance to note are as follows: 

Conclusion 

Income is £11.1m ahead of plan 

Pay is £3.3m over budget to the end of February. The majority of this 

relates to overspends against medical and dental budgets. 

Non pay expenditure is £2.9m over budget. Of this number £2.4m 

relates to under delivery of planned cost improvement programmes with 

the residual caused by in year cost pressures and activity variations. 

Depreciation and interest charges are £0.6m higher than budgeted. 

CIP schemes that have not been identified against the original target 

total £7.6m year to date. 

The Board is asked to note the financial position at the end of February. 

2

Item 10 

Safety 

9. Infection Control 

MRSA 

Performance for February for hospital apportioned MRSA bacteraemia 

was 0 cases against a trajectory of 0. Performance for the year to date 

is 3 hospital apportioned cases against a trajectory of 8. 

Clostridium Difficile 

Performance for February for hospital apportioned Clostridium Difficile 

infection was 3 cases against a trajectory of 14. Performance for the 

year to date is 29 hospital apportioned cases against a trajectory of 115. 

10. Accident and Emergency 4 Hour Standard 

Monthly performance against the national Accident and Emergency 4 

hour wait target (95%) improved to 96.3% in February. With the 

inclusion of community based Minor Injury Units (MIUs) monthly 

performance remained above target at 97.7%. 

This improvement represents a recovery above target from the 

significant performance drop in December. Year-to-date performance for 

the Trust remains above the 95% national target at 96.80% (97.98% 

including community MIUs). 

11. Hospital Standardised Mortality Rates 

Quality 

The Hospital Standardised Mortality Rate (HSMR) is a statistical 

calculation that measures the overall rate of deaths within a hospital, 

compared with a national benchmark. Each hospital’s HSMR should be 

compared with ‘100’, representing the expected level given the types of 

cases treated. A hospital with a rate below 100 had fewer deaths than 

would be expected; conversely a rate above 100 will have had more 

deaths than would be expected. 

The HSMR for Plymouth Hospitals NHS Trust is 77.2 for the 12 months 

to January 2010; a mortality rate almost 23% lower (better) than 

expected. 

12. Referral to Treatment 

Although this standard has been removed from the revised NHS 

Operating Framework it is still reported and monitored for contractual 

reasons. 

During February 92.1% of patients treated on an admitted care pathway 

were treated within 18 weeks of referral, significantly better than the 

3

Item 10 

national target of 90%. The aggregated performance for non-admitted 

pathways at 97.9% was also above the national target of 95%. 

Target rates were achieved in all reportable specialties with the 

exceptions of: 

• General Surgery admitted 

• Urology admitted 

• Plastic Surgery admitted 

• Dermatology admitted 

• Gynaecology admitted 

• Neurosurgery non-admitted 

• Geriatric Medicine non-admitted 

• Neurology non-admitted 

During February the decrease in the RTT Admitted backlog has 

continued. (December 2010 = 715, January 2011 = 665, February 2011 

= 580). This was a planned event and explains the drop in admitted 

performance since December 2010 and, more specifically, why five key 

surgical specialties failed to achieve 90% in February. 

Neurology & Neurosurgery failed to achieve 95% for non-admitted due 

to capacity issues in Outpatients and Geriatric Medicine also failed as 

there were two breaches out of 21 patients both of which were due to 

administrative errors. 

From 1 April 2011, we are no longer required to monitor against the 90% 

and 95% standards but will move to measuring against median waits, 

maximum waits and 95 th percentile thresholds. 

13. Reperfusion Waiting Times 

The Trust has moved to the primary percutaneous coronary intervention 

(pPCI) as its preferred first treatment for patients suffering heart attack, 

although in certain circumstances thrombolysis may still be administered 

when clinical judgement deems this appropriate. 

In-month performance against the new pPCI standard improved in 

February to 92% which sees our year to date performance at 82%, 

which is above the target level (75%). This standard is susceptible to 

fluctuations in month on month performance due to the small number of 

patients involved. 

14. Existing Cancer Standards 

The performance against all existing cancer standards is above the 

required target for both in month and year to date performance. 

4

Item 10 

15. Going Further on Cancer Waits (GFOCW) Standards 

The performance against all GFOCW standards is above the required 

target for both in month and year to date performance with the following 

exception:- 

• In-month performance 62 Day from screening referral to first 

treatment (87.9% in February vs 90% target). 

The associated breaches within this standard were due to patient 

choice. Hence, the shortfall in February’s performance was attributable 

to factors outside of the Trust’s control. 

16. Diagnostic Waits 

There were 80 patients waiting over six weeks for a diagnostic test as at 

the 28 February 2011, of which 71 fell within the Endoscopy 

Department. This is an improvement on the January position when 180 

were waiting for an Endoscopy. 

The main reason for the drop in performance seen in Endoscopy is due 

to the unexpected loss of two key operators resulting in significant 

capacity reduction. Plans are now in place to cover this shortfall going 

forward. 

In addition, there are 146 patients waiting six weeks longer than their 

planned date for a Surveillance Endoscopy. Please note that, of the 

146, only five were waiting over 13 weeks. The progress made on 

reducing waits in this area has been hampered by the loss of capacity 

described above. 

17. Cancelled Operations 

The proportion of patients cancelled on the day of surgery represented 

1.5% of elective admissions (69 patients) during February, above the 

Care Quality Commission target of 0.8%. 

Of the 69 cancellations, 25 were due to theatre list overruns or 

emergencies taking priority and 24 were a result of sick or unavailable 

surgeons. 

During February there were three patients with a cancelled operation 

whose operations had been cancelled previously. These patients fell 

within the following specialties:- 

• Neurosurgery 

• Orthopaedics 

• Cardiology 

5

Item 10 

Health 

There were no breaches of the 28 day standard for re-booking 

previously cancelled patients during February. 

18. GUM Clinics/Breast Feeding/Smoking 

Workforce 

Performance for all indicators remains constant and within tolerance, 

with no significant concerns to report. 

19. Run Rate/Workforce numbers 

The current monthly pay bill run rate has decreased by £354k since 

October 2010 with a decrease in the last month to £19,513k in year to 

date. Over the same period, the discretionary pay bill run rate has 

reduced by £280k per month to £968k per month representing a 22% 

reduction in run rate. 

20. Staff in Post and Vacancies 

The current Trust budgeted establishment has remained relatively static 

for the last month at 5,877 FTE. Staff in post has reduced by 

approximately 12 FTE to 5,391 over the same period. This differential 

reduction between establishment and staff in post has had the effect of 

increasing the Trust’s budgeted vacancies over the same period to 485 

FTE. 

21. Mandatory/Essential Skills training 

The completion of Mandatory Training and Essential Skills has 

decreased slightly in February and now stands at 81% completed taking 

into account future booked courses and long term absence. This is 

principally due to the historic training year and the traditional distribution 

of training throughout the final quarter. Trust-wide, no training area 

currently sits below 79%. This figure changes weekly as staff complete 

training, therefore the future booked figure indicates this dynamic. 

22. Appraisal 

Appraisal completion rates (for non-medical staff) has continued to 

increase and stands at 76.93% in February 2011. 

23. Sickness Absence 

Sickness absence has continued to decrease during February to 3.91%. 

The number of staff with Bradford Scores of more than 300 has 

continued to reduce month on month, standing at 705 in February 2011, 

in comparison to 930 in March 2010. 

6

Item 10 

The Trust’s 12 month average sickness rate stands at 4.45%. The Trust 

has set a trajectory to aim for a target of 3.25% by March 2011. 

The Trust is about to review the Sickness Absence Policy and approach 

to managing attendance, and Occupational Health will support the 

reduction in sickness absence rates. 

Conclusion 

The Board is asked to note the contents of this report. 

7

Item 10 

Performance Dashboard 

Feb-11 

Current 

Month 

Year to 

Date 

(where 

applicable) 

Standard 

Safety 

Incidence of Clostridium Difficile 115 3 29 

Incidence of MRSA 8 0 3 

Total Time in A&E 95% 96.3% 96.8% 

See 

below ^ 5.5% 3.3% 

Delayed Transfers of Care 

Quality 

18 week referral to treatment Admitted 90% 92.1% N/A 

Nonadmitted 

95% 97.9% N/A 

All cancers: one month diagnosis to treatment 96% 98.2% 98.2% 

All cancers: two month urgent referral to treatment 85% 86.2% 86.7% 

All cancers: two week wait 93% 95.6% 95.3% 

62 day wait for first treatment from consultant screening service 

referral 90% 87.9% 91.6% 

31 day wait for second or subsequent treatment: anti cancer 

drug treatment 98% 100.0% 100.0% 

31 day wait for second or subsequent treatment: surgery 94% 100% 97.0% 

31 day wait for second or subsequent treatment: radiotherapy 

treatments 94%^ 98.6% 96.1% 

Two week wait for symptomatic breast patients 93%^ 97.1% 97.9% 

Rapid Access Chest Pain Service 98% 100% 100% 

Patients with stroke spend at least 90% of time on stroke unit** 80%^ 70% 68% 

Cancelled Operations on Day of Operation 0.8% 1.5% 1.6% 

Those cancelled not admitted within 28 days 5% 0.0% 3.2% 

Time to reperfusion for patients who have had a heart attack 75% 92% 82% 

Health 

Data quality on ethnic group 85% 100% 100% 

Access to GUM 100% 100% 100% 

Breast Feeding Initiation 

Smoking During Pregnancy 

** This is a March 2011 target 

^ The standards or thresholds for these areas have not been set 

nationally 

Achieving 

Under-achieving 

Failing 

See 

below ^ 76% 69% 

See 

below ^ 18% 17% 

8

Item 11 



Subject 

Prepared by 

Approved by 

Presented by 

Chairman’s Report and key issues arising from the March Finance, 

Performance & Investment Committee meeting 

NED Committee Chairman, Ian Douglas 



Purpose 

To provide an update on key issues discussed at the Finance, Performance & 

Investment Committee meeting held on 16 March 2011. 


Decision 

Approval 

Information 

Other 


• 


Key issues considered by Finance, Performance & Investment Committee included: 

• Stock update 

• Monthly Performance 

• 2011/2012 Budget 

• Capital Programme 

• Cash Management 

• Asset Valuation from District Valuation Officer 

• Assurance Framework 

• 


Board Members are asked to consider the contents of the report. 


This update refers to assurances relating to section E1 of the Assurance Framework (achieve the 

Trust’s planned financial position). 

Next Steps 

The Committee will continue to address its Forward Work Plan and to report progress to the Trust 

Board. 


CQC Regulations None 

Financial Implications Assessment of year end position and 2011/2012 Budget 

Legal Implications None 

Equality & Diversity None 

1

Item 11 



Subject 

Prepared by 

Approved by 

Presented by 

Chairman’s Report and key issues arising from the March Finance, 

Performance & Investment Committee meeting 




Purpose 

To provide an update on key issues discussed at the Finance, Performance & Investment 

Committee meeting held on 16 March 2011. 

1. Stock Update 

This was a positive paper, welcomed by the Committee. The Head of Procurement 

forecasted a potential annual saving of c£2.2m due to standardisation, reduced stock levels 

and reduced obsolescence. The Head of Procurement was tasked with a longer-term project 

(end 2011/12) to introduce Vendor Managed Inventory and inventory pull processes across 

the Trust. 

2. Monthly Performance 

The month 11 figures (February 2011) showed a reduced deficit of c£3.5m. This was better 

than plan, but it was confirmed that month 12 would see a number of pressures on the 

financial position. The Director of Financial Services gave strong assurance that the Trust 

would achieve its year-end breakeven position. 

The Medical Director and the Finance Director would present the year’s results to the 

Hospital Medical Staff Committee, with focus on the areas of non-delivery of Cost 

Improvement Plans. 

Discussions to mitigate Delayed Transfers of Care were onging with health community 

colleagues. 

3. 2011/12 Budget 

The Committee discussed the draft 2011/2012 budget and projected outturn and noted the 

requirement for adequate contingency planning for unforeseen events. 

The Committee discussed ‘re-admission’ penalties and were concerned by the lack of clarity 

of the definition, which appeared to suggest that the Trust would be penalised for most readmissions 

regardless of whether they were related to the original procedure or not. The 

Director of Financial Services would liaise with health community colleagues and other 

relevant bodies to agree a sensible approach to this. 

It was confirmed that agreed budgets would be written into departmental and individual 

objectives for 2011/12. 

The Committee asked the Director of Financial Services for a monthly statement of reserves 

and releases. 

2

Item 11 

The Director of Financial Services and the Chief Operating Officer reassured the Committee 

that the additional Bank Holiday on 29 April 2011 would be covered without recourse to 

bank/agency staff and additional, non-budgeted costs. 

The Committee received strong assurance that the budgeting system for this year was 

comprehensive and robust. 

4. Capital Programme 

The Committee received an update on the capital programme. 

5. Cash Management 

The Committee received a much improved presentation. The Director of Financial Services 

confirmed that the year-end forecast of £140k surplus cash remained accurate and the 

revised External Financing Limit had been agreed with NHS South West. 

6. District Valuation Officer 

The Director of Financial Services tabled a report on the discussion with the District 

Valuation Officer (DV). The Committee requested that a dialogue be undertaken with the DV 

so that consistent budgeting for depreciation and Public Dividend Capital payments could be 

effected. 

7. Assurance Framework 

The Committee reviewed the Efficiency section of the Assurance Framework and agreed 

revised risk scores. 

Recommendations 

1 The Board are asked to discuss this report and to note the assurances provided. 

3

Item 12 



Subject 

Prepared by 

Approved by 

Presented by 

2010 Staff Survey 

Associate Director of Organisational Development 

Chief Executive Officer/Interim Director of Workforce 

Interim Director of Workforce 

Purpose 

This report is a summary of the findings from this Trust’s staff survey data 

from the National Staff Survey full data. The report highlights key findings 

and makes recommendations for future action. 


Decision 

Approval 

Information 

Other 


• • 


The data provided by the National Staff Survey provides an insight into they way staff feel 

about their work at Plymouth Hospitals NHS Trust. The data for 2010 repeats some of the key 

improvement messages seen in 2009. Positive findings include: 

• Staff report high levels of appraisal and personal development plans being in place, for 

which the Trust is in the top 20% nationally. 

• There is evidence of increased confidence in relation to governance with staff recording 

improvements in areas such as feedback following the reporting of incidents. 

• Questions relating to how well staff feel communicated with show a small improvement. 

Overall, however, significant and important messages from staff indicate that there are key 

issues relating to how they are led and how motivated they feel at work. Capturing this and 

improving it will impact positively on the success and productivity of the Trust. 

This is recognised and is being addressed by the Trust, which has placed the “people 

agenda” and particularly the issue of leadership, at the heart of its strategic plans going 

forward. 

The Trust Board is in the final stages of agreeing and endorsing an Organisational 

Development programme. Organisational Development focuses on improving the culture of 

the organisation to develop a workforce which feels valued, supported, involved, engaged 

and empowered, leading to higher productivity and release of greater discretionary effort. 

This Organisational Development programme supports and indeed is embedded in the 

interim Trust Strategy, which has leadership at all levels as one of its three core parts. 

The Trust finds itself at a crossroads and recognises the need to do things differently, with a 

different focus, and to use the staff survey data as a tool to learn from. The Organisational 

Development programme and the essential leadership development component of that plan 

is the key that will deliver a demonstrable change. 

• 

1

Item 12 


1. Continue to support the development and implementation of the Organisational Development 

programme. 

2. Give priority to the leadership component of the Trust Interim Strategy. 

3. Ensure that “organisational health” measures around engagement, leadership, development 

and well-being are reported alongside other Trust performance metrics. 


The report identifies the risks associated with achieving the Trust’s workforce objectives and 

seeks to provide assurance that appropriate action will be taken to address these risks. 

Next Steps 

The OD programme will be developed and agreed by the Trust Board. 


CQC Regulations Outcomes 9,12,13,14 

Financial Implications None. 

Legal Implications None. 

Equality & Diversity The survey gives the Trust feedback on equality and diversity. 

2

Item 12 



Subject 

Prepared by 

Approved by 

Presented by 

2010 Staff Survey 

Associate Director of Organisational Development 


Interim Director of Workforce 

Purpose 

This report is a summary of the findings from this Trust’s staff survey data from the National 

Staff Survey full data. More information is available at the Care Quality Commission’s 

website. The report highlights key findings and makes recommendations for future action. 

Background 

The National Staff Survey results for the Trust in 2010 mirror the challenging environment 

within which the NHS as a whole finds itself. Although there is evidence of improvement (in 

all Key Findings the Trust’s performance has either improved or remained the same as last 

year), overall the results indicates more there is more work to be done to improve the 

experience of the Trust as a place to work. 

Nationally, the most significant change reported in the 2010 staff survey is in respect of 

appraisals, which have increased substantially in volume across the NHS. This Trust is in 

the top 20% of Trusts for the number of staff being appraised and for having a personal 

development plan in place, which reflects the hard work taking place across the directorates 

to ensure staff have the opportunity of an annual appraisal. 

Encouragingly, more staff than last year were satisfied with the quality of work and patient 

care that they are able to deliver and this is one of the Trust’s largest local changes since the 

2009 survey. Some areas requiring focus are highlighted as: 

• Low levels of staff motivation at work. 

• Staff not feeling there are good opportunities to develop their potential at work. 

• Staff not feeling that they receive the necessary job related training or development. 

• Low numbers of staff reporting feeling that their role makes a difference to patients. 

There is clearly more work to be done in relation to making sure staff feel they can influence 

changes to their work, use their initiative and help drive improvements in patient care. Staff 

engagement is recognised as the most important factor for increasing the effectiveness and 

productivity of an organisation. 

Organisational Development Programme 

Organisational Development (OD) work seeks to develop a learning organisation which is 

flexible and fit to deliver the transformational agenda. The OD programme sets out how we 

will address the concerns raised in the staff survey and through other sources of feedback. 

The programme will be supported by a newly re-focused team following the HR re-structure 

and progress on it will be reported directly to the Trust Board through the Workforce and OD 

Committee. 

3

Item 12 

The OD programme sets out the Trust’s plans to establish a “Leadership Academy” 

approach to developing the necessary skills and capability in our leaders at every level. One 

of the first areas of focus will be on skills to lead staff through change and to manage 

performance issues, which will be supported with new policies and procedures. 

In addition to the focus on leadership skills there will also be a focus on leadership behaviour 

with the launch of a self assessment behaviour tool linked to appraisal. Additionally, a key 

focus will be on developing a coaching approach to leading and for performance 

improvement as well as establishing a coaching network so that staff will be able to access a 

coach to support them. 

There will continue to be a focus on staff engagement with further Staff Forums to engage 

with staff on issues at the heart of the Trust. Further use of the Listening into Action model 

will be embedded across the Trust. 

Key Positive Findings 

Staff pledge 1: To provide all staff with clear roles, responsibilities and rewarding jobs 

• 82% of those staff surveyed told us they are satisfied with the quality of care they give to 

patients, compared to 81% last year. 

• 68% of staff in the Trust agreed with at least two of the following three statements: that 

they are satisfied with the quality of care they give to patients; that they are able to deliver 

the patient care they aspire to; and that they are able to do their job to a standard they 

are personally pleased with. It is a better score than in 2009, when the Trust scored 62%. 

Staff pledge 2: To provide all staff with personal development, access to appropriate 

training for their jobs and line management support to succeed 

• 47% of staff surveyed have had equality and diversity training in the last 12 months, 6 

percentage points higher than the national average for all Trusts. 

• 46% of staff told us that they had had training for handling confidential information, 2% 

higher than the national average for all Trusts. 43% also told us that they had had major 

incident training, 6 percentage points higher than the national average for all Trusts. 

• 72% of our staff felt that their line managers were supportive in a crisis. 2 percentage 

points higher than the national average for all Trusts. 

• 85% of staff reported to have had an appraisal in the last 12 months; 12 percentage point 

increase on last year and 8 percentage points higher than the national average for all 

Trusts. Plymouth Hospitals NHS Trust is in the best 20% of Trusts for having staff 

appraised in the last 12 months and having personal development plans in place. 

Staff pledge 3: To provide support and opportunities for staff to maintain their health, 

wellbeing and safety 

• 27% of staff reported feeling unwell as a result of work-related stress and is better than 

the national average (28%). 

• 14% of staff at the Trust said that, in the last year, they had been injured or felt unwell as 

a result of at least one of the following: moving and handling; needlestick and sharps 

injuries; slips, trips or falls; or exposure to dangerous substances. The Trust's score of 

14% is below (better than) average when compared with Trusts of a similar type and it is 

also a better score than in 2009 when the Trust scored 20%. 

4

Item 12 

• 86% of staff felt that the Trust encourages the reporting of errors, this is a better result 

both on last year and compared to all Trusts. There was an 8% point increase from 2009 

in staff saying that they are given feedback on changes following incidents. 

• 76% of staff said they were aware of counselling services to support staff, 10 percentage 

points better than the all Trust average. 99% of our staff also said they were aware of the 

occupational health support, as opposed to the 96% all Trust average. 

Staff pledge 4: To engage staff in decisions that affect them, the services they provide 

and empower them to put forward ways to deliver better and safer services 

• 38% of staff felt senior managers encouraged them to suggest new ideas for improving 

services an improvement of 33% from last year. 

Key Areas for Improvement 

Staff pledge 1: To provide all staff with clear roles, responsibilities and rewarding jobs 

• Although a slight improvement on last year, only 58% of staff agreed they are able to 

deliver the patient care they aspire to, compared to the national average for all Trusts of 

70%. 

• 48% of staff said they could not meet the conflicting demands on them as opposed to 

42% nationally. 44% of staff agreed they had adequate material supplies and equipment 

to do their job, as opposed to the 57% average for all Trusts. 

• 36% of staff feel the Trust is committed to helping staff balance their work and home life, 

compared to 41% nationally. 

Staff pledge 2: To provide all staff with personal development, access to appropriate 

training for their jobs and line management support to succeed 

• 34% of staff felt there was strong support for training in their area of work in comparison 

to 43% nationally. 

• 44% of staff felt their appraisal had helped them improve how they do their job (nationally 

54%) and only 42% had received the training identified in their Personal Development 

Plans compared to 50% nationally. 

Staff pledge 3: To provide support and opportunities for staff to maintain their health, 

wellbeing and safety 

• 29% of staff reported being informed of incidents (35% nationally) and 32% of staff 

reported to being given feedback about changes made in response to reporting incidents 

(37% nationally). 

• 50% of staff said the last time they had experienced physical violence, either they or their 

colleague had reported it, this compares to a national average of 69% for all Trusts. 

Staff pledge 4: To engage staff in decisions that affect them, the services they provide 

and empower them to put forward ways to deliver better and safer services 

• 20% of staff believe senior managers try to involve staff in decisions that affect work as 

opposed to 24% nationally. 21% of staff believe that senior managers act on staff 

feedback, compared to 29% nationally. 

5

Item 12 

• 40% of staff feel that senior managers are committed to patient care, 10% les than the 

national average and 49% of staff told us they believe patient care is the top priority of 

the Trust (58% nationally). 

Other important issues 

• 39% of staff would recommend the Trust as a place of work, compared to 55% nationally. 

No change from last year’s position. 

• 53% of staff would recommend the Trust as a place to be treated, this represents a 3% 

point increase on 2009, but 10 % points less than the national average. 

Conclusion 

The messages from the nationally staff survey are compelling; there are encouraging signs 

of improvement in some areas and clear data about what needs to change from other 

responses. A key focus will be to raise levels of staff engagement and involvement across 

the whole organisation whilst at the same time raising the bar of leadership capability and 

behaviours. The OD programme will have the highest levels of support from the Board to 

deliver the key aspects of the people agenda. 

Recommendations 

1 Continue to support the development and implementation of the Organisational 

Development programme. 

2 Give priority to the leadership component of the Trust Interim Strategy. 

3 Ensure that “organisational health” measures around engagement, leadership, 

development and well-being are reported alongside other Trust performance metrics. 

6

Item 13 



Subject 

Prepared by 

Approved by 

Presented by 

NIHR Research & Development Capability Statement 

Martin Quinn, Academic Services Manager 



Purpose 

The R&D Operational Capability Statement provides a Board level 

operational framework which empowers a R&D Office to undertake the 

management of R&D within the Organisation. The National Institute of Health 

Research (NIHR) expects that all Organisations intending to sponsor or 

participate in research have a R&D Operational Capability Statement. 


Decision 

Approval 

Information 

Other 


• • 


The NIHR Research Support Services provide a national framework for NHS R&D Offices to 

offer a consistent professional service that manages risk at the right time with the right people 

and in a proportionate way. The R&D Operational Capability Statement in one of three 

elements of the Research Support Service initiative currently available. It includes an 

operational overview of R&D capabilities, services and interests and its approval empowers 

the R&D Office to undertake the management of R&D within the Trust. 

The Statement is included at Annex 1 to the detailed report and the Board should note that 

the format of this is mandated. 


Approve the proposed R&D Operational Capability Statement. 


The Statement sets out how the Board plans to meet its research related responsibilities. 

Next Steps 

The approved R&D Operational Capability Statement will be published internally on 

Healthnet. The NIHR is considering how a version of these statements in a format more 

appropriate for external users of R&D services might be made available through its website. 

• 

1

Item 13 






R&D policies and operating procedures are designed to protect the dignity, 

rights, safety and well-being of patients participating in clinical research. 

The Trust’s annual income for R&D activities is approximately £4m. In 

addition, the Trust’s participation in clinical trials in which the trial drugs are 

provided by industry saves the NHS £1m+ per annum. 

Clinical Research Studies are required to adhere to the Department of Health 

Research Governance Framework for Health and Social Care 2005. Clinical 

Trials, a subgroup of Clinical Research, are also subject to the Medicines for 

Human Use (Clinical Trials) Regulations 2004 and subsequent amendments 

and have a legal requirement to comply with Guidelines for Good Clinical 

Practice (GCP). 

Most Clinical Research Studies require the processing and/or storage of 

personal and sensitive information relating to living individuals (e.g. patients) 

and is therefore governed by the Data Protection Act 1998. 

R&D standard operating procedures are designed to ensure compliance with 

all of the above. 

No impact on E&D requirements is anticipated. 

2

Item 13 



Subject 

Prepared by 

Approved by 

Presented by 

NIHR Research & Development Capability Statement 

Martin Quinn, Academic Services Manager 



Purpose 

The R&D Operational Capability Statement provides a board level operational framework 

which empowers a R&D Office to undertake the management of R&D within the Trust. The 

National Institute of Health Research (NIHR) expects that all organisations intending to 

sponsor or participate in research have a R&D Operational Capability Statement. 

Background 

The vision of the National Institute for Health Research (NIHR) is to improve the health and 

wealth of the nation through research. NHS Trust R&D Offices are contributing to this vision 

by harmonising and streamlining complex local research management and governance 

processes in a risk-proportionate environment. This is being managed through the NIHR 

Research Support Services initiative which provides a national framework for local NHS 

research management. 

The NIHR Research Support Services provide a national framework for R&D Offices to offer 

a consistent professional service that manages risk at the right time with the right people and 

in a proportionate way. 

To provide a consistent professional service, Trusts need standard operating procedures 

(SOPs) that are relevant to the Trust and to the research study, and that are supported by an 

appropriate local capability statement and risk management plan. The NIHR Research 

Support Services Framework, includes guidelines for SOPs, capability statements and risk 

management. NIHR has asked Trusts to implement these from April 2011. 

The Trust already has a comprehensive set of SOPs for R&D. The Trust’s Research 

Governance manager is currently reviewing the NIHR’s guideline SOPs with a view to filling 

gaps and adopting consistent practice. The second element of the framework currently 

available is a planning tool which provides a quick assessment of likely operational risks in 

giving NHS Permission and in study delivery. The R&D Manager is currently trialling this 

tool. The third element of the framework currently in place is the R&D Operational Capability 

Statement which the Board is being invited to consider. 

The Capability Statement 

The R&D Operational Capability Statement provides a board level operational framework 

which empowers a R&D Office to undertake the management of R&D within the Trust. The 

Statement gives the R&D Office an approved management framework, supporting timely and 

efficient decisions whether to support a particular research Study. It empowers the R&D 

Office to undertake its responsibilities with support from staff within clinical and other service 

departments in the Trust. 

3

Item 13 

The Statement is not meant to be read as an R&D Strategy or as a report on activity. The 

current R&D Strategy is being reviewed by the R&D Committee and an annual report on 

activity will be provided to the Trust Board for its meeting in June. The Statement will be 

reviewed at least annually and in future will be provided to the Board as an appendix to the 

R&D Annual Report. 

The appended Statement is in a format to provide information to the Trust Board and 

internally within the Trust and follows the template prescribed by the NIHR. 

Conclusion 

The NIHR Research Support Services provide a national framework for local NHS research 

management. This framework of best practice enables front line staff to collaborate in 

offering a consistent professional streamlined service, with proportionate procedures, to 

support clinical research in the NHS in England. The R&D Operational Capability Statement 

is one of the three elements of the framework currently available and Trusts have been 

asked by the NIHR to have an approve Statement in place by April 2011. 

4

Item 13 

Operational Capability Statement Annex 1 

NIHR Guideline B01 - R&D Operational Capability Statement 

Version History 

Version no. Valid from Valid to Date approved Approved by Updated by 

RDOCS 001 01/04/2011 31/03/13 25/03/2011 Trust Board R&D Office 

Contents 

Organisation R&D Management Arrangements 

Organisation Study Capabilities 

Organisation Services 

Organisation R&D Interests 

Organisation R&D Planning and Investments 

Organisation R&D Standard Operating Procedures Register 

Planned and Actual Studies Register 

Other Information 

Organisation R&D Management Arrangements 

Organisation Details 

Name of Organisation 


R&D Lead / Director (with responsibility for reporting on R&D 

to the Organisation Board) 

Dr Simon Rule - Associate Medical Director for 

R&D 

Key Contact Details e.g. Research Governance Lead, NHS Permissions Signatory contact details 

Contact 1: 

Role: 

Academic Services Manager (Head of R&D 

Office) 

Name: 

Martin Quinn 

Contact Number: 01752 439849 

Contact Email: 

martin.quinn@phnt.swest.nhs.uk 

Contact 2: 

Role: 

R&D manager 

Name: 

Dr Lisa Vickers 



lisa.vickers@phnt.swest.nhs.uk 

Contact 3: 

Role: 

Clinical Trials Finance Manager 

Name: 

Corinna Mossop 



corinna.mossop@phnt.swest.nhs.uk 

Contact 4: 

Role: 

Research Governance Manager 

Name: 

Dr Chris Rollinson 



chris.rollinson@phnt.swest.nhs.uk 

Contact 5: 

Role: 

Lead Research Nurse (Trust wide) 

Name: 

Clare Meachin 



clare.meachin@phnt.swest.nhs.uk 

Contact 6: 

Role: 

Lead Research Nurse (Oncology) 

Name: 

Nicola Donlin 



nicola.donlin@phnt.swest.nhs.uk 

5

Information on staffing of the R&D Office 

R&D Office Roles 

(e.g. Governance, Contracts, etc) 

Whole Time Equivalent 

Item 13 

Comments 

indicate if part time/full time/shared/joint etc 

Academic Services Manager 1.0 

Also supports wider academic 

developments 

R&D Management and administration 3.3 

The 1.0 wte Assistant Research Manager 

post is shared with Plymouth Teaching 

PCT, South Devon Healthcare NHS Trust 

and Torbay Care Trust 

Research Advisor 1.0 Also supports Plymouth Teaching PCT 

Research Governance 1.8 

Clinical Trials Finance 3.7 

Total 10.8 

Lead Research Nurse (Trust wide) 0.93 

Lead Research Nurse (Oncology) 1.0 

Responsible for 45 (head count) research 

nurses and associated staff 

Responsible for 8 (head count) research 

nurses and associated staff 

Reporting Structures 

The Trust's R&D Committee is responsible for the development of research strategy and the approval of 

research related policies. 

An annual report is submitted to the Trust Board. 

The Associate Medical Director for R&D represents the R&D Department on appropriate senior committees. 

6

Item 13 

Research Networks 

Research Network (name/location) 

Peninsula Comprehensive Research Network 

South West Dementia and Neurodegenerative diseases Network (DeNDRoN) 

South West Stroke Research Network 

South West Peninsula Diabetes Research Network 

National Cancer Research Network - Peninsula 

South West Medicines for Children Research Network 

Role/relationship of the Research Network eg host 

Organisation 

Member organisation 

Participating organisation 





Current Collaborations / Partnerships 

Organisation Name 

University of Plymouth 

University of Plymouth 

Peninsula College of 

Medicine and Dentistry 

Details of Collaboration / Partnership (eg University/Organisation 

Joint Office, external provider of pathology services to 

Organisation, etc, effective dates) 

The Trust and the University of Plymouth have a wide range of 

research links particularly with the Faculty of Health & Education 

and the School of Biomedical and Biological Sciences 

Weekly statistical advice clinics provided by the Centre for Health 

and Environmental Statistics 

The Trust and the Peninsula College of medicine and Dentistry 

have a wide range of research links including PenCLAHRC and 

PenCTU and are parties to a framework agreement on intellectual 

property. 

Contact Name 

Professor Graham Sewell (Fac of Health & 

Educ.) 

Professor Neil Avent (School of Biomedical 

and Biological Sciences) 

Sue Varley 

Nick Church - Research Services manager 

Email address 

graham.sewell@plymouth.ac.uk 

neil.avent@plymouth.ac.uk 

sue.varley@plymouth.ac.uk 

nick.church@pcmd.ac.uk 

Contact 

Number 

01752 

588817 

01752 

584884 

01752 

764437 

01392 

262917 

7

Organisation study capabilities 

Types of Studies Organisation has capabilities in (please tick applicable) 

CTIMPs 

(indicate Phases) 

Clinical Trial of a Medical Device Other Clinical Studies Human Tissue: 

Tissue Samples 

Studies 

As Sponsoring 

Organisation 

As Participating 

Organisation 

As Participant 

Identification Centre 

√ 

Study Administering 

Questionnaires 

√ (phase 2-4) √ √ √ √ √ 

√ (phase 1-4) √ √ √ √ √ 

Qualitative 

Study 

Item 13 

OTHER 

Organisation Licences 

Licence Name Licence Details Licence Start Date (if 

applicable) 

Licence End Date (if 

applicable) 

Human Tissue Authority Licence Licence number is 12034 - The holder is PHNT. There is a separate licence for therapeutic use of tissue 

which Helmy Fekry is responsible for. 

10.05.10 No expiry date 

Organisation Services 

Clinical Service Departments 

Service Department Specialist facilities that may be provided (e.g. number/type of scanners) Contact Name within Service 

Department 

Contact number 

DCL/Microbiology/Pathology/Cytology Clinical Chemistry/haematology/cytology/pathology/coag/immunology Rob Wosley 01752 431357 

Imaging CT/X-Ray/MRI/Tomosynthesis/ultrasound/doplar Ann Pinder 01752 517646 

Pharmacy Dispensing / Aspectic Unit/ Repackaging Maggie Kalita 01752 763423 

Medical Physics IRMER Assessments / DEXA Scanning/radiotherapy/brachytherapy. Nick Rowles 01752 439669 

Breast Clinic Mammogram Dr Jim Steel 01752 517563 

Nuclear Medicine Bone Scans/MUGA/GFR/ARSAC licenses Dr Thomas Gruning 01752 792280 

Ophthalmology OCT/Fluorescein angiography. Mr Thomas Freegard 01752 439355 

Cardiology ECHO Linda Zacharkiw 01752 792659 

Chest Clinic Spirometry / Pulmonary Function Testing Andrew Collingwood 01752 763867 

Details of any 

internal agreement 

templates 

8

Item 13 

Management Support e.g. Finance, Legal Services, Archiving 

Department Specialist services that may be provided Contact Name within 

Service Department 

Contact email 

Contact 

number 

Central Medical 

Archiving of research study files Denise Roddy Denise.roddy@phnt.swest.nhs.uk 01752 

Records Library 

Legal and Contracts 

437086 

Laura Joines Laura.joynes@phnt.swest.nhs.uk 01752 

431057 

Advice on research study contracts. Refers to 

Trust solicitors as appropriate. 

Finance Overall Sarah Brampton Sarah.brampton@phnt.swest.nhs.uk 01752 

439088 

Personnel 

Processing of Research Passports and 

Honorary contracts. 

Carole Davey Carole.davey@phnt.swest.nhs.uk 01752 

439787 

Details of any internal agreement 

templates 

Standard ABPI commercial / 

non-com contracts 

Organisation R&D interests 

Organisation R&D Areas of Interest 

Details Contact Name Contact Number 

Area of Interest 

Oncology Supported by the National Cancer Research Network. (63 NCRN studies in period 2009 -11) 

Nicola Donlin 01752 431960 

We have a broad portfolio of studies, including haematology, breast, gynaecology, lung, upper GI, renal, urology, brain, skin, 

colorectal and palliative care with Commercial & Non-Commercial sponsors. 

Diabetes Supported by the Diabetes Research Network. (15 DRN studies in period 2009 -11) Clare Meachin 01752 439102 

Stroke Supported by the Stroke Research Network. (14 SRN studies in period 2009 -11) Clare Meachin 01752 439102 

Medicines for 

Children 

Dementias and 

Neurodegenerative 

Diseases 

Supported by the Medicine for Children Research Network. (8 MCRN studies in period 2009 -11) Clare Meachin 01752 439102 

Supported by the Dementias and Neurodegenerative Diseases Research Network. (6 DeNDRoN studies in period 2009 -11) 

The Trust holds a £2m NIHR Programme Grant for Applied Research: ‘Clinical Trials Methods in Neurodegenerative 

Diseases’ 

Clare Meachin 

Professor John 

Zajicek 

01752 439102 

Research 

throughout the 

Trust 

There is a broad portfolio of studies, with Commercial & Non-Commercial sponsors, in all areas of the Trust. Specialist areas 

of interest for research are: Cardiovascular, Anaesthetics, Critical Care, Injury & Accident, Hepatology, Reproductive Health 

and Childbirth. In addition, the generic Portfolio Research Team is working across all areas to facilitate and enable 

recruitment. This involves working with clinicians in their specialist areas and offering research expertise in the set up, 

screening and recruitment phase of studies; for example dermatology, metabolic and endocrine, musculoskeletal, nervous 

systems disorders, renal and urogenital. 

Clare Meachin 01752 439102 

9

Specialty Group Membership (Local and National) 

National / Local Specialty Group 

National Hepatology 

National Reproductive health and childbirth 

National 

National 

Surgery 

Anaesthetics, peri-operative medicine 

and pain 

National Metabolic and endocrine 

Specialty Area (if only specific areas 

within group) 

Contact Name Contact Email 

Contact 

Number 

Dr M Cramp matthew.cramp@phnt.swest.nhs.uk 01752 

792725 

Professor R 

robert.freeman@phnt.swest.nhs.uk 01752 

Freeman 

763725 

Professor A 

andrew.kingsnoth@phnt.swest.nhs.uk 01752 

Kingsnorth 

763016 

Dr G Minto gary.minto@phnt.swest.nhs.uk 01752 

431736 

Professor T Wilkin terence.wilkin@phnt.swest.nhs.uk 01752 

792728 

Item 13 

Organisation R&D Planning and Investments 

Planned Investment 

Area of 

Description of Planned Investment Value of Investment Indicative dates 

Investment 

Staffing Clinical Research Training Fellowship - Hepatology £150K 2010-13 

Staffing Clinical Research Training Fellowship - Radiology £100K 2010-12 

Staffing Clinical Research Training Fellowship - Neurology £100K 2011-13 

The Trust Board approved a Research Strategy for 2009-13 which proposed establishing an investment framework for research activity which reflects research specialisations, methodologies and 

care programme benefits. The above decisions have been informed by such a framework but future plans are to be considered by a newly constituted R&D Committee. 

10

Organisation R&D Standard Operating Procedures Register 

Item 13 

Trust Generic 

Research SOP 

Ref Number 

G1 

SOP Title Version Valid 

from 

Valid to 

Preparation, Approval, Review and Issue Version 03 Current Oct-11 

of SOPs 

G2 R&D and Ethics Application Version 03 Current Dec-12 

G3 

Study Files and Filing- Investigational Version 04 Current Oct-11 

Medicinal Products 

G4 

Study files and filing Non-Investigational Version 03 Current Oct-11 

Medicinal Products 

G5 Delegation of duties Version 03 Current Oct-11 

G6 

Consent Procedures for Entry into a Version 04 Current Dec-11 

Research Study 

G7 Data Protection Version 04 Current Oct-11 

G8 Case Record Form Completion Version 03 Current Oct-11 

G9 Research Related Adverse Event Report Version 05 Current Dec-12 

G10 Archiving Version 04 Current Dec-12 

G11 Research Training Version 03 Current Oct-11 

G12 

Research Involving Medical Exposures Version 03 Current Feb-13 

(using Ionising Radiations) 

G13 Study Closure Version 02 Current Dec-12 

G14 Managing protocol amendments Version 01 Current Oct-11 

G15 Non-compliance reporting Version 02 Current Dec-12 

G16 

Document Control/version control Version 01 Current Nov-12 

general guideline 

G17 Urgent Safety measures Version 02 Current Dec-12 

G18 Conflicts of interest Version 01 Current Oct-11 

G19 Suspected research fraud Version 01 Current Jan-12 

G20 Human Tissue for Research Version 01 Current Dec-11 

G21 

Recording of research information in Version 01 Current Oct-11 

patient medical notes 

G22 Research Passport Version 01 Current Jan-12 

G23 

Provision of virology test information to Version 01 Current Jan-12 

clinical trial volunteers. 

G24 Study Start up. Version 01 Current Dec-12 

G25 Data Management Version 01 Current Dec-12 

G26 

Database management, security, design Version 01 Current Dec-12 

and validation 

G27 

Computerised Systems for Supporting Version 01 Current Jan-12 

Clinical Trials 

G28 Case Report Forms Design Version 01 Current Dec-12 

G29 Statistical Analysis Plan Version 01 Current Dec-12 

G30 Randomisation & Blinding Version 01 Current Dec-12 

G31 

Preparing and Submitting Progress and 

Safety Reports 

Version 01 Current Dec-12 

11

R&D SOP Ref 

Number 

SOP Title Version Valid 

from 

Item 13 

Valid to 

R&D 1 Trial Risk Assessment Version 03 Current Oct-11 

R&D 2 Research Governance Audit Version 04 Current Jan-12 

R&D 3 

Study suspension and or discontinuation Version 05 Current Dec-12 

due to failure to comply with Research 

Governance Framework 

R&D 4 

Reporting SUSARs in CTIMPs for PHNT Version 04 Current Dec-12 

UK sponsored studies. 

R&D 5 Reporting of serious breaches in CTIMPs Version 02 Current Dec-12 

R&D 6 

Process of Agreement of the Trust to Version 01 Current Dec-12 

take on the Sponsorship of Studies 

R&D 7 

Management & maintenance of 

Version 01 Current Jan-12 

agreements and Contracts 

R&D 8 Contracting with 3rd parties Version 01 Current Jan-12 

R&D 9 Contract review Version 01 Current Jan-12 

R&D 10 Study specific R&D files DRAFT 

Version 01 

Sent for 

review 

R&D 11 Study tracking DRAFT 

Version 01 

Sent for 

review 

R&D 12 Regulatory Inspection Version 01 Current Oct-11 

R&D 13 

Review of Pharmacy details for Clinical Version 01 Current Jan-12 

Trials 

R&D 14 Monitoring Version 01 Current Jan-12 

R&D Guidance 

Title Version Valid Valid to 

document Ref 

Number 

from 

RGD 1 

Guidance on who can be identified as a Version 01 Current Jan-12 

Professional Legal Representative 

(PrLR) 

RGD 2 Consent in Emergency Research Version 01 Current Jan-12 

RGD 3 

Guideline notes on - Trial Steering Version 01 Current Jan-12 

RDG 4 

Committee (TSC). 

Guidance on contracting for PHNT 

sponsored IMP Trials 

Version 01 

Sent for 

review 

12

Information on the processes used for managing Research Passports 

Item 13 

The R&D office will process research passports on behalf of the Trust. Researchers should contact Dr Lisa 

Vickers, R&D Manager, Telephone 10752 315114 or e-mail lisa.vickers@phnt.swest.nhs.uk 

Escalation Process 

See SOP R&D 3 - Study suspension and or discontinuation due to failure to comply with Research Governance 

Framework - Version 05 - for review Dec 2012 

Planned and Actual Studies Register 

The Trust has maintained a comprehensive database of planned and actual research studies on ReDA 

(research management software) since 1997. 

Other Information 

The R&D Office collects details of staff publications each calendar year. Research published in substantive 

research papers in 2009 is detailed on the HealthNet at: 

http://nww.picts.nhs.uk/PHNetLive/Portals/57ad7180-c5e7-49f5-b282- 

c6475cdb7ee7/ingramp_Research%20Pubs%202009.xls 

In 2010 responsibility for matters relating to the protection and commercialisation of intellectual property was 

transferred from the Finance Department to the R&D Office. The policy for the management of intellectual 

property (TRW.RAD.POL.149.2) is available to staff in the Trust documents folder. 

13

Item 14 


Trust Board (Part 1) Date: 25 March 2011 

Subject 

Prepared by 

Approved by 

Presented by 

Trust Seal 


Lee Budge 


Purpose 

The purpose of this report is to update the Board on the use of the Trust’s Seal. 


Decision 

Approval 

Information 

Other 


• 


In accordance with the Trust’s Standing Orders, the Trust Board receives regular quarterly 

updates on the use of the Trust’s Seal. The documents signed and sealed since the last report in 

December 2010, until 9 March 2011, are listed below: 

Contract Description Between PHNT and: Date 

• 

JCT 2005 Minor Works Building Contract for 

internal conversion and change of use of 

cloakroom area at Plymouth Guildhall to digital 

mammography unit 

SML Contractors 09.12.10 

Deed of Variation, 1 Brest Road, Plymouth 

JCT 2005 Minor Works Building Contract for 

Argyll Ward alterations 

JCT 2005 Intermediate Form of Building Contract 

for Stannon Ward Refurbishment 

Lone Eagle Properties 

Ltd 

KMS Contract Building 

Services 

Steve Mitchell Ltd 

(operating as SML 

Contracts) 

09.12.10 

23.12.10 

23.12.10 

Lease, Unit 4, Eaton Business Park, Thornbury 

Road, Estover, Plymouth 

Variation of an Agreement to Lease, premises at 

Eaton Business Park, Thornbury Road, Estover, 

Plymouth 

The Una Group Ltd 23.12.10 

The Una Group Ltd 12.01.11 


The Board is asked to note this report. 


This report demonstrates good governance and compliance with Standing Orders. 

Next Steps 

Not applicable.


CQC Regulations Not applicable. 

Financial Implications Not applicable. 

Legal Implications Adherence to Standing Orders demonstrates probity and good governance. 

Equality & Diversity Not applicable

Performance Databook 

February 2011 

Part 1 Trust Board 

… safety | quality | efficiency | health

Performance Information Databook 

Page No 

Performance Databook 

Safety Objective Databook 1 

‣ Accident and Emergency 4 Hour Standard 2 

‣ A&E Breach Reasons 3 

‣ Accident and Emergency 2 Hour Standard 4 

‣ Accident and Emergency Median Waits 4 

‣ Ambulance Handover Times 5 

‣ Emergency Inpatients 6 

‣ Delayed transfers of care 7 

‣ MRSA Bacteraemia/ Clostridium Difficile infection 8 

‣ MRSA Screening 9 

‣ Stroke Quality Outcomes 10 

Quality Objective Databook 13 

‣ Out-Patient Waiting Times and Related Activity 14 

‣ In-Patient & Day Care Waiting Times Related Activity 16 

‣ RTT Performance – Admitted Patients 18 

‣ RTT Performance – Non Admitted Patients 19 

‣ RTT – other information including median wait times 20 

‣ Rapid Access Chest Pain Clinic 25 

‣ Angiogram Waiting Times 25 

‣ Revascularisation Waiting Times 25 

‣ Diagnostic Waiting Times 26 

‣ Planned Waiting Lists 29 

‣ Suspended Waiting Lists 30 

‣ Cancelled Operations 31 

‣ Choose and book slot availability 33 

‣ Cancer Targets 34 

‣ Reperfusion Waiting Times 41 

Efficiency and Business Management Objective Databook 42 

‣ Income and Expenditure Performance Against Plan 43 

Health Objective Databook 44 

‣ Access to GUM Clinics 45 

‣ Breast Feeding 46 

‣ Smoking During Pregnancy 47 

‣ Maternity Data Quality 48 

‣ Participation in Heart Disease Audits 49 

‣ Data Quality on Ethic Group 50 

Workforce Objective Databook 51 

‣ Human Resources Scorecard 52

SAFETY OBJECTIVE 

PERFORMANCE REPORT 

Page 1

11 

TOTAL TIME IN A&E 

Maintain the 4 hour maximum wait in A&E from arrival to admission, transfer or discharge 

Current Month: February 2011 

Feb-11 Qtr 1 Qtr 2 Qtr 3 

Qtr 4 To 

Date 

Year To 

Date 

Total Patients Seen in A&E 6539 24550 24581 22019 13592 84742 

Total No. Admitted, Transferred or Discharged Within 4 Hours 6298 24042 24065 20973 12949 82029 

% Within 4 Hours - Plymouth Hospitals NHS Trust Only 96.31% 97.93% 97.90% 95.25% 95.27% 96.80% 

% Within 4 Hours Including Additional Community MIUs 97.70% 98.70% 98.67% 97.00% 97.04% 97.98% 

4 Hour Internal Standard 98% 98% 98% 98% 98% 98% 

4 Hour National Standard 95% 95% 95% 95% 95% 95% 

100% 

98% 

96% 

94% 

92% 

90% 

% Admitted, Transferred or Discharged Within 4 Hours - PHNT Only 

Apr-06 

May- 

Jun-06 

Jul-06 

Aug-06 

Sep-06 

Oct-06 

Nov-06 

Dec-06 

Jan-07 

Feb-07 

Mar-07 

Apr-07 

May- 

Jun-07 

Jul-07 

Aug-07 

Sep-07 

Oct-07 

Nov-07 

Dec-07 

Jan-08 

Feb-08 

Mar-08 

Apr-08 

May- 

Jun-08 

Jul-08 

Aug-08 

Sep-08 

Oct-08 

Nov-08 

Dec-08 

Jan-09 

Feb-09 

Mar-09 

Apr-09 

May- 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May- 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Actual Monthly 

National Standard 

100% 

99% 

98% 

97% 

96% 

95% 

94% 

93% 

92% 

% Admitted, Transferred or Discharged Within 4 Hours - Includes Community MIUs 

AVERAGE DAILY A&E ATTENDANCES BY MONTH & SITE 

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 

2009/10 Derriford 231 242 251 235 227 242 244 232 233 209 226 230 

REI 36 35 35 27 25 27 23 25 23 20 21 21 

TOTAL 267 277 286 262 253 269 267 258 256 229 247 252 

2010/11 Derriford 241 255 256 251 236 243 239 231 237 228 234 

REI 23 17 17 20 24 28 11 0 0 0 0 

TOTAL 264 272 273 270 260 271 250 231 237 228 234 0 

310 

290 

270 

250 

230 

210 

190 

170 

150 

Average Daily A&E Attenders by Site 

Derriford 

REI 

Apr-06 

Jun-06 

Aug-06 

Oct-06 

Dec-06 

Feb-07 

Apr-07 

Jun-07 

Aug-07 

Oct-07 

Dec-07 

Feb-08 

Apr-08 

Jun-08 

Aug-08 

Oct-08 

Dec-08 

Feb-09 

Apr-09 

Jun-09 

Aug-09 

Oct-09 

Dec-09 

Feb-10 

Apr-10 

Jun-10 

Aug-10 

Oct-10 

Dec-10 

Feb-11 

Apr-06 

May- 

Jun-06 

Jul-06 

Aug-06 

Sep-06 

Oct-06 

Nov-06 

Dec-06 

Jan-07 

Feb-07 

Mar-07 

Apr-07 

May- 

Jun-07 

Jul-07 

Aug-07 

Sep-07 

Oct-07 

Nov-07 

Dec-07 

Jan-08 

Feb-08 

Mar-08 

Apr-08 

May- 

Jun-08 

Jul-08 

Aug-08 

Sep-08 

Oct-08 

Nov-08 

Dec-08 

Jan-09 

Feb-09 

Mar-09 

Apr-09 

May- 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May- 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 


National Standard 

100% 

99% 

98% 

97% 

96% 

95% 

94% 

Cumulative Performance By Week - PHNT Only 

09/10 10/11 Target 08/09 

Week 1 

Week 2 

Week 3 

Week 4 

Week 5 

Week 6 

Week 7 

Week 8 

Week 9 

Week 10 

Week 11 

Week 12 

Week 13 

Week 14 

Week 15 

Week 16 

Week 17 

Week 18 

Week 19 

Week 20 

Week 21 

Week 22 

Week 23 

Week 24 

Week 25 

Week 26 

Week 27 

Week 28 

Week 29 

Week 30 

Week 31 

Week 32 

Week 33 

Week 34 

Week 35 

Week 36 

Week 37 

Week 38 

Week 39 

Week 40 

Week 41 

Week 42 

Week 43 

Week 44 

Week 45 

Week 46 

Week 47 

Week 48 

Week 49 

Week 50 

Week 51 

Week 52 

Page 2

A&E BREACH REASONS 2010/11 


YTD 

Waiting for 

assessment 110 68% 95 61% 80 50% 74 42% 75 60% 103 44% 117 48% 87 52% 279 59% 310 56% 158 66% 1488 55% 

Waiting for 

diagnostic 5 3% 5 3% 12 8% 8 5% 8 6% 5 2% 6 2% 5 3% 9 2% 3 1% 5 2% 71 3% 

Waiting for 

treatment 27 17% 25 16% 30 19% 39 22% 25 20% 46 20% 44 18% 29 17% 59 13% 52 9% 41 17% 417 16% 

Waiting for 

specialist 7 4% 10 6% 10 6% 11 6% 4 3% 16 7% 16 7% 5 3% 20 4% 17 3% 8 3% 124 5% 

Waiting for 

portering 0 0% 1 1% 2 1% 2 1% 1 1% 3 1% 2 1% 2 1% 2 0% 5 1% 0 0% 20 1% 

Waiting for 

transport 0 0% 0 0% 2 1% 0 0% 0 0% 3 1% 0 0% 0 0% 5 1% 1 0% 3 1% 14 1% 

Waiting for 

bed 7 4% 17 11% 24 15% 12 7% 7 6% 53 23% 55 22% 34 20% 85 18% 153 28% 17 7% 464 17% 

Other 5 3% 4 3% 0 0% 31 18% 5 4% 3 1% 5 2% 6 4% 12 3% 10 2% 7 3% 88 3% 

TOTAL 161 157 160 177 125 232 245 168 471 551 239 2686 

600 

500 

400 

300 

200 

100 

0 

A&E Breaches By Reason 2010/11 


Other 

Waiting for bed 

Waiting for transport 

Waiting for portering 

Waiting for specialist 

Waiting for treatment 

Waiting for diagnostic 

Waiting for assessment 

Page 3

11 

TOTAL TIME IN A&E 

Achieve a maximum of 2 hrs in A&E from arrival to admission, transfer or discharge by March 

2011 for 60% of patients 


% Within 2 Hours - Plymouth 

Target 


42.6% 41.3% 44.9% 42.6% 43.4% 41.8% 40.0% 40.3% 34.3% 35.9% 31.2% 

52.5% 52.5% 52.5% 55.0% 55.0% 55.0% 55.0% 55.0% 55.0% 55.0% 55.0% 

60% 

% Admitted, Transferred or Discharged Within 2 Hours - PHNT Only 

50% 

40% 

30% 

20% 

10% 

0% 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 


Target Monthly 

Median Wait (Mins) In A&E (From Arrival To Discharge Transfer Or Admission) 


2010/11 Total Median 149 148 137 148 151 155 149 144 161 154 159 

Minors Median 121 119 107 120 117 125 119 108 121 120 132 

Majors Median 206 210 205 206 205 213 210 210 219 213 208 

250 

A&E Median Wait Times 

Total Median Minors Median Majors Median 

200 

150 

100 

50 

0 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Page 4

AMBULANCE HANDOVER TIMES 

Maximum of 10% waiting > 15 minutes from arrival to transfer in A&E/MAU by 31 March 2010 and zero patients 

waiting > 30 mins from arrival to transfer in A&E/MAU by 31 March 2009 


2010/11 Total Handovers 2741 2948 2744 2919 2807 2764 3030 2787 3296 2929 2734 

No. Waiting >15 mins 544 533 565 352 188 233 289 277 402 230 240 

% Waiting > 15 mins 20% 18% 21% 12% 7% 8% 10% 10% 12% 8% 9% 

Target 10% 10% 10% 10% 10% 10% 10% 10% 10% 10% 10% 10% 

No. Waiting >30 mins 66 69 64 42 30 46 52 45 63 52 29 

% Waiting > 30 mins 2% 2% 2% 1% 1% 2% 2% 2% 2% 2% 1% 

Target 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 

35% 

30% 

25% 

20% 

15% 

10% 

5% 

0% 

Ambulance Handover Times - % waiting > 15 mins 

% > 15 mins 

Target 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

6% 

5% 

4% 

3% 

2% 

1% 

0% 

Ambulance Handover Times - % waiting > 30 mins 

% > 30 mins 

Target 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

Page 5

# 

Non Elective Inpatient Activity 

Current Month: 

February 2011 

Performance Against Plan : 

Comparison to Previous Year : 

Forecast Emergency Admissions 39,365 Actual Admissions to M11 2009/10 39,516 

Actual Emergency Admissions 40,399 Actual Admissions to M11 2010/11 40,399 

Variance (1,034) Variance 

(883) 

Variance (%) (2.6%) Variance (%) 

(2.2%) 

** Please note numbers in the tables above exclude Obstetrics & Gynaecology 

No. of FFCEs 

5500 

5000 

4500 

4000 

3500 

3000 

2500 

2000 

No. of FFCEs by Month 

Apr-05 

May-05 

Jun-05 

Jul-05 

Aug-05 

Sep-05 

Oct-05 

Nov-05 

Dec-05 

Jan-06 

Feb-06 

Mar-06 

Apr-06 

May-06 

Jun-06 

Jul-06 

Aug-06 

Sep-06 

Oct-06 

Nov-06 

Dec-06 

Jan-07 

Feb-07 

Mar-07 

Apr-07 

May-07 

Jun-07 

Jul-07 

Aug-07 

Sep-07 

Oct-07 

Nov-07 

Dec-07 

Jan-08 

Feb-08 

Mar-08 

Apr-08 

May-08 

Jun-08 

Jul-08 

Aug-08 

Sep-08 

Oct-08 

Nov-08 

Dec-08 

Jan-09 

Feb-09 

Mar-09 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

Actual 

Plan 

4500 

4000 

No. of FFCEs by Month (Excludes Obstetrics & Gynaecology) 

Actual 

Plan 

No. of FFCEs 

3500 

3000 

2500 

2000 

Apr-05 

May-05 

Jun-05 

Jul-05 

Aug-05 

Sep-05 

Oct-05 

Nov-05 

Dec-05 

Jan-06 

Feb-06 

Mar-06 

Apr-06 

May-06 

Jun-06 

Jul-06 

Aug-06 

Sep-06 

Oct-06 

Nov-06 

Dec-06 

Jan-07 

Feb-07 

Mar-07 

Apr-07 

May-07 

Jun-07 

Jul-07 

Aug-07 

Sep-07 

Oct-07 

Nov-07 

Dec-07 

Jan-08 

Feb-08 

Mar-08 

Apr-08 

May-08 

Jun-08 

Jul-08 

Aug-08 

Sep-08 

Oct-08 

Nov-08 

Dec-08 

Jan-09 

Feb-09 

Mar-09 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

VARIANCE FROM PLAN 

VARIANCE FROM 2009/10 ACTUAL 

SPECIALTY No. % No. % 

Anaesthestics & Theatres 

Chronic Pain 7 70.0% 6 66.7% 

Intensive Care 7 1.8% (40) (11.7%) 

Cardiothoracics 

Cardiac Surgery 28 10.6% 24 9.3% 

Cardiology (106) (26.5%) (102) (25.2%) 

Thoracic Surgery (10) (9.7%) (13) (13.0%) 

Vascular Surgery (41) (36.0%) (42) (37.2%) 

Children's Services 

Paediatrics 170 3.5% 289 5.8% 

Emergency Services 

A&E 303 9.7% 313 9.9% 

Acute Medicine (1,000) (23.2%) (550) (11.6%) 

Gastroenterology, Surgery & Renal Services 

Gastroenterology (206) (8.0%) 144 4.9% 

Hepatology (262) (63.7%) (382) (131.3%) 

Colorectal Surgery 625 17.5% 606 17.0% 

Upper GI Surgery (106) (5.8%) (113) (6.2%) 

Endoscopy (26) (41.3%) (35) (64.8%) 

General Surgery (479) (45.5%) (455) (42.2%) 

Urology (5) (13.2%) (4) (10.3%) 

Nephrology 4 1.1% (57) (19.8%) 

Haematology & Oncology 

Clinical Oncology 97 16.5% 82 14.3% 

Medical Oncology 12 34.3% 13 36.1% 

Palliative Medicine (4) (200.0%) (4) (200.0%) 

Clin Haematology 79 27.6% 72 25.8% 

Clin Immunology (3) (3) 

Head & Neck Surgery 

Plastic Surgery (129) (24.2%) (138) (26.3%) 

Plastic Surgery Hands (10) (76.9%) (11) (91.7%) 

Oral Surgery 36 14.4% 34 13.7% 

Dermatology 5 71.4% 5 71.4% 

Imaging 

Neuroradiology (2) (2) 

Radiology (1) (1) 

Medical Specialties 

Diabetic Medicine 0 0.0% 47 2.2% 

Endocrinology 36 100.0% 0 

General Medicine 1,100 99.9% 51 98.1% 

HCE (891) (49.2%) (348) (14.8%) 

Thoracic Medicine (247) (9.0%) (180) (6.4%) 

Neurosciences & Ophthalmology 

Neurosurgery 79 12.4% 67 10.7% 

Neurology (82) (6.3%) (81) (6.3%) 

Neurophysiology 2 100.0% 2 100.0% 

Orthopaedics & Rheumatology 

Trauma 83 4.3% 51 2.7% 

Rheumatology 12 75.0% 11 73.3% 

Reproductive, Womens & Neonatal Services 

Gynaecology 1,209 34.1% 1,195 33.8% 

Uro-Gynaecology (7) (41.2%) (8) (50.0%) 

PAC (6) (6) 

Obstetrics 1,090 9.9% 1,087 9.9% 

Neonatology (234) (22.3%) (248) (24.0%) 

TOTAL 1,265 2.3% 1,399 2.6% 

Page 6

DELAYED TRANSFERS OF CARE 


February 2011 

The number of acute patients (aged 18 and over) whose transfer 

of care was delayed 

2009/10 

Cumulative Occupancy 42,043 

Delayed Transfers 1,271 

Percentage Delayed 3.0% 

Current Month 

Occupancy 3,085 

Delayed Transfers 170 


Year To Date 

Cumulative Occupancy 37,341 

Delayed Transfers 1249 


6.0% 

5.0% 

4.0% 

3.0% 

2.0% 

1.0% 

0.0% 

Apr-09 

Jun-09 

Aug-09 

Delayed Transfers as % of Occupancy 

Oct-09 

Dec-09 

Feb-10 

Apr-10 

Jun-10 

Aug-10 

Oct-10 

Dec-10 

Feb-11 

No of Delayed Patients by Council 

Council Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 TOTAL 

Plymouth 63 47 66 72 56 56 51 51 21 48 94 0 625 

Devon 42 38 27 16 22 33 13 9 13 45 35 0 293 

Cornwall 60 31 26 23 20 24 12 7 30 57 41 0 331 

Other 0 0 0 0 0 0 0 0 0 0 0 0 0 

TOTAL 165 116 119 111 98 113 76 67 64 150 170 0 1249 

180 

160 

No. of Delayed Patients By Council 

No. of Delayed Patients 

140 

120 

100 

80 

60 

40 

Other 

Cornwall 

Devon 


20 

0 

Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 

No of Beddays Used by Delayed Patients by Council 

Council Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 TOTAL 

Plymouth 468 301 395 449 373 321 327 298 139 218 222 0 3511 

Devon 249 224 162 123 124 203 116 57 66 207 232 0 1763 

Cornwall 390 190 173 146 109 141 59 34 179 305 246 0 1972 

Other 0 0 0 0 0 0 0 0 0 0 0 0 0 

TOTAL 1107 715 730 718 606 665 502 389 384 730 700 0 7246 

1200 

No. of Beddays Used by Delayed Patients & Council 

1000 

No. of Beddays 

800 

600 

400 

200 

Other 

Cornwall 

Devon 


0 


Page 7

11 

3 

MRSA Bacteraemia 


February 2011 

Remain below Trust trajectory for Hospital apportioned cases i.e. 

post 48 hrs 

2010/11 

YTD 

Apr-10 

May-10 

Jun-10 

No. of Infections - All cases 8 2 0 1 1 2 1 1 0 0 0 0 

Less No. of Infections - Community 

apportioned (pre 48 hrs) 

No. of Infections - Hospital 

apportioned (post 48 hrs) 

Upper threshold - Hospital 


Variance: better/(worse) than 

threshold 

(5) (2) (1) (1) (1) 

Jul-10 

Aug-10 

3 0 0 0 1 1 1 0 0 0 0 0 

Sep-10 

8 1 0 1 1 1 1 1 0 1 1 0 1 

5 1 0 1 0 0 0 1 0 1 1 0 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

3.5 

3 

2.5 

2 

1.5 

1 

0.5 

0 

No. of MRSA Trust Apportioned cases against Upper Threshold 

Actual - Hospital 

Trajectory 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

2 

Rolling 3 monthly average of No. of MRSA Trust Apportioned cases 

1.5 

1 

0.5 

0 

Clostridium Difficile 


February 2011 

Remain below Trust trajectory for Hospital apportioned cases i.e. 

post 72 hours 

2010/11 

YTD 

Apr-10 

May-10 

Jun-10 

No. of Infections - All cases 55 3 2 6 11 5 5 3 3 3 6 8 

No. of Infections - Community 

apportioned (pre 72 hrs) 

(26) (2) (2) (3) (5) (1) 0 (1) (1) (2) (4) (5) 

No. of Infections - Hospital 


29 1 0 3 6 4 5 2 2 1 2 3 

Upper threshold - Hospital 

apportioned (post 72 hrs) 115 13 11 9 11 9 8 8 8 8 16 14 13 

Variance: better/(worse) than 

threshold 

Jul-10 

Aug-10 

86 12 11 6 5 5 3 6 6 7 14 11 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

18 

16 

14 

12 

10 

8 

6 

4 

2 

0 

No. of C. Diff Trust Apportioned cases against Upper Threshold 

Actual - Hospital 

Trajectory 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

Apr- 

09 

May- 

09 

Jun- 

09 

Jul- 

09 

Aug- 

09 

Sep- 

09 

Oct- 

09 

Nov- 

09 

Dec- 

09 

Jan- 

10 

Feb- 

10 

Mar- 

10 

Apr- 

10 

May- 

10 

Jun- 

10 

Jul- 

10 

Aug- 

10 

Sep- 

10 

Oct- 

10 

Nov- 

10 

Dec- 

10 

Jan- 

11 

Feb- 

11 

Mar- 

11 

Page 8

# 

MRSA SCREENING 


February 2011 

ELECTIVE & NON ELECTIVE 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

YTD 

All MRSA Screens 6140 5746 6044 6182 6586 5782 6507 6707 7372 6363 7193 7193 71675 

All Admissions (Elective & Non 

Elective) 

6161 5446 5409 5773 5879 5549 5715 5392 5829 5461 5599 5285 61337 

Percentage Screened - Total 100% 106% 112% 107% 112% 104% 114% 124% 126% 117% 128% 136% 117% 

Patient Level Monitoring 

Every effort is being made to monitor this at patient level on a live, day-to-day basis. However, it does require matching lab data, PAS data and 

paper records from other organisations (which are often not received in a timely manner). As a result, it should be acknowledged that we cannot 

guarantee 100% accuracy. 

ELECTIVE 

No of Elective Admissions 

No of Screened Elective Adms 

Screening Target 

Percentage Screened - Patient level 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

3642 3043 2965 3344 3365 3159 3340 3124 3518 2927 3115 3075 34975 

3302 2773 2730 3106 3189 3041 3197 2990 3385 2821 2989 2933 33154 

95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 

91% 91% 92% 93% 95% 96% 96% 96% 96% 96% 96% 95% 95% 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

YTD 

100% 

95% 

90% 

85% 

80% 

75% 

70% 

Percentage of Elective Patients Subject to MRSA Target who have been Screened 

Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 

Elective Admissions Subject to MRSA Screen 


NON-ELECTIVE 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

No of Non-Elective Admissions 2519 2403 2444 2429 2514 2390 2375 2268 2311 2534 2484 2210 26362 

No of Screened Non-Elective Adms 1620 1659 1733 1681 1758 1636 1734 1899 2082 2249 2254 2074 20759 

Screening Improvement Trajectory 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 92% 93% 94% 90% 

Percentage Screened - Patient level 64% 69% 71% 69% 70% 68% 73% 84% 90% 89% 91% 94% 79% 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

YTD 

100% 

Percentage of Non-Elective Patients Subject to MRSA Target who have been Screened 

90% 

80% 

70% 

60% 

50% 


Non-Elective Admissions Subject to MRSA Screen 


Page 9

9 

Health Improvement - Stroke 


February 2011 

Target: by the end of 2010-11: 80% of people with stroke spend at least 90% 

of their time on a stroke unit 

Patients who spend at least 

90% of their time on a 

stroke unit 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

24 38 35 43 38 40 44 51 53 44 35 38 459 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

2010/11 

YTD 

Number of people who were 

admitted to hospital 

following a stroke 

44 53 56 61 56 66 67 65 71 69 53 54 671 

%age of people spending at 

least 90% of their time on a 

stroke unit 

55% 72% 63% 70% 68% 61% 66% 78% 75% 64% 66% 70% 68% 

Month is based on Discharge Date 

90% 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

10% 

0% 

%age spending at least 90% of their time on a Stroke Unit 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

Page 10

7 

Stroke Indicators 


February 2011 

CQUIN Target: Percentage of Stroke patients having CT within 12 Hours of 

Admission 

No of patient having CT 

within 12 Hours of 

Admission 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

2010/11 

YTD 

31 59 50 46 59 49 57 54 50 45 47 547 

Number of people who 

were admitted to hospital 

following a stroke (Excludes 

those having pre admission 

CT) 

%age of patient having CT 


Admission 

43 68 58 63 82 64 77 70 74 68 61 728 

72% 87% 86% 73% 72% 77% 74% 77% 68% 66% 77% 75% 

100% 

90% 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

10% 

0% 

Percentage of Stroke Patients receiving CT within 12 Hours of Admission 

Please note percentages may change due to ongoing data collection 

9 


Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

2010/11 

YTD 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 


February 2011 

CQUIN Target: Percentage of Stroke patients having CT within 24 Hours of 

Admission 

No of patient having CT 

with 24 Hours of Admission 

42 65 55 51 66 56 64 60 57 51 53 620 



following a stroke (Excludes 

those having pre admission 

CT) 

43 68 58 63 82 64 77 70 74 68 61 728 


with 24 Hours of Admission 

98% 96% 95% 81% 80% 88% 83% 86% 77% 75% 87% 85% 

100% 

90% 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

10% 

0% 

Percentage of Stroke Patients receiving CT within 24 Hours of Admission 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 


Page 11

7 



February 2011 

Percentage of Stroke patients having 1st Swallow Screening within 24 

Hours of Admission 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

2010/11 

YTD 

No of patient having 1st 

Swallow Screening within 

24 Hours of Admission 

41 66 49 53 66 58 68 58 60 57 49 625 






Admission 

43 68 58 63 82 64 77 70 74 68 61 728 

95% 97% 84% 84% 80% 91% 88% 83% 81% 84% 80% 86% 

100% 

90% 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

10% 

0% 

Percentage of Stroke patients having 1st Swallow Screening within 24 Hours of Admission 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

% within 24hrs Target % 


9 



February 2011 

Percentage of Stroke patients having SLT specialist assessment within 72 

Hours of Admission 

No of patient having SLT 

Spec assessment within 72 

hours of adm 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

2010/11 

YTD 

21 31 15 18 30 18 20 15 18 13 24 223 

Number of patients Eligible 

for a SLT assessment 


%age of patient having SLT 

Spec assessment within 72 

hours of adm 

27 42 36 35 48 49 32 38 48 40 31 426 

78% 74% 42% 51% 63% 37% 63% 39% 38% 33% 77% 52% 

Percentage of Stroke patients having SLT specialist assessment within 72 Hours of Admission 

100% 

90% 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

10% 

0% 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

% within 72hrs Target % 


Page 12

QUALITY OBJECTIVE 


Page 13

11 

Consultant Outpatient Waiting List & Related Activity 

Current Month : February 2011 

12000 

11000 

10000 

9000 

8000 

7000 

6000 

5000 

4000 

TOTAL NEW OUTPATIENT WAITING LIST 

Apr-08 

May- 

Jun-08 

Jul-08 

Aug-08 

Sep-08 

Oct-08 

Nov-08 

Dec-08 

Jan-09 

Feb-09 

Mar-09 

Apr-09 

May- 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May- 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

12000 

11500 

11000 

10500 

10000 

9500 

9000 

8500 

8000 

7500 

7000 

Referrals Received 

Apr-08 

May- 

Jun-08 

Jul-08 

Aug-08 

Sep-08 

Oct-08 

Nov-08 

Dec-08 

Jan-09 

Feb-09 

Mar-09 

Apr-09 

May- 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May- 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

11500 

11000 

10500 

10000 

9500 

9000 

8500 

8000 

7500 

7000 

New Seen 

Apr-08 

May- 

Jun-08 

Jul-08 

Aug-08 

Sep-08 

Oct-08 

Nov-08 

Dec-08 

Jan-09 

Feb-09 

Mar-09 

Apr-09 

May- 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May- 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

Page 14

Consultant Outpatients Waiting & Related Activity - variances from planned levels 

Current Month : 

February 2011 

VARIANCES (Actual against Plan) 

Referrals New Activity ROTTs Total List size 

SPECIALTY No. % No. % No. % No. % 

General Surgery 200 9.7% (145) (7.6%) (41) (21.0%) 8 6.7% 

Vascular Surgery 239 16.0% (77) (6.0%) (38) (34.2%) 83 55.0% 

Hepatobiliary & Pancreatic Surgery 0 0.0% 0 0.0% 0 0.0% 0 0.0% 

Urology 499 11.6% (94) (2.5%) (20) (5.5%) 192 37.1% 

Nephrology 224 24.4% (213) (24.1%) (2) (4.1%) 13 18.6% 

ENT 368 4.4% (143) (1.9%) (177) (29.4%) 22 3.0% 

Audiological Medicine 0 0.0% 0 0.0% 0 0.0% 0 0.0% 

Plastic Surgery (403) (13.1%) 334 12.6% (51) (19.5%) 20 10.9% 

Plastic Surgery Hands (128) (14.3%) (97) (10.0%) 14 20.0% 5 11.4% 

Dermatology (55) (0.9%) 279 6.2% (112) (26.1%) 123 23.4% 

Oral Surgery 132 2.3% (95) (2.2%) (8) (0.6%) (103) (19.8%) 

Orthodontics 29 2.9% (43) (4.8%) 31 34.4% 26 19.5% 

Rest Dent 45 8.8% (9) (2.0%) (15) (30.0%) (24) (80.0%) 

Neurosurgery 76 2.0% (397) (13.6%) 13 1.2% (261) (88.2%) 

Neurology 401 10.8% (477) (14.6%) (132) (32.2%) 25 6.4% 

Neurophysiology 2 18.2% 0 0.0% 0 0.0% 0 0.0% 

Neuropsychology 0 0.0% 0 0.0% 0 0.0% 0 0.0% 

Ophthalmology (172) (1.8%) 396 4.9% (68) (10.0%) 217 24.5% 

Optician 0 0.0% 0 0.0% 0 0.0% 0 0.0% 

Orthoptist 0 0.0% 0 0.0% 0 0.0% 0 0.0% 

Orthopaedics 287 3.3% (247) (3.1%) (196) (25.1%) (161) (22.4%) 

Trauma 11 0.2% (129) (2.7%) 272 394.2% 0 0.0% 

Rheumatology 117 5.5% (28) (1.5%) (29) (17.4%) 31 9.7% 

Chronic Pain 373 17.1% (493) (25.4%) 12 4.8% (23) (7.6%) 

Acute Medicine 0 0.0% 0 0.0% 0 0.0% 0 0.0% 

Intensive Care (40) 0.0% 44 0.0% 0 0.0% 0 0.0% 

Gynaecology (584) (15.7%) 899 33.1% (197) (53.4%) (41) (15.5%) 

Gynaecological Oncology 256 41.5% (782) (60.7%) 5 15.6% 45 81.8% 

Uro-Infertility 112 21.1% (65) (15.3%) (18) (28.1%) 21 42.9% 

Uro-Gynaecology (89) (10.6%) 8 0.9% (10) (21.7%) (3) (2.9%) 

Gynae - Colposcopy Suite 209 17.5% (179) (16.2%) (17) (20.2%) 66 61.1% 

Gynae - Hysteroscopy (126) (29.3%) 141 31.5% (4) (12.1%) (32) (145.5%) 

Breast Surgery 253 8.9% (266) (9.8%) (6) (5.1%) 23 34.8% 

PAC (43) (3.2%) 63 5.5% (22) (10.3%) 53 80.3% 

Obstetrics (514) (19.1%) 528 23.1% (17) (4.3%) 8 16.3% 

GUM 0 0.0% (936) (8.2%) 0 0.0% 0 0.0% 

Paediatrics (291) (9.7%) 311 11.6% (36) (12.5%) 93 31.6% 

Neonatology (38) (13.7%) 24 8.7% 9 52.9% 1 2.7% 

Community Paediatrics 57 20.6% (59) (24.7%) (34) (64.2%) (19) (105.6%) 

Child Psychology 0 0.0% 0 0.0% 0 0.0% 0 0.0% 

Cardiac Surgery (41) (7.6%) (4) (0.7%) 8 14.8% (17) (41.5%) 

Cardiology 534 12.6% (347) (9.0%) (165) (38.2%) 147 42.6% 

Thoracic Surgery (6) (2.1%) (11) (5.1%) 8 50.0% 12 70.6% 

A&E 283 8.5% (323) (12.1%) (19) (86.4%) 23 24.7% 

Clinical Oncology 47 3.1% 42 3.0% 28 28.0% 15 12.7% 

Medical Oncology 35 25.2% (11) (8.9%) (8) (53.3%) (2) (33.3%) 

Palliative Medicine 20 9.2% (44) (25.3%) 11 17.2% (10) (142.9%) 

Clin Haematology 54 2.7% (59) (7.0%) 13 13.7% 29 29.0% 

Clin Immunology (106) (11.4%) (27) (4.7%) 353 212.7% 60 30.8% 

Diabetic Medicine (26) (3.5%) 6 0.9% (4) (5.6%) (42) (102.4%) 

Endocrinology 3 0.4% (53) (8.2%) (7) (15.6%) (51) (96.2%) 

General Medicine 65 38.7% (58) (36.5%) (26) (57.8%) 14 82.4% 

HCE 40 6.9% 95 18.4% 148 164.4% (42) (43.8%) 

Thoracic Medicine (32) (1.4%) (53) (2.5%) 4 1.6% (28) (12.3%) 

Gastroenterology 374 12.3% (15) (0.6%) (3) (1.2%) 95 23.9% 

Hepatology (149) (23.8%) 88 15.5% 3 7.1% (32) (266.7%) 

Colorectal Surgery (648) (17.2%) 1097 37.4% 87 25.5% 82 20.3% 

Upper GI Surgery (446) (24.7%) 106 6.2% 6 5.6% 4 3.6% 

Endoscopy 0 0.0% 0 0.0% 0 0.0% 0 0.0% 

Clin Chemistry 20 11.9% 14 10.3% (7) (35.0%) 18 64.3% 

Neuroradiology 12 60.0% 1 0.0% 0 0.0% 0 0.0% 

Neuropathology 0 0.0% 0 0.0% 0 0.0% 0 0.0% 

Nuclear Medicine 18 11.3% (21) (13.7%) 5 71.4% 2 22.2% 

Radiology 0 0.0% 0 0.0% 0 0.0% 0 0.0% 

TOTAL 1458 1.3% (1524) (1.4%) (459) (4.2%) 685 7.2% 

Page 15

11 

Inpatient & Day Case Waiting List & Related Activity 


8000 

7500 

7000 

6500 

6000 

5500 

5000 

4500 

4000 

3500 

IP & DC Total WL Size 

Apr-08 

May-08 

Jun-08 

Jul-08 

Aug-08 

Sep-08 

Oct-08 

Nov-08 

Dec-08 

Jan-09 

Feb-09 

Mar-09 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

5500 

5300 

5100 

4900 

4700 

4500 

4300 

4100 

3900 

3700 

Elective Inpatient & Day Case FFCEs 

Apr-08 

May- 

Jun-08 

Jul-08 

Aug-08 

Sep-08 

Oct-08 

Nov-08 

Dec-08 

Jan-09 

Feb-09 

Mar-09 

Apr-09 

May- 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May- 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

5500 

Additions to WL 

5000 

4500 

4000 

3500 

3000 

Apr-08 

May-08 

Jun-08 

Jul-08 

Aug-08 

Sep-08 

Oct-08 

Nov-08 

Dec-08 

Jan-09 

Feb-09 

Mar-09 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

Page 16


Inpatient & Day Case Waiting List & Related Activity - variances from planned levels 

VARIANCES : ACTUAL AGAINST PLAN 

Additions FFCEs ROTTs Total List size 

SPECIALTY No. % No. % No. % No. % 

General Surgery 77 4.8% (173) (11.8%) 14 7.5% (118) (48.2%) 

Vascular Surgery 9 1.1% (11) (1.3%) 35 38.0% (13) (12.4%) 

Hepatobiliary & Pancreatic Surgery 0 0.0% 0 0.0% 0 0.0% 0 0.0% 

Urology 79 2.2% (137) (3.0%) 26 9.6% (63) (26.1%) 

Nephrology 133 29.6% (174) (17.6%) (6) (16.2%) 8 20.5% 

ENT 80 3.4% (103) (4.5%) 44 19.6% (18) (4.5%) 

Audiological Medicine 0 0.0% 0 0.0% 0 0.0% 0 0.0% 

Plastic Surgery (202) (5.0%) (153) (3.9%) 65 17.5% (212) (44.3%) 

Plastic Surgery Hands 10 40.0% (34) (50.0%) 1 0.0% 0 0.0% 

Dermatology (122) (6.1%) 187 9.7% 89 61.8% 35 14.6% 

Oral Surgery 104 6.8% (44) (3.1%) (17) (12.1%) (28) (14.4%) 

Orthodontics 4 4.5% 5 5.8% 1 33.3% 4 18.2% 

Rest Dent (10) (13.0%) (3) (4.3%) 7 87.5% (12) (150.0%) 

Neurosurgery (43) (2.7%) 75 5.3% 10 3.9% (26) (12.3%) 

Neurology (33) (7.0%) (61) (8.3%) 46 63.0% 14 16.1% 

Neurophysiology 41 87.2% (25) (80.6%) (16) (94.1%) 1 100.0% 

Neuropsychology 0 0.0% 0 0.0% 0 0.0% 0 0.0% 

Ophthalmology (396) (7.1%) 189 3.6% 20 3.9% (251) (31.2%) 

Optician 0 0.0% 0 0.0% 0 0.0% 0 0.0% 

Orthoptist 0 0.0% 0 0.0% 0 0.0% 0 0.0% 

Orthopaedics 68 1.2% 223 4.6% (138) (11.9%) (60) (7.2%) 

Trauma 0 0.0% 0 0.0% 0 0.0% 0 0.0% 

Rheumatology 15 10.6% (7) (1.3%) (17) (68.0%) (9) (450.0%) 

Chronic Pain 290 43.2% (309) (41.0%) (37) (32.5%) 15 46.9% 

Intensive Care 0 0.0% (1) (100.0%) 0 0.0% 0 0.0% 

Gynaecology 186 8.2% (202) (10.0%) (61) (20.7%) (97) (30.5%) 

Gynaecological Oncology (8) (5.4%) 10 7.1% 3 37.5% (7) (100.0%) 

Uro-Infertility (2) 0.0% 2 0.0% 0 0.0% 0 0.0% 

Uro-Gynaecology 0 0.0% 2 200.0% 0 0.0% 0 0.0% 

Gynae - Colposcopy Suite 0 0.0% 0 0.0% 0 0.0% 0 0.0% 

Gynae - Hysteroscopy 0 0.0% (1) (100.0%) 1 0.0% 0 0.0% 

Breast Surgery 29 4.0% (6) (0.9%) (9) (18.0%) 1 2.5% 

PAC (118) (11.5%) 106 11.3% 15 16.9% 23 67.6% 

Obstetrics 0 0.0% 0 0.0% 0 0.0% 0 0.0% 

GUM 0 0.0% 0 0.0% 0 0.0% 0 0.0% 

Paediatrics (20) (5.0%) 9 1.7% 5 15.2% (6) (54.5%) 

Neonatology 1 9.1% 3 12.5% (2) (66.7%) 0 0.0% 

Community Paediatrics 0 0.0% (1) (100.0%) 0 0.0% 0 0.0% 

Child Psychology 0 0.0% 0 0.0% 0 0.0% 0 0.0% 

Cardiac Surgery 4 0.4% (35) (4.3%) (31) (16.4%) (96) (69.1%) 

Cardiology (127) (6.1%) 82 3.8% 19 8.4% (64) (34.6%) 

Thoracic Surgery 46 7.6% (12) (2.1%) (36) (51.4%) (1) (5.0%) 

A&E 0 0.0% 0 0.0% 0 0.0% 0 0.0% 

Acute Medicine 0 0.0% 17 0.0% 0 0.0% 0 0.0% 

Clinical Oncology (671) (13.5%) 452 8.5% 60 14.7% (26) (11.4%) 

Medical Oncology 4 1.3% 1 0.3% (7) (18.4%) (5) (35.7%) 

Palliative Medicine 0 0.0% 4 400.0% 0 0.0% 0 0.0% 

Clin Haematology (28) (127.3%) 43 1.9% 4 133.3% (5) 0.0% 

Clin Immunology (9) 0.0% 0 0.0% 0 0.0% (2) 0.0% 

Diabetic Medicine 0 0.0% 292 0.0% (1) (100.0%) 0 0.0% 

Endocrinology (123) (150.0%) (242) (80.9%) 7 77.8% (13) (216.7%) 

General Medicine 1 4.5% (98) (100.0%) 3 300.0% 0 0.0% 

HCE (17) (23.0%) 10 27.8% (30) (62.5%) 1 100.0% 

Thoracic Medicine (48) (11.3%) 32 6.3% 5 12.8% (17) (188.9%) 

Gastroenterology (91) (44.2%) 10 1.6% 6 15.4% (14) (200.0%) 

Hepatology (152) (163.4%) 66 14.3% 23 1150.0% (12) (150.0%) 

Colorectal Surgery 135 7.9% (93) (6.1%) 24 8.9% 1 0.4% 

Upper GI Surgery (159) (10.5%) (77) (5.4%) 18 10.2% (214) (78.4%) 

Endoscopy 2 28.6% 0 0.0% 0 0.0% 0 0.0% 

Clin Chemistry 1 100.0% (1) (100.0%) 0 0.0% 0 0.0% 

Neuroradiology (28) (186.7%) 7 18.4% 6 0.0% 2 66.7% 

Neuropathology (11) (14.5%) 15 25.0% (5) (23.8%) 0 0.0% 

Nuclear Medicine (1) 0.0% 0 0.0% 0 0.0% 0 0.0% 

Radiology 9 32.1% (19) (61.3%) 2 0.0% (2) (100.0%) 

TOTAL (1091) (2.3%) (180) (0.3%) 146 2.6% (1286) (23.4%) 

Page 17

11 

Referral To Treatment (RTT) Times - 18 weeks monitoring 

RTT for Admitted Patients 


February 2011 

Target = To Achieve Max 18 wks wait for 90% of Admitted Patients 

on RTT Pathways by Dec 2008 


Treated within 18 weeks 3411 2809 2733 3257 3039 3094 3321 3186 3393 2828 2948 2946 

Treated after 18 weeks 211 151 70 91 126 98 112 116 150 112 227 253 

% Treated within 18 weeks 94.2% 94.9% 97.5% 97.3% 96.0% 96.9% 96.7% 96.5% 95.8% 96.2% 92.9% 92.1% 

DoH target 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 

100% 

95% 

90% 

85% 

80% 

75% 

70% 

% Admitted Patients Treated within 18 weeks 

Apr-08 

May-08 

Jun-08 

Jul-08 

Aug-08 

Sep-08 

Oct-08 

Nov-08 

Dec-08 

Jan-09 

Feb-09 

Mar-09 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

SPECIALTY 

Current Month 

Target 

Of which are 

Mar-10 

NHS 

Adms < 18 

Constitution 

wks Adms 18+ wks Breaches % < 18 wks 


AN Chronic Pain 94% 17 

0 

0 100.0% 90% 

IC Intensive Care 


CS Cardiac Surgery 100% 

0 

64 

0 

2 

0 

1 

97.0% 90% 

CD Cardiology 99% 76 

2 

1 

97.4% 90% 

TS Thoracic Surgery 100% 32 

0 

0 100.0% 90% 

VS Vascular Surgery 89% 57 

1 

0 

98.3% 90% 


PD Paediatrics 100% 16 

0 

0 100.0% 90% 

CMChild Psychology 


AE A&E 


GA Gastroenterology 100% 

0 

0 

11 

0 

0 

0 

0 

0 

0 100.0% 90% 

HP Hepatology 100% 22 

0 

0 100.0% 90% 

ed Endoscopy 0 

0 

0 

90% 

CO Colorectal Surgery 92% 91 

10 

7 

90.1% 90% 

UG Upper GI Surgery 79% 97 

30 

22 76.4% 90% 

ED Endoscopy 

GS General Surgery 99% 

0 

59 

0 

34 

0 

18 63.4% 90% 

UR Urology 92% 114 

26 

23 81.4% 90% 

NF Nephrology 100% 17 

0 

0 100.0% 90% 


RT Clinical Oncology 100% 451 

1 

1 

99.8% 90% 

MOMedical Oncology 100% 24 

0 

0 100.0% 90% 

PT Palliative Medicine 0 

0 

0 

90% 

HMClin Haematology 4 

0 

0 100.0% 90% 

CI Clin Immunology 0 

0 

0 

90% 


ET ENT 94% 128 

7 

7 

94.8% 90% 

AU Audiological Medicine 0 

0 

0 

90% 

PL Plastic Surgery 94% 273 

34 

30 88.9% 90% 

OS Oral Surgery 96% 103 

1 

0 

99.0% 90% 

OD Orthodontics 100% 13 

0 

0 100.0% 90% 

RD Rest Dent 100% 5 

0 

0 100.0% 90% 

DMDermatology 96% 125 

21 

15 85.6% 90% 

Imaging 

NR Neuroradiology 100% 0 

0 

0 

90% 

NMNuclear Medicine 0 

0 

0 

90% 

RA Radiology 100% 1 

0 

0 100.0% 90% 


DI Diabetic Medicine 0 

0 

0 

90% 

EN Endocrinology 2 

0 

0 100.0% 90% 

GMGeneral Medicine 100% 0 

0 

0 

90% 

HE HCE 1 

0 

0 100.0% 90% 

TM Thoracic Medicine 100% 3 

0 

0 100.0% 90% 

Neurosciences 

NS Neurosurgery 85% 79 

8 

7 

90.8% 90% 

NL Neurology 100% 21 

1 

1 

95.5% 90% 

NP Neurophysiology 0 

0 

0 

90% 

Ophthalmology 

OP Ophthalmology 93% 433 

31 

17 93.3% 90% 

Pathology & SDU 

CC Clin Chemistry 0 

0 

0 

90% 

NY Neuropathology 0 

0 

0 

90% 


OR Orthopaedics 92% 349 

9 

7 

97.5% 90% 

TR Trauma 0 

0 

0 

90% 

RH Rheumatology 100% 11 

0 

0 100.0% 90% 


GY Gynaecology 88% 108 

34 

30 76.1% 90% 

BS Breast Surgery 100% 47 

1 

0 

97.9% 90% 

PA PAC 100% 91 

0 

0 100.0% 90% 

OB Obstetrics 0 

0 

0 

90% 

GU GUM 0 

0 

0 

90% 

NE Neonatology 1 

0 

0 100.0% 90% 

TT TOTAL 94% 2946 253 

187 92.1% 90% 

Page 18

11 


RTT for Non Admitted Patients 


February 2011 

Target = To Achieve Max 18 wks wait for 95% of Non Admitted 

Patients on RTT Pathways by December 2008 


Treated within 18 weeks 7305 6511 6196 6889 7125 6699 7319 6622 7274 5440 6267 5909 

Treated after 18 weeks 181 189 136 196 238 235 212 233 254 159 158 128 

% Treated within 18 weeks 97.6% 97.2% 97.2% 97.2% 97.2% 97.2% 97.2% 97.2% 97.2% 97.2% 97.5% 97.9% 

DOH Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 

100% 

98% 

96% 

94% 

92% 

90% 

88% 

86% 

84% 

% Non Admitted Patients Treated within 18 weeks 

Apr-08 

May-08 

Jun-08 

Jul-08 

Aug-08 

Sep-08 

Oct-08 

Nov-08 

Dec-08 

Jan-09 

Feb-09 

Mar-09 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

SPECIALTY 

Current Month 

Mar-10 

Of which are 

NHS 

Target 

Constitution 

Atts < 18 wks Atts 18+ wks Breaches % < 18 wks 


AN Chronic Pain 95% 69 8 5 

89.6% 95% 

IC Intensive Care 0 0 

0 

95% 


CS Cardiac Surgery 100% 4 0 0 100.0% 95% 

CD Cardiology 97% 153 0 0 100.0% 95% 

TS Thoracic Surgery 100% 7 0 0 100.0% 95% 

VS Vascular Surgery 100% 14 0 0 100.0% 95% 


PD Paediatrics 99% 194 1 1 

99.5% 95% 

CMChild Psychology #N/A 1 0 0 100.0% 95% 


AE A&E 0 0 

0 

95% 


GA Gastroenterology 97% 143 7 7 

95.3% 95% 

HP Hepatology 95% 28 0 0 100.0% 95% 

ed Endoscopy 0 0 

0 

95% 

CO Colorectal Surgery 91% 179 14 9 

92.7% 95% 

UG Upper GI Surgery 98% 60 1 1 

98.4% 95% 

ED Endoscopy 0 0 

0 

95% 

GS General Surgery 97% 48 5 5 

90.6% 95% 

UR Urology 95% 135 2 0 

98.5% 95% 

NF Nephrology 100% 32 0 0 100.0% 95% 


RT Clinical Oncology 100% 16 0 0 100.0% 95% 

MOMedical Oncology 100% 1 0 0 100.0% 95% 

PT Palliative Medicine 100% 10 0 0 100.0% 95% 

HMClin Haematology 99% 59 1 0 

98.3% 95% 

CI Clin Immunology 90% 49 4 2 

92.5% 95% 


ET ENT 98% 414 9 7 

97.9% 95% 

AU Audiological Medicine 0 0 

0 

95% 

PL Plastic Surgery 99% 195 9 3 

95.6% 95% 

OS Oral Surgery 98% 366 2 2 

99.5% 95% 

OD Orthodontics 100% 83 0 0 100.0% 95% 

RD Rest Dent 91% 38 2 1 

95.0% 95% 

DMDermatology 98% 257 3 1 

98.8% 95% 

Imaging 

NR Neuroradiology 1 0 0 100.0% 95% 

NMNuclear Medicine 100% 4 0 0 100.0% 95% 

RA Radiology 0 0 

0 

95% 


DI Diabetic Medicine 100% 20 0 0 100.0% 95% 

EN Endocrinology 95% 37 0 0 100.0% 95% 

GMGeneral Medicine 100% 9 0 0 100.0% 95% 

HE HCE 100% 19 2 2 

90.5% 95% 

TM Thoracic Medicine 99% 128 0 0 100.0% 95% 

Neurosciences 

NS Neurosurgery 95% 162 12 10 93.1% 95% 

NL Neurology 97% 159 11 9 

93.5% 95% 

NX Neuropsychology 0 0 

0 

95% 

NP Neurophysiology 0 0 

0 

95% 

Ophthalmology 

OP Ophthalmology 96% 396 6 3 

98.5% 95% 


CC Clin Chemistry 100% 6 0 0 100.0% 95% 

NY Neuropathology 1 0 0 100.0% 95% 


OR Orthopaedics 96% 461 14 13 97.1% 95% 

TR Trauma 0 0 

0 

95% 

RH Rheumatology 99% 128 4 4 

97.0% 95% 


GY Gynaecology 98% 330 11 4 

96.8% 95% 

BS Breast Surgery 100% 174 0 0 100.0% 95% 

PA PAC 100% 37 0 0 100.0% 95% 

OB Obstetrics 0 0 

0 

95% 

GU GUM 100% 1171 0 0 100.0% 95% 

NE Neonatology 100% 63 0 0 100.0% 95% 

TT TOTAL 97.6% 5909 128 89 97.9% 95% 

Page 19

11 


Admitted & Non-Admitted Clock Stops - Reportable Specialties 


February 2011 

Target = 90% of Admitted Patients & 95% of 

Non Admitted Patients. 

Admitted Pathways 

Treated & Not Treated Clock Stops 

First Treatment Subsequent Treatment Total Clock 

Stops Within 

Unknown Within Breach Within Breach Target (DoH) 

General Surgery 0 200 56 151 20 82.2% 

Urology 0 55 19 59 7 81.4% 

Trauma & Orthopaedics 0 156 3 193 6 97.5% 

Ear, Nose & Throat (ENT) 0 52 2 76 5 94.8% 

Ophthalmology 0 155 19 278 12 93.3% 

Oral Surgery 0 79 1 24 0 99.0% 

Neurosurgery 0 39 5 40 3 90.8% 

Plastic Surgery 0 193 26 80 8 88.9% 

Cardiothoracic Surgery 0 27 1 69 1 98.0% 

General Medicine 0 0 0 0 0 

Gastroenterology 0 2 0 9 0 100.0% 

Cardiology 0 3 0 73 2 97.4% 

Dermatology 0 93 17 32 4 85.6% 

Thoracic Medicine 0 1 0 2 0 100.0% 

Neurology 0 7 1 14 0 95.5% 

Rheumatology 0 1 0 10 0 100.0% 

Geriatric Medicine 0 1 0 0 0 100.0% 

Gynaecology 0 162 17 37 17 85.4% 

Other 0 33 1 540 0 99.8% 

Total 0 1259 168 1687 85 92.1% 

Non-Admitted Pathways 

Treated & Not Treated Clock Stops 

First Treatment Subsequent Treatment Total Clock 

Stops Within 

Unknown Within Breach Within Breach Target (DoH) 

General Surgery 0 475 20 1 0 96.0% 

Urology 0 135 2 0 0 98.5% 

Trauma & Orthopaedics 0 461 14 0 0 97.1% 

Ear, Nose & Throat (ENT) 0 414 9 0 0 97.9% 

Ophthalmology 0 393 5 3 1 98.5% 

Oral Surgery 0 342 2 24 0 99.5% 

Neurosurgery 0 160 12 2 0 93.1% 

Plastic Surgery 0 194 9 1 0 95.6% 

Cardiothoracic Surgery 0 11 0 0 0 100.0% 

General Medicine 0 9 0 0 0 100.0% 

Gastroenterology 0 143 7 0 0 95.3% 

Cardiology 0 153 0 0 0 100.0% 

Dermatology 0 255 3 2 0 98.8% 

Thoracic Medicine 0 128 0 0 0 100.0% 

Neurology 0 160 11 0 0 93.6% 

Rheumatology 0 128 4 0 0 97.0% 

Geriatric Medicine 0 19 2 0 0 90.5% 

Gynaecology 0 386 11 1 0 97.2% 

Other 0 1905 16 4 0 99.2% 

Total 0 5871 127 38 1 97.9% 

Page 20

11 


RTT Backlogs 


February 2011 Aspiration to Clear backlogs by end July 2010 in order to be 100% 

compliant with NHS Constitution 

Admitted Backlog i.e. Patients on IP/DC Waiting List for Treatment who have already breached 18 weeks 


Admitted backlog size 298 277 293 307 304 400 512 618 715 665 580 

Plan 300 296 292 288 284 280 276 272 268 264 260 250 

800 

700 

600 

500 

400 

300 

200 

100 

0 

Admitted Pathway Backlog 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

Actual 

Plan 

Non Admitted Backlog i.e. Patients on Follow Up Waiting List for Treatment who have already breached 18 weeks 


Non Admitted backlog 

size 

845 601 395 307 345 336 332 186 220 255 269 

Plan 850 600 300 200 100 50 50 50 50 50 50 50 

Non Admitted Pathway Backlog 

900 

800 

700 

600 

500 

400 

300 

200 

100 

0 

Apr-10 

May- 

10 

Jun-10 

Jul-10 

Aug- 

10 

Sep- 

10 

Oct-10 

Nov- 

10 

Dec- 

10 

Jan-11 

Feb-11 

Mar-11 

Actual 

Plan 

No DTT Backlog i.e. Patients on an incomplete pathway not on a treatment WL who have already breached 18 weeks 


No DTT backlog size 750 604 541 699 452 449 368 296 340 323 301 

Plan 750 600 500 400 300 200 100 100 100 100 100 100 

900 

800 

700 

600 

500 

400 

300 

200 

100 

0 

DTT (Decision To Treat) Backlog 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

Actual 

Plan 

Page 21

11 

Referral To Treatment (RTT) Times 

Median Waits 


February 2011 

Admitted Pathways - Median Waits (weeks) 


PHNT 7.2 6.7 6.9 6.8 7.6 7.8 8.2 8.1 7.4 9.2 9.0 

NHS South West 7.5 8.5 7.6 7.7 7.8 7.9 8.1 7.8 7.2 8.5 

DoH Threshold 11.1 11.1 11.1 11.1 11.1 11.1 11.1 11.1 11.1 11.1 11.1 11.1 

Weeks 

12 

10 

8 

6 

4 

2 

0 

Admitted Pathways - Median Waits 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

PHNT NHS South West DoH Threshold 

Non Admitted Pathways - Median Waits (weeks) 


PHNT 2.5 3.5 3.5 3.7 3.7 4.0 3.6 3.8 3.1 4.0 2.5 

NHS South West 4.5 4.5 4.2 4.2 4.4 4.6 3.6 4.3 4.0 4.9 

DoH Threshold 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 

Non Admitted Pathways - Median waits 

Weeks 

7 

6 

5 

4 

3 

2 

1 

0 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 


Incomplete Pathways - Median Waits (weeks) as at Last day of Month 


PHNT 5.5 5.5 5.3 5.4 5.8 5.8 5.7 5.4 6.0 6.3 4.7 

NHS South West 5.5 5.5 5.5 6.0 5.8 5.8 5.7 5.7 6.7 6.5 

DoH Threshold 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 

Weeks 

8 

7 

6 

5 

4 

3 

2 

1 

0 

Incomplete Pathways - Median waits 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 


Page 22

11 


RTT for Audiology Direct Access 


February 2011 

Target = To Achieve Max 18 wks wait for 95% of Direct Access 

Audiology Referrals 


Treated within 18 weeks 346 419 443 473 405 423 459 509 372 419 411 

Treated after 18 weeks 16 15 21 24 25 22 12 13 11 16 15 

% Treated within 18 

weeks 

95.6% 96.5% 95.5% 95.2% 94.2% 95.1% 97.5% 97.5% 97.1% 96.3% 96.5% 

Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 

100% 

% Patients Treated within 18 weeks 

98% 

96% 

94% 

92% 

90% 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

% Within 18 wks Target 

Data Completeness Indicator 


Actual 95.3% 118% 109% 116% 105% 105% 115% 120% 98% 116% 114% 

Tolerance Lower Limit 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 

Tolerance Upper Limit 120% 120% 120% 120% 120% 120% 120% 120% 120% 120% 120% 120% 

125.0% 

115.0% 

105.0% 

95.0% 

85.0% 

75.0% 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

Actual Tolerance Lower Limit Tolerance Upper Limit 

Page 23

11 

Referral To Treatment (RTT) Times - IP/DC WL Patients 

No. & % Admitted Patients Waiting Over 14 Weeks With No TCI 


February 2011 


Total > 14 Weeks 280 291 407 365 576 756 792 866 1035 744 609 

Percentage > 14 Weeks 8.1% 8.0% 10.0% 8.9% 13.4% 16.3% 17.3% 18.2% 21.0% 18.1% 15.4% 

1200 

25.0% 

1000 

20.0% 

800 

600 

400 

15.0% 

10.0% 

200 

5.0% 

0 

0.0% 

Apr-2010 

May-2010 

Jun-2010 

Jul-2010 

Aug-2010 

Sep-2010 

Oct-2010 

Nov-2010 

Dec-2010 

Jan-2011 

Feb-2011 

Mar-2011 

Total > 14 Weeks 

% > 14 Weeks 

SPECIALTY 

Current Month 

Total > 14 

Weeks 

with no 

TCI 

% > 14 

weeks 

with no 

TCI 


ANChronic Pain 

3 33.3% 


CSCardiac Surgery 

10 7.5% 

CDCardiology 

13 18.6% 

TS Thoracic Surgery 

0 

VS Vascular Surgery 

0 


PDPaediatrics 

0 

Gastroenterology, Surgery & Renal 

GAGastroenterology 

1 100.0% 

HPHepatology 

0 

ed Endoscopy 

0 

COColorectal Surgery 

10 6.4% 

UGUpper GI Surgery 

80 22.6% 

EDEndoscopy 

0 

GSGeneral Surgery 

96 37.8% 

URUrology 

35 19.7% 

NF Nephrology 

1 33.3% 


RT Clinical Oncology 

0 

MOMedical Oncology 

0 

HMClin Haematology 

0 

CI Clin Immunology 

1 50.0% 


ET ENT 

13 4.7% 

AUAudiological Medicine 

0 

PL Plastic Surgery 

109 22.9% 

OSOral Surgery 

5 4.6% 

ODOrthodontics 

0 

RDRest Dent 

0 

DMDermatology 

22 18.5% 

Imaging 

NRNeuroradiology 

0 

RARadiology 

1 33.3% 


DI Diabetic Medicine 

0 

ENEndocrinology 

0 

GMGeneral Medicine 

0 

HEHCE 

0 

TMThoracic Medicine 

0 

Neurosciences 

NSNeurosurgery 

47 29.7% 

NL Neurology 

0 

Ophthalmology 

OPOphthalmology 

34 4.8% 


NYNeuropathology 

0 


OROrthopaedics 

41 8.0% 

TR Trauma 

0 

RHRheumatology 

0 

Reproductive, Womens & Neonatal 

GYGynaecology 

87 31.5% 

BS Breast Surgery 

0 

PA PAC 

0 

NENeonatology 

0 

TT TOTAL 

609 15.4% 

Page 24

RAPID ACCESS CHEST PAIN SERVICE 


February 2011 

Target : At least 98% of patients referred by their 

GP to a rapid access chest pain clinic must be 

seen within 2 weeks 

Percentage Seen Within 2 Weeks 

Current Month 

100.0% 

Year To Date 

100.0% 

Target 

100% 

% Within 2 Wks 

100% 

90% 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

10% 

0% 

120 

100 

80 

60 

40 

20 

0 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

No. of referrals 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

No. of Referrals 

% Seen Within 2 Wks 

ANGIOGRAM WAITING TIMES 


February 2011 

Internal target to achieve Max Wait of 4 weeks by 

end Sep 2010. 

2010/11 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 

No waiting 0-1 wks 57 2 35 35 11 42 24 32 20 21 24 

No. waiting 2-5 wks 65 62 49 77 47 26 50 38 47 19 33 

No. waiting 6+ wks 2 

Target No. of 6+ weeks 0 0 0 0 0 0 0 0 0 0 0 0 

140 

Numbers On Angiogram Waiting List Over Time 

120 

100 

80 

60 

40 

20 

0 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

No waiting 0-1 wks No. waiting 2-5 wks No. waiting 6+ wks 

REVASCULARISATION WAITING TIMES 


February 2011 

Inpatient Stage of treatment wait : for information 


Total 0-6 wks 111 94 111 87 68 111 120 116 117 107 124 

Total 7-10 wks 40 41 50 55 45 25 30 41 40 58 42 

Total 11+ wks 1 22 33 40 54 44 17 11 33 34 39 

250 

Numbers On Revascularisations on Waiting List Over Time 

200 

150 

100 

50 

0 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

Total 0-6 wks Total 7-10 wks Total 11+ wks 

Page 25

MRI WAITING TIMES 


February 2011 Internal target to achieve Max Wait of 4 weeks by end Sep 10. 


No. waiting 0-1 wks 402 427 506 483 453 570 454 520 327 527 515 

No. waiting 2-5 wks 251 232 203 260 332 390 645 658 787 614 642 

No. waiting 6-12 wks 4 1 5 5 2 

No. waiting 13+ wks 

1400 

1200 

1000 

800 

600 

400 

200 

0 

Numbers On MRI Waiting List Over Time 

Apr-08 

Jun-08 

Aug-08 

Oct-08 

Dec-08 

Feb-09 

Apr-09 

Jun-09 

Aug-09 

Oct-09 

Dec-09 

Feb-10 

Apr-10 

Jun-10 

Aug-10 

Oct-10 

Dec-10 

Feb-11 

No. waiting 0-1 wks No. waiting 2-5 wks No. waiting 6-12 wks No. waiting 13+ wks 

CT WAITING TIMES 




No. waiting 0-1 wks 315 405 493 415 367 418 440 434 310 480 450 

No. waiting 2-5 wks 237 323 423 357 251 279 292 313 485 263 260 

No. waiting 6-12 wks 5 5 5 46 32 49 50 


1000 

Numbers On CT Waiting List Over Time 

800 

600 

400 

200 

0 

Apr-08 

Jun-08 

Aug-08 

Oct-08 

Dec-08 

Feb-09 

Apr-09 

Jun-09 

Aug-09 

Oct-09 

Dec-09 

Feb-10 

Apr-10 

Jun-10 

Aug-10 

Oct-10 

Dec-10 

Feb-11 


OTHER IMAGING WAITING TIMES 

Includes Non Obstetric Ultrasound, Barium Enemas, Nuclear Medicine, X-Ray, IVU, Flurography, Symphomatic Mammography 




No. waiting 0-1 wks 1609 1542 1508 1405 1304 1520 1311 1556 1030 1544 1605 

No. waiting 2-5 wks 839 862 784 724 786 722 960 707 937 472 603 

No. waiting 6-12 wks 1 4 1 


3500 

3000 

Numbers On Other Imaging Waiting List Over Time 

2500 

2000 

1500 

1000 

500 

0 

Apr-08 

May-08 

Jun-08 

Jul-08 

Aug-08 

Sep-08 

Oct-08 

Nov-08 

Dec-08 

Jan-09 

Feb-09 

Mar-09 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 


Page 26

DIAGNOSTIC NEUROPHYSIOLOGY WAITING TIMES 


February 2011 

Internal target to achieve Max Wait of 4 weeks by end Sep 10. 


No. waiting 0-1 wks 205 211 200 203 135 198 218 240 134 163 128 

No. waiting 2-5 wks 206 251 224 202 200 160 176 192 302 209 226 

No. waiting 6-12 wks 2 4 1 3 2 14 8 2 

No. waiting 13+ wks 1 

500 

400 

300 

200 

100 

0 

Numbers On Neurophysiology Waiting List Over Time 

Apr-08 

Jun-08 

Aug-08 

Oct-08 

Dec-08 

Feb-09 

Apr-09 

Jun-09 

Aug-09 

Oct-09 

Dec-09 

Feb-10 

Apr-10 

Jun-10 

Aug-10 

Oct-10 

Dec-10 

Feb-11 


DIAGNOSTIC CARDIOLOGY WAITING TIMES (excludes Angiograms) 


February 2011 

Internal target to achieve Max Wait of 4 weeks by end Sep 10. 


No. waiting 0-1 wks 269 262 257 252 229 242 176 207 180 312 228 

No. waiting 2-5 wks 107 178 189 201 224 204 194 181 239 160 214 

No. waiting 6-12 wks 


600 

Numbers On Diagnostic Cardiology Waiting List Over Time 

500 

400 

300 

200 

100 

0 

Apr-08 

Jun-08 

Aug-08 

Oct-08 

Dec-08 

Feb-09 

Apr-09 

Jun-09 

Aug-09 

Oct-09 

Dec-09 

Feb-10 

Apr-10 

Jun-10 

Aug-10 

Oct-10 

Dec-10 

Feb-11 


AUDIOLOGY WAITING TIMES 


February 2011 

Internal target to achieve Max Wait of 4 weeks by end 

Sep 10. 


No. waiting 0-1 wks 378 319 339 365 293 284 285 266 172 263 288 

No. waiting 2-5 wks 213 193 171 179 210 179 215 182 251 181 202 

No. waiting 6-12 wks 1 5 2 7 3 

No. waiting 13+ wks 1 1 

800 

700 

600 

500 

400 

300 

200 

100 

0 

Numbers On Audiology Waiting List Over Time 

Apr-08 

Jun-08 

Aug-08 

Oct-08 

Dec-08 

Feb-09 

Apr-09 

Jun-09 

Aug-09 

Oct-09 

Dec-09 

Feb-10 

Apr-10 

Jun-10 

Aug-10 

Oct-10 

Dec-10 

Feb-11 


Page 27

URODYNAMICS WAITING TIMES 




No. waiting 0-1 wks 26 19 19 21 14 24 21 26 15 19 22 

No. waiting 2-5 wks 31 7 4 6 5 8 5 9 35 17 3 

No. waiting 6-12 wks 3 2 3 


90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Numbers On Urodynamics Waiting List Over Time 

Apr-08 

May-08 

Jun-08 

Jul-08 

Aug-08 

Sep-08 

Oct-08 

Nov-08 

Dec-08 

Jan-09 

Feb-09 

Mar-09 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 


ALL OTHER DIAGNOSTICS WAITING TIMES 

Includes Endoscopies, Other Scopes, Respiratory Physiology, Ophthalmics, GI Physiology & Miscellaneous Others 




No. waiting 0-1 wks 767 756 873 730 584 722 674 662 455 637 766 

No. waiting 2-5 wks 696 793 669 590 706 595 564 517 672 471 577 

No. waiting 6-12 wks 3 8 54 114 81 43 16 17 32 181 76 

No. waiting 13+ wks 2 1 1 32 29 17 3 4 4 2 2 

1800 

1600 

1400 

1200 

1000 

800 

600 

400 

200 

0 

Numbers On Other Diagnostic Waiting List Over Time 

Apr-08 

May-08 

Jun-08 

Jul-08 

Aug-08 

Sep-08 

Oct-08 

Nov-08 

Dec-08 

Jan-09 

Feb-09 

Mar-09 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 


ENDOSCOPY SURVEILLANCE WAITING TIMES 

Planned Follow-Up Patients Who Have Passed Their Appointment By Date 


February 2011 


No. waiting 0-1 wks 74 91 57 74 42 71 63 80 56 92 76 

No. waiting 2-5 wks 61 81 65 65 81 51 79 78 84 124 117 

No. waiting 6-12 wks 44 49 73 29 41 58 36 20 38 53 141 

No. waiting 13+ wks 111 97 77 68 62 75 55 15 14 38 5 

Maximum Wait (Weeks) 43 47 52 56 52 47 30 30 17 21 21 

400 

350 

300 

250 

200 

150 

100 

50 

0 

Numbers On Other Endoscopy Surveillance List Over Time 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 


Page 28

# 

Inpatient & Day Case Waiting List : Planned Patients 


February 2011 

No. on List 

1600 

1500 

1400 

1300 

1200 

1100 

1000 

Total Number on Planned Waiting List 

Apr-08 

May-08 

Jun-08 

Jul-08 

Aug-08 

Sep-08 

Oct-08 

Nov-08 

Dec-08 

Jan-09 

Feb-09 

Mar-09 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

25% 

20% 

% on Planned Waiting List who have Passed Their Treat By Date 

No. on List 

15% 

10% 

5% 

0% 

Apr-08 

May-08 

Jun-08 

Jul-08 

Aug-08 

Sep-08 

Oct-08 

Nov-08 

Dec-08 

Jan-09 

Feb-09 

Mar-09 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

No. Waiting Longer 

Than "Treat By Date" 

No. with no "Treat By 

Date" recorded on 

iPM 

SPECIALTY 

Total Number on List 


Chronic Pain 17 5 0 


Cardiac Surgery 0 0 0 

Cardiology 34 10 0 

Thoracic Surgery 8 0 0 

Vascular Surgery 8 0 0 


Paediatrics 1 1 0 


Gastroenterology 21 14 0 

Hepatology 9 3 0 

Colorectal Surgery 17 1 0 

Upper GI Surgery 3 0 0 

Endoscopy 0 0 0 

General Surgery 2 2 0 

Urology 628 34 0 

Nephrology 69 8 2 


Clinical Oncology 45 14 0 

Medical Oncology 2 1 0 

Clin Haematology 45 22 0 

Clin Immunology 2 2 0 


ENT 100 24 1 

Plastic Surgery 53 11 0 

Oral Surgery 2 0 0 

Orthodontics 0 0 0 

Rest Dent 0 0 0 

Dermatology 15 4 0 

Imaging 

Neuroradiology 0 0 0 

Radiology 0 0 0 


Diabetic Medicine 0 0 0 

Endocrinology 14 4 1 

General Medicine 3 0 0 

HCE 0 0 0 

Thoracic Medicine 8 6 0 

Neurosciences 

Neurosurgery 11 2 0 

Neurology 26 2 0 

Neurophysiology 0 0 0 

Ophthalmology 

Ophthalmology 23 8 8 


Neuropathology 0 0 0 


Orthopaedics 28 3 0 

Rheumatology 37 11 0 


Gynaecology 1 1 0 

Breast Surgery 0 0 0 

PAC 0 0 0 

Neonatology 0 0 0 

TOTAL 1232 193 12 

Page 29

# 

Inpatient & Day Case Waiting List : Suspended Patients 


No. on List 

800 

700 

600 

500 

400 

300 

200 

100 

0 

Total Number of Patients Currently Suspended 

Apr-08 

May-08 

Jun-08 

Jul-08 

Aug-08 

Sep-08 

Oct-08 

Nov-08 

Dec-08 

Jan-09 

Feb-09 

Mar-09 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

Total Number on 

Active Waiting List 

Total Number 

Suspended 

% Suspended of Total 

WL 

SPECIALTY 


Chronic Pain 17 0 0.0% 


Cardiac Surgery 235 1 0.4% 

Cardiology 249 5 2.0% 

Thoracic Surgery 21 2 8.7% 

Vascular Surgery 118 3 2.5% 


Paediatrics 17 0 0.0% 


Gastroenterology 21 0 0.0% 

Hepatology 20 1 4.8% 

Colorectal Surgery 248 12 4.6% 

Upper GI Surgery 487 18 3.6% 

Endoscopy 0 0 0.0% 

General Surgery 363 26 6.7% 

Urology 304 19 5.9% 

Nephrology 31 0 0.0% 


Clinical Oncology 255 0 0.0% 

Medical Oncology 19 0 0.0% 

Palliative Medicine 0 0 0.0% 

Clin Haematology 5 0 0.0% 

Clin Immunology 2 0 0.0% 


ENT 420 29 6.5% 

Plastic Surgery 0 0 0.0% 

Plastic Surgery - Hands 691 43 5.9% 

Oral Surgery 222 24 9.8% 

Orthodontics 18 2 10.0% 

Rest Dent 20 0 0.0% 

Dermatology 205 12 5.5% 

Imaging 

Neuroradiology 1 0 0.0% 

Radiology 4 0 0.0% 


Diabetic Medicine 0 0 0.0% 

Endocrinology 19 0 0.0% 

General Medicine 0 0 0.0% 

HCE 0 0 0.0% 

Thoracic Medicine 26 0 0.0% 

Neurosciences 

Neurosurgery 237 3 1.3% 

Neurology 73 1 1.4% 

Neurophysiology 0 0 0.0% 

Ophthalmology 

Ophthalmology 1056 35 3.2% 


Neuropathology 4 0 0.0% 


Orthopaedics 889 79 8.2% 

Trauma 0 0 0.0% 

Rheumatology 11 0 0.0% 


Gynaecology 415 65 13.5% 

Gynaecological Oncology 14 0 0.0% 

Breast Surgery 39 4 9.3% 

PAC 11 0 0.0% 

Neonatology 0 0 0.0% 

TOTAL 6787 384 5.4% 

Page 30

# 

CANCELLED OPERATIONS - Number cancelled on the day of admission or later for non clinical reasons 


February 2011 

Cancelled on Day 

of Operation 

and/or Admission 

As % of total 

Elective FFCEs 

Feb-11 YTD Feb-11 YTD 

Trust Total 69 848 1.5% 1.6% 

No of Cancelled 

Operations 

200 

150 

100 

50 

0 

No. of Operations Cancelled On Day of Operation Or Admission 

4.0% 

3.5% 

3.0% 

2.5% 

2.0% 

1.5% 

1.0% 

0.5% 

0.0% 

Apr-08 

Jun-08 

Aug-08 

Oct-08 

Dec-08 

Feb-09 

Apr-09 

Jun-09 

Aug-09 

Oct-09 

Dec-09 

Feb-10 

Apr-10 

Jun-10 

Aug-10 

Oct-10 

Dec-10 

Cancelled / Total of 

Elective FFCEs (%) 

Feb-11 

No of Cancelled Operations % Cancelled Planned Trajectory for % cancelled 

Reasons for Cancellations By Month Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 YTD 

Anaesthetist Sick/Unavailable 1 1 1 2 1 6 

Anaesthetist On Leave 3 1 4 

Surgeon Sick/Unavailable 4 5 7 2 7 3 22 4 24 78 

Surgeon On Leave 

No General Bed Available 17 24 20 15 11 1 3 10 12 20 5 138 

No Critical Care Bed Available Post 

Operatively 6 3 1 2 1 4 2 6 7 1 33 

Equipment Missing/Failure 12 5 3 2 3 4 6 14 5 2 56 

No Space On Theatre List/Emerg Took 

Priority 13 12 11 17 9 23 18 20 10 10 12 155 

Theatre List Overran 24 21 23 19 31 28 11 38 21 31 13 260 

Lack Of Theatre Staff 1 4 7 2 1 8 3 7 8 7 5 53 

Other 12 9 6 5 2 3 6 7 5 4 6 65 

Total 86 82 79 68 58 69 58 93 98 88 69 848 

Reasons for Cancellations By 

Directorate Year To Date 

Anaesthestics & 

Theatres 



Gastro, Surgery & 

Renal 

Haematology & 

Oncology 

Head & Neck 

Surgery 

Imaging 


Neurosciences 

Ophthalmology 

Orthopaedics & 

Rheumatology 

Reproductive, 

Womens & Neonatal 

Services 

TOTAL 

Anaesthetist Sick/Unavailable 2 1 2 1 6 

Anaesthetist On Leave 3 1 4 

Surgeon Sick/Unavailable 6 10 8 20 6 15 10 3 78 

Surgeon On Leave 

No General Bed Available 18 1 18 18 2 5 46 18 12 138 

No Critical Care Bed Available Post 

Operatively 26 1 1 2 2 1 33 

Equipment Missing/Failure 16 13 9 1 1 2 2 9 3 56 

No Space On Theatre List/Emerg Took 

Priority 37 15 30 2 35 1 25 10 155 

Theatre List Overran 26 55 65 21 5 57 31 260 

Lack Of Theatre Staff 1 31 6 2 5 1 7 53 

Other 1 7 18 1 16 2 10 3 3 4 65 

Total 8 174 1 137 2 161 5 10 127 27 132 64 848 

# 

CANCELLED OPERATIONS - Number who breach the 28 day standard on offering another binding date 


February 2011 

Breaches of the 28 Day Standard 

2009/10 Current Month 

2010/11 Year To 

Date 

No. % No. % No. % 

155 14.1% 0 0.0% 

27 3.2% 

No. of breaches 

30 

25 

20 

15 

10 

5 

Breaches of the 28 Day Standard 

35.0% 

30.0% 

25.0% 

20.0% 

15.0% 

10.0% 

5.0% 

% Breaches 

0 

0.0% 

Apr-08 

Jun-08 

Aug-08 

Oct-08 

Dec-08 

Feb-09 

Apr-09 

Jun-09 

Aug-09 

Oct-09 

Dec-09 

Feb-10 

Apr-10 

Jun-10 

Aug-10 

Oct-10 

Dec-10 

Feb-11 

No. of Breaches 

% Breaches 

Page 31

CANCELLED OPERATIONS BY SPECIALTY 


Feb-11 

No. of 

Cancelled 

Operations 

No. of 

FFCEs 

Year To Date Figures 

% of 

Patients 

Cancelled 

No. 

breaching 28 

day rebooking 

standard 

% of Canc 

Ops 

Breaching 28 

days 

No. of 

Cancelled 

Ops With 

Previous 

Cancelled 

Op 

SPECIALTY 


Chronic Pain 8 444 1.8% 0 0.0% 0 

Intensive Care 0 0 0.0% 0 0.0% 0 


Cardiac Surgery 94 787 11.9% 1 1.1% 3 

Cardiology 27 2225 1.2% 1 3.7% 1 

Thoracic Surgery 9 555 1.6% 0 0.0% 0 

Vascular Surgery 44 805 5.5% 1 2.3% 1 


Paediatrics 1 533 0.2% 0 0.0% 0 


A&E 0 0 0.0% 0 0.0% 0 

Acute Medicine 0 17 0.0% 0 0.0% 0 


Gastroenterology 4 640 0.6% 1 25.0% 0 

Hepatology 7 527 1.3% 1 14.3% 0 

Colorectal Surgery 23 1437 1.6% 0 0.0% 0 

Upper GI Surgery 35 1351 2.6% 3 8.6% 2 

Endoscopy 0 8 0.0% 0 0.0% 0 

General Surgery 22 1295 1.7% 1 4.5% 0 

Urology 42 4422 0.9% 3 7.1% 0 

Nephrology 4 813 0.5% 0 0.0% 0 


Clinical Oncology 1 5787 0.0% 0 0.0% 0 

Medical Oncology 0 355 0.0% 0 0.0% 0 

Palliative Medicine 0 5 0.0% 0 0.0% 0 

Clin Haematology 1 2339 0.0% 0 0.0% 0 

Clin Immunology 0 323 0.0% 0 0.0% 0 


ENT 54 2169 2.5% 2 3.7% 0 

Audiological Medicine 0 0 0.0% 0 0.0% 0 

Plastic Surgery 54 3804 1.4% 0 0.0% 1 

Maxillo-Facial Surgery 27 1374 2.0% 0 0.0% 0 

Orthodontics 1 91 1.1% 0 0.0% 0 

Rest Dent 0 67 0.0% 0 0.0% 0 

Dermatology 25 2106 1.2% 0 0.0% 0 

Imaging 

Neuroradiology 5 45 11.1% 0 0.0% 0 

Nuclear Medicine 0 0 0.0% 0 0.0% 0 

Radiology 0 12 0.0% 0 0.0% 0 


Diabetic Medicine 0 292 0.0% 0 0.0% 0 

Endocrinology 3 57 5.3% 1 33.3% 1 

General Medicine 0 0 0.0% 0 0.0% 0 

HCE 0 46 0.0% 0 0.0% 0 

Thoracic Medicine 7 540 1.3% 0 0.0% 0 

Neurosciences 

Neurosurgery 108 1481 7.3% 8 7.4% 6 

Neurology 19 672 2.8% 2 10.5% 0 

Neurophysiology 0 6 0.0% 0 0.0% 0 

Ophthalmology 

Ophthalmology 27 5373 0.5% 1 3.7% 0 


Clin Chemistry 0 0 0.0% 0 0.0% 0 

Neuropathology 0 75 0.0% 0 0.0% 0 


Orthopaedics 129 5100 2.5% 1 0.8% 2 

Trauma 0 0 0.0% 0 0.0% 0 

Rheumatology 3 518 0.6% 0 0.0% 0 


Gynaecology 51 1967 2.6% 0 0.0% 1 

Gynaecology Oncology 5 300 1.7% 0 0.0% 0 

Breast Surgery 8 677 1.2% 0 0.0% 0 

PAC 0 1043 0.0% 0 0.0% 0 

Obstetrics 0 0 0.0% 0 0.0% 0 

GUM 0 0 0.0% 0 0.0% 0 

Neonatology 0 27 0.0% 0 0.0% 0 

TOTAL 848 52510 1.6% 27 3.2% 18 

Page 32

9 

Choose And Book Slot unavailability 

Latest Data up to 

Week Ending 23/01/2011 

PHNT Versus Regional Acute Providers Average 

Last 13 Weeks 

actual 

31-Oct-10 

07-Nov-10 

14-Nov-10 

21-Nov-10 

28-Nov-10 

PHNT 2% 2% 6% 8% 10% 10% 8% 10% 7% 2% 2% 2% 3% 

Regional Average 8% 8% 7% 6% 7% 7% 7% 7% 5% 4% 4% 4% 4% 

Gap 6% 6% 1% (2%) (3%) (3%) (1%) (3%) (2%) 2% 2% 2% 1% 

05-Dec-10 

12-Dec-10 

19-Dec-10 

26-Dec-10 

02-Jan-11 

09-Jan-11 

16-Jan-11 

23-Jan-11 

20% 

PHNT v Regional Acute Providers Average (actual) 

18% 

16% 

14% 

12% 

10% 

8% 

6% 

4% 

2% 

0% 

28-Feb-10 

14-Mar-10 

28-Mar-10 

11-Apr-10 

25-Apr-10 

09-May-10 

23-May-10 

06-Jun-10 

20-Jun-10 

04-Jul-10 

18-Jul-10 

01-Aug-10 

15-Aug-10 

29-Aug-10 

12-Sep-10 

26-Sep-10 

10-Oct-10 

24-Oct-10 

07-Nov-10 

21-Nov-10 

05-Dec-10 

19-Dec-10 

02-Jan-11 

16-Jan-11 

PHNT Regional Average Target %age 

7 

Choose And Book Slot unavailability 

Latest Data up to 

Week Ending 23/01/2011 

PHNT Versus Regional Acute Providers Average 

Last 13 Weeks 

rolling 4 weekly 

average 

31-Oct-10 

07-Nov-10 

14-Nov-10 

21-Nov-10 

28-Nov-10 

PHNT 4% 4% 4% 5% 7% 9% 9% 9% 8% 7% 6% 3% 2% 

Regional Average 8% 7% 7% 7% 7% 7% 7% 7% 7% 6% 5% 4% 4% 

Gap 4% 3% 3% 2% 0% (2%) (2%) (2%) (1%) (1%) (1%) 1% 2% 

05-Dec-10 

12-Dec-10 

19-Dec-10 

26-Dec-10 

02-Jan-11 

09-Jan-11 

16-Jan-11 

23-Jan-11 

16% 100% 

PHNT v Regional No. Seen Acute within Providers 48 hrs Average of Contacting (rolling Service 4 weekly average) 

14% 

90% 

12% 

10% 

80% 

8% 

6% 70% 

4% 

60% 

2% 

0% 

50% 

07-Mar-10 

40% 

21-Mar-10 

04-Apr-10 

18-Apr-10 

02-May-10 

16-May-10 

30-May-10 

13-Jun-10 

27-Jun-10 

11-Jul-10 

25-Jul-10 

08-Aug-10 

22-Aug-10 

05-Sep-10 

19-Sep-10 

03-Oct-10 

17-Oct-10 

31-Oct-10 

14-Nov-10 

28-Nov-10 

12-Dec-10 

26-Dec-10 

09-Jan-11 

23-Jan-11 

15% 

14% 

PHNT Regional Average Target %age 

15% 

Page 33

February 2011 

Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 YTD 

Number 1st Seen 849 813 934 1040 814 937 940 841 931 660 846 1052 10657 

Number of Breaches 54 36 66 61 54 59 46 31 53 44 22 47 573 

Number of Breaches excluding patient 

choice & medical reasons 

CANCER TARGETS : 2 Week Wait from Urgent GP referral for suspected cancer 

10 0 2 1 2 3 0 0 4 0 0 1 23 

Performance 93.6% 95.6% 92.9% 94.1% 93.4% 93.7% 95.1% 96.3% 94.3% 93.3% 97.4% 95.5% 94.6% 

DOH Target 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 


Number 1st Seen 900 860 1032 1054 920 1031 909 970 798 752 969 10195 

Number of Breaches 47 45 47 42 47 51 39 45 28 47 43 481 


choice & medical reasons 

10 3 2 0 2 3 2 1 1 0 0 24 

Performance 94.8% 94.8% 95.4% 96.0% 94.9% 95.1% 95.7% 95.4% 96.5% 93.8% 95.6% 95.3% 

DOH Target 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 

1100 

100% 

1000 

95% 

900 

90% 

800 

85% 

700 

600 

500 

400 

80% 

75% 

70% 

300 

65% 

200 

60% 

100 

55% 

0 

Apr- 

07 

Jun- 

07 

Aug- 

07 

Oct- 

07 

Dec- 

07 

Feb- 

08 

Apr- 

08 

Jun- 

08 

Aug- 

08 

Oct- 

08 

Dec- 

08 

Feb- 

09 

Apr- 

09 

Jun- 

09 

Aug- 

09 

Oct- 

09 

Dec- 

09 

Feb- 

10 

Apr- 

10 

Jun- 

10 

Aug- 

10 

Oct- 

10 

Dec- 

10 

Feb- 

11 

50% 

Number 1st Seen Trust Performance DOH Target 

Breaches 

Patient Choice 43 

Medical Reasons 

Outpatient Capacity 

Administration delay 

TOTAL 43 

Patient Choice 




Page 34

CANCER TARGETS : 31 Day "Decision To Treat to Treatment" 

February 2011 


Number First Treated 226 208 259 268 245 240 280 272 222 272 257 275 3024 


Number of Breaches excluding patient choice, 

medical reasons & complex diagnostic pathways 

1 3 2 5 6 13 0 0 0 7 0 2 39 

Performance 98.2% 97.6% 97.3% 97.8% 97.1% 93.8% 98.6% 98.2% 98.2% 96.7% 100.0% 98.5% 97.7% 

DOH Target 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 


Number First Treated 264 223 278 276 275 261 248 315 246 298 276 2960 



medical reasons & complex diagnostic pathways 

6 3 2 0 2 1 4 5 7 6 2 38 

Performance 97.0% 98.2% 98.9% 100.0% 98.5% 98.9% 98.0% 98.1% 97.2% 97.0% 98.2% 98.2% 

DOH Target 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 

Performance Against Target 

300 

275 

250 

225 

200 

175 

150 

125 

40% 

100 

30% 

75 

20% 

50 

25 

10% 

0 

0% 

Apr-07 Jun-07 Aug-07 Oct-07 Dec-07 Feb-08 Apr-08 Jun-08 Aug-08 Oct-08 Dec-08 Feb-09 Apr-09 Jun-09 Aug-09 Oct-09 Dec-09 Feb-10 Apr-10 Jun-10 Aug-10 Oct-10 Dec-10 Feb-11 

Month 

Number of Patients Trust Performance DOH Target 

100% 

90% 

80% 

70% 

60% 

50% 

Breaches 


Medical Reasons 2 


Administration delay 1 

Inpatient Capacity 

Cancellation for non medical reasons 1 

Delay in diganostics 

Failure in clinical pathway 

Delay due to referral between Trusts 

TOTAL 5 






Cancellation for non medical 

reasons 




Page 35

CANCER TARGETS : 62 Day "GP Urgent referral to Treatment" 

February 2011 


Number First Treated 112.0 83.5 107.0 132.5 123.5 110.5 137.0 123.5 107.5 127.5 106.0 135.0 1405.5 

Number of Breaches 12.0 16.0 18.0 21.0 17.0 19.0 17.0 18.5 14.0 20.0 24.0 14.0 210.5 


medical reasons & complex diagnostic 

pathways 

7.0 4.5 7.5 7.5 10.5 14.0 0.0 0.0 0.0 5.5 7.0 4.5 68.0 

Performance 89.3% 80.8% 83.2% 84.2% 86.2% 82.8% 87.6% 85.0% 87.0% 84.3% 77.4% 89.6% 85.0% 

DOH Target 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 


Number First Treated 121.0 98.0 116.0 106.5 143.0 125.0 118.0 129.5 102.0 132.0 123.0 1314.0 

Number of Breaches 14.5 12.5 20.0 11.5 18.5 18.5 20.5 17.0 14.0 10.5 17.0 174.5 


medical reasons & complex diagnostic 

pathways 

7.0 3.0 5.5 2.0 8.5 7.0 4.0 2.0 2.5 3.0 4.0 48.5 

Performance 88.0% 87.2% 82.8% 89.2% 87.1% 85.2% 82.6% 86.9% 86.3% 92.0% 86.2% 86.7% 

DOH Target 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 

Performance Against Target 

160 

140 

120 

100 

80 

60 

40 

20 

100% 

90% 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

10% 

0 

0% 

Apr-07 Jun-07 Aug-07 Oct-07 Dec-07 Feb-08 Apr-08 Jun-08 Aug-08 Oct-08 Dec-08 Feb-09 Apr-09 Jun-09 Aug-09 Oct-09 Dec-09 Feb-10 Apr-10 Jun-10 Aug-10 Oct-10 Dec-10 Feb-11 

Month 

Number of Patients Trust Performance DOH Target 

Breaches 


Medical Reasons 2 

Complex Diagnostic Pathway 3 

Outpatient Capacity 1 



Cancellation for non medical reasons 2 


Failure in clinical pathway 1 


Unknown 

TOTAL 17 



Complex Diagnostic Pathway 




Cancellation for non medical reasons 




Unknown 

Page 36

GFOCW TARGETS : 62 Days from Screening Referrals to First Treatment 

February 2011 

Standard - Maximum 62 days from referral from NHS Cancer Screening Programmes (breast, cervical and bowel) to first treatment for patients first treated 

January 2009 onwards 

Month Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 YTD 

Number of Patients 8 8 24 7 8 15 14 19 15 18 17 16 169 


Number of Breaches excluding patient cho 0 1 1 0 0 0 0 0 0 0 0 0 2 

% Performance Against Target 100.0% 87.5% 87.5% 71.4% 100.0% 93.3% 85.7% 94.7% 100.0% 88.9% 100.0% 100.0% 92.9% 

DOH Target 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 


Number of Patients 7.0 19.0 14.5 13.5 17.0 13.0 11.5 21.0 7.0 15.0 16.5 155 

Number of Breaches 1.0 2.0 0.0 0.5 0.0 1.0 3.5 0.0 2.0 1.0 2.0 13 


choice, medical reasons & complex 

diagnostic pathways 

0.0 0.0 0.0 0.0 0.0 0.0 2.0 0.0 0.0 0.0 0.0 2 

% Performance Against Target 85.7% 89.5% 100.0% 96.3% 100.0% 92.3% 69.6% 100.0% 71.4% 93.3% 87.9% 91.6% 

DOH Target 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 

30 

25 

20 

15 

10 

5 

0 

0% 

Apr-08 Jun-08 Aug-08 Oct-08 Dec-08 Feb-09 Apr-09 Jun-09 Aug-09 Oct-09 Dec-09 Feb-10 Apr-10 Jun-10 Aug-10 Oct-10 Dec-10 Feb-11 

100% 

90% 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

10% 

Number Treated % Against Target DOH Target 

February 2011 

GFOCW TARGETS : 62 Days from Consultant Upgrade to First Treatment 

Standard - Maximum 62 days from consultant upgrade of urgency of a referral to first treatment for patients treated Jan 2009 onwards 


Number of Patients 7.0 13.0 13.0 5.0 6.0 17.0 7.0 14.0 15.5 13.0 13.0 16.0 139.5 

Number of Breaches 2.0 0.0 1.0 1.0 1.0 4.0 1.0 1.0 2.0 1.5 0.0 1.0 15.5 

Number of Breaches excluding patient cho 1.0 0.0 0.0 0.0 0.0 4.0 0.0 0.0 0.0 0.0 0.0 0.0 5.0 


Possible DOH Target 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 


Number of Patients 7.0 10.0 19.0 13.0 10.5 10.0 10.5 14.0 8.0 15.5 19.5 137.0 

Number of Breaches 0.0 1.0 1.0 1.0 1.0 2.0 1.0 2.0 1.0 1.0 2.0 13.0 




0.0 0.0 0.0 1.0 1.0 0.0 1.0 0.0 1.0 0.0 0.0 4.0 


Possible DOH Target 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 

NB: The target for 62 Days from Consultant Upgrade to First Treatment has been set at 85% as per the Monitor target, currently 

the CQC has not issued a target due to lack of data nationally 

25 

20 

15 

10 

5 

0 

0% 


100% 

90% 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

10% 

Number Treated % Against Target Possible DOH Target 

Page 37

GFOCW TARGETS : 31 Days from Decision to Treatment to Treatment for Subsequent Treatments of Surgery or Anti Cancer 

Drugs 

Surgery 

February 2011 

Standard - Maximum 31 days from decision to treat/earliest clinically appropriate date to start of second or subsequent treatment(s) for all cancer patients including those 

diagnosed with recurrence for treatments Jan 2009 onwards and where the treatment is surgery or anti cancer drug treatment 







5 1 5 5 12 11 0 0 0 2 2 1 44 


DOH Target 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 


Number of Patients 68 90 78 102 76 96 103 102 78 76 73 942 





8 0 2 2 2 5 2 3 2 0 0 26 


DOH Target 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 

120 

100 

80 

60 

40 

20 

100% 

80% 

60% 

40% 

20% 

0 

0% 



Anti Cancer Drugs 







2 0 0 0 0 0 0 0 0 3 0 0 5 


DOH Target 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 







0 0 0 0 0 0 0 0 0 0 0 0 


DOH Target 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 

100% 

90 

80% 

75 

60 

CHART 

60% 

45 

40% 

30 

15 

20% 

0 

0% 



Page 38

GFOCW TARGETS : 2 Week Wait for Breast Symptom Referrals 

February 2011 

Standard - Maximum 2 week wait from referral for general breast symptoms (where cancer is initially not suspected) to date first seen from Jan 2010 onwards 

Month Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Q4 



Number of Breaches excluding 

patient choice 

N/A N/A N/A N/A N/A 5 7 1 0 0 0 0 0 


DOH Target 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 





patient choice 

0 0 0 0 0 0 0 0 0 0 0 0 


DOH Target 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 

200 

100% 

175 

90% 

80% 

150 

70% 

125 

60% 

100 

50% 

75 

40% 

30% 

50 

20% 

25 

10% 

0 

0% 


Number 1st Seen % Against Target DOH Target 

GFOCW TARGETS : 31 Days from Decision to Treatment to Treatment for Subsequent Treatments of Radiotherapy 

February 2011 

Standard - Maximum 31 days from decision to treat/earliest clinically appropriate date to start of second or subsequent treatment(s) for all cancer patients including those 

diagnosed with recurrence for treatments Jan 2011 onwards and where the treatment is radiotherapy 





patient choice, medical reasons & 1 1 0 1 2 8 0 0 0 9 1 1 24 

complex diagnostic pathways 


DOH Target 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 





patient choice, medical reasons & 9 3 1 0 1 1 1 1 0 1 0 18 

complex diagnostic pathways 


DOH Target 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 

125 

100% 

90% 

100 

80% 

70% 

75 

60% 

50% 

50 

40% 

30% 

25 

20% 

10% 

0 

0% 


Number 1st Treated % Against Target DOH Target 

Page 39

CANCER TARGETS : Breach Analysis 

February 2011 



Complex clinical pathway 





Delay in diagnostics 



Unknown 

TOTAL 

2ww 

31 Day First 

Treatment 

62 Day 2ww to 

Treatment 

43 1 8 

2 2 

3 

1 

1 

1 

2 

1 

43 5 17 

Breaches 

highlighted in 

green are 

beyond Trust 

control 



Complex clinical pathway 





Delay in diagnostics 



Unknown 

TOTAL 

Screening 

Consultant 

Upgrades Sub Surgery Sub Chemo 

Breast 

Symptom 

Sub 

Radiotherapy 

2 1 3 1 

1 

2 2 0 0 3 1 

Page 40

Reperfusion Waiting Times 


February 2011 

PART 1 

Thrombolysis - 60 minutes call to needle time 

Number of patients eligible for thrombolysis 

Number of patients receiving thrombolysis within 60 

mins of call for help 

% Achievement of Call to Needle Target 

Target 


3 11 3 5 4 5 31 

3 7 3 4 2 3 22 

100% 64% 100% 80% 50% 60% N/A N/A N/A N/A N/A N/A 71% 

68% 68% 68% 68% 68% 68% 68% 68% 68% 68% 68% 68% 68% 

100% 

80% 

60% 

40% 

20% 

0% 

% Thrombolysed (Call To Needle) 

Apr-06 

May-06 

Jun-06 

Jul-06 

Aug-06 

Sep-06 

Oct-06 

Nov-06 

Dec-06 

Jan-07 

Feb-07 

Mar-07 

Apr-07 

May-07 

Jun-07 

Jul-07 

Aug-07 

Sep-07 

Oct-07 

Nov-07 

Dec-07 

Jan-08 

Feb-08 

Mar-08 

Apr-08 

May-08 

Jun-08 

Jul-08 

Aug-08 

Sep-08 

Oct-08 

Nov-08 

Dec-08 

Jan-09 

Feb-09 

Mar-09 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

% Actual % National Target 

PART 2 

Primary PCI - 150 minutes call to first balloon inflation 

NB Primary PCI service started October 2009 

Number of patients eligible for pPCI 

Number of patients receiving pPCI within 150 mins of 

call for help 

% Achievement of Call to Balloon Target 

Target 



call for help 


Target 




Target 

Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 YTD 

14 14 10 38 

12 12 7 

31 

86% 86% 70% 82% 

75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 


7 10 6 8 12 10 8 11 12 12 10 14 120 

7 9 5 6 10 8 6 8 8 8 8 13 96 

100% 90% 83% 75% 83% 80% 75% 73% 67% 67% 80% 93% 80% 

75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 


10 12 22 

7 11 18 

70% 92% 82% 

75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 

100% 

80% 

60% 

40% 

20% 

0% 

Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 


National Target 

NB Primary PCI service started October 2009 

PART 3 

Primary PCI - 150 minutes call to first balloon inflation 3 months rolling percentage 




Target 




Target 




Target 


14 14 10 38 

12 12 7 31 

82% 82% 

75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 


7 10 6 8 12 10 8 11 12 12 10 14 120 

7 9 5 6 10 8 6 8 8 8 8 13 96 

84% 85% 91% 83% 81% 80% 80% 76% 71% 69% 71% 81% 80% 

75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 


10 12 22 

7 11 18 

82% 86% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 82% 

75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 

100% 

80% 

60% 

40% 

20% 

0% 

Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 

3 Months Rolling National Target 

Page 41

EFFICIENCY AND BUSINESS 

MANAGEMENT OBJECTIVE 


Page 42

PLYMOUTH HOSPITALS NHS TRUST Trust performance report - February 2011 Table 1 

Income and Expenditure Performance against plan 

2 

Trust surplus against plan 

0 

Plan 

-2 

£m 

-4 

-6 

Actual 

-8 

-10 

-12 


Month 

Revised Plan 

Current Month 

Year to Date 

Year to Date 

Annual 

Budget 

Actual 

Variance - 

Adverse/ 

(Favourable) 

Original Budget 

Actual 

Variance - 

Adverse/ 

(Favourable) 

Revised Plan 

Actual 

Variance - 

Adverse/ 

(Favourable) 

Budget 

Revised Plan 

Variance - 

Adverse/ 

(Favourable) 

£000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 

OPERATIONAL PERFORMANCE 

INCOME 

Provision of healthcare (25,953) (27,696) (1,743) (297,462) (308,704) (11,242) (307,502) (308,704) (1,202) (326,004) (339,252) (13,248) 

Education, training and research (1,880) (1,661) 219 (20,669) (24,084) (3,415) (23,536) (24,084) (548) (22,550) (25,679) (3,129) 

Other Income (1,610) (3,079) (1,469) (17,746) (20,420) (2,674) (19,689) (20,420) (732) (19,396) (21,857) (2,461) 

TOTAL INCOME (29,443) (32,435) (2,992) (335,877) (353,208) (17,331) (350,727) (353,208) (2,482) (367,951) (386,788) (18,837) 

EXPENDITURE 

Pay 19,329 19,513 183 213,534 216,839 3,305 215,611 216,839 1,228 232,871 234,556 1,686 

Non-pay 9,487 10,510 1,023 107,781 116,954 9,173 113,947 116,954 3,007 117,910 124,348 6,439 

TOTAL EXPENDITURE 28,816 30,023 1,207 321,315 333,793 12,479 329,558 333,793 4,235 350,780 358,904 8,124 

RESERVES 0 0 0 0 0 (0) 2,222 0 (2,222) 321 2,643 2,322 

CIPS IDENTIFIED BUT NOT YET TRANSFERRED 

NET (SURPLUS)/DEFICIT BEFORE DEPRECIATION 

AND INTEREST 

(931) 0 931 (7,625) 0 7,625 0 0 0 (8,536) 0 8,536 

(1,558) (2,413) (855) (22,188) (19,415) 2,772 (18,946) (19,415) (469) (25,386) (25,240) 145 

Depreciation Charges 1,429 1,560 131 15,721 16,146 425 16,395 16,146 (248) 17,150 17,926 776 

Impairments 0 0 0 0 0 0 0 0 0 0 0 0 

Profit/Loss on Asset Disposal 0 (8) (8) 58 233 175 139 233 94 58 139 81 

Interest Payable 14 13 (1) 150 151 1 150 151 0 164 164 0 

Interest Receivable (3) (2) 1 (28) (25) 3 (29) (25) 4 (30) (31) (1) 

Public Dividend Capital Interest 587 587 (0) 6,456 6,455 (1) 6,456 6,455 (1) 7,043 7,043 0 

TOTAL DEPRECIATION AND INTEREST 2,027 2,150 122 22,358 22,961 603 23,111 22,961 (150) 24,386 25,241 855 

NET (SURPLUS)/DEFICIT 469 (263) (732) 171 3,546 3,375 4,165 3,546 (619) (1,000) 0 1,001 

Page 43

HEALTH OBJECTIVE 


Page 44

8 

Access to GUM clinics - Offered to be Seen within 48 Hours 


February 2011 Target = Achieve 100% by 2008 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

No. Seen who were 

offered to be seen 1124 1061 935 1018 1177 1130 1213 1006 1059 839 1052 1171 11661 

within 48 hrs 

No. New Attending 1124 1061 935 1018 1177 1130 1213 1006 1059 839 1052 1172 11662 

% Seen who were 

Offered to be seen 

within 48 hrs 

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

2010/11 

YTD 

100% 

95% 

90% 

85% 

80% 

75% 

70% 

65% 

60% 

No. Seen who were offered to be seen within 48 hrs of Contacting Service 

Apr-07 

Jun-07 

Aug-07 

Oct-07 

Dec-07 

Feb-08 

Apr-08 

Jun-08 

Aug-08 

Oct-08 

Dec-08 

Feb-09 

Apr-09 

Jun-09 

Aug-09 

Oct-09 

Dec-09 

Feb-10 

Apr-10 

Jun-10 

Aug-10 

Oct-10 

Dec-10 

Feb-11 

9 

Access to GUM clinics - Seen within 48 Hours 


February 2011 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

No. Seen within 48 

hrs 

1037 973 845 937 1049 1022 1105 898 987 783 951 1055 10605 

No. New Attending 1124 1061 935 1018 1177 1130 1213 1006 1059 839 1052 1172 11662 

% Seen within 48 

Hours 

92% 92% 90% 92% 89% 90% 91% 89% 93% 93% 90% 90% 91% 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

2010/11 

YTD 

100% 

No. Seen within 48 hrs of Contacting Service 

90% 

80% 

70% 

60% 

50% 

40% 

Mar-08 

Apr-08 

May-08 

Jun-08 

Jul-08 

Aug-08 

Sep-08 

Oct-08 

Nov-08 

Dec-08 

Jan-09 

Feb-09 

Mar-09 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

Page 45

INFANT HEALTH & INEQUALITIES 

# 

BREAST FEEDING INITIATION 

Data Completeness Indicator 


February 2011 

Target = To Achieve 100% coverage (must be above 95% for valid 

return) 

2010/11 

2009/10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

No. of Maternities with 

Breast Feeding Status 4533 351 351 397 388 348 371 420 377 429 379 392 0 4203 

Known 

No. of Maternities 4739 366 379 421 397 377 380 438 389 441 394 395 0 4377 

% Completeness 96% 96% 93% 94% 98% 92% 98% 96% 97% 97% 96% 99% 96% 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

YTD 

100% 

% of Maternity Episodes with Breast Feeding Status Known 

90% 

80% 

70% 

60% 

50% 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

Breast Feeding Initiation Rate 


February 2011 

2010/11 

2009/10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

No. of mothers known to 

initiate breast feeding 3243 238 243 282 279 231 254 305 284 331 281 299 0 3027 


% Initiation 68% 65% 64% 67% 70% 61% 67% 70% 73% 75% 71% 76% 69% 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

YTD 

100% 

90% 

80% 

70% 

60% 

50% 

40% 

30% 

% of Maternity Episodes where Breast Feeding was Initiated 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

Page 46

INFANT HEALTH & INEQUALITIES 

# 

SMOKING DURING PREGNANCY 

Data Completeness 


February 2011 

Target = To Achieve 100% coverage (must be above 95% for valid 

return) 

2009/10 

2009/10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

No. of Maternities with 

Smoking Status Known 

4735 366 379 421 397 366 370 429 381 426 385 390 0 4310 


% Completeness 100% 100% 100% 100% 100% 97% 97% 98% 98% 97% 98% 99% 98% 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

YTD 

100% 

99% 

98% 

97% 

96% 

95% 

94% 

93% 

92% 

91% 

90% 

% of Maternity Episodes with Smoking Status Known 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

2 

"Smokers at Time of Delivery" Rate 


February 2011 

2009/10 

2009/10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

No. of Mothers known to 

be Smokers at the Time 836 67 47 70 68 59 62 72 56 88 81 71 0 741 

of Delivery 


% Smokers 18% 18% 12% 17% 17% 16% 16% 16% 14% 20% 21% 18% 17% 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

YTD 

30% 

% of Mothers known to be Smokers at Time of Delivery 

25% 

20% 

15% 

10% 

5% 

0% 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

Page 47

# 


MATERNITY DATA QUALITY 

February 2011 

Note : Data is only available from SUS 2 months in arrears 

DATA COMPLETENESS 

INDICATOR 1 - completeness of 

fields 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

Data Validity - Birth 95.6% 95.6% 95.7% 95.6% 93.8% 92.1% 90.9% 90.2% 89.5% 

Data Validity - Delivery 95.2% 95.2% 96.0% 95.5% 93% 91.2% 90.5% 90.1% 89.6% 

2009/2010 CQC Target (minimum 

required) 

85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 

98% 

96% 

94% 

92% 

90% 

88% 

86% 

84% 

82% 

80% 

Maternity Data Completeness Indicator 

DATA COMPLETENESS 

INDICATOR 2 : logic check 

between births and deliveries 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

01-Apr- 

10 

01-May- 

10 

01-Jun- 

10 

01-Jul- 

10 

01-Aug- 

10 

01-Sep- 

10 

01-Oct- 

10 

01-Nov- 

10 

01-Dec- 

10 

01-Jan- 

11 

01-Feb- 

11 

01-Mar- 

11 

Data Validity - Birth Data Validity - Delivery 2009/2010 CQC Target (minimum required) 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

Ratio of birth episodes to number 

of babies delivered on delivery 

episodes - Must be between 0.9 

and 1.1 

1.209 1.209 1.013 1.006 1.023 1.005 1.021 1.028 1.03 

Page 48

PARTICIPATION IN HEART DISEASE AUDITS 


February 2011 

INDICATOR THRESHOLDS 

Part 1 Part 2 Part 1 Part 2 Part 1 Part 2 

Achieve 100% 66% Underachieve 

50% 25% Fail

# 


DATA QUALITY ON ETHNIC GROUP 

February 2011 

Target = To Achieve 100% coverage 

No. of FCEs with Valid 

Ethnic Category 

2009/10 

2010/11 

YTD 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

134503 121595 11032 10578 11409 11553 11192 11369 11168 11690 10773 10668 10163 0 

No. of FCEs 134526 121609 11034 10579 11411 11553 11192 11371 11171 11692 10774 10669 10163 0 

% with Valid Ethnic 

Category 

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 0% 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

101% 

100% 

99% 

98% 

97% 

96% 

95% 

% of FCEs with Valid Ethnic Category 

Apr-09 

May-09 

Jun-09 

Jul-09 

Aug-09 

Sep-09 

Oct-09 

Nov-09 

Dec-09 

Jan-10 

Feb-10 

Mar-10 

Apr-10 

May-10 

Jun-10 

Jul-10 

Aug-10 

Sep-10 

Oct-10 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

Page 50

WORKFORCE OBJECTIVE 


Page 51

Workforce Planning and Performance Scorecard 

For the Period March 2010 thru' February 2011 

Component 

Establishment (WTE) 

Staff in Post (WTE) 

Vacancies (WTE) 

Headcount 

Turnover % (Exc Rotational Dctrs) 

Appraisals % 

Sickness % 

Sickness Cost 

Bradford Scores (>300) 

NHSP/Agency Spend 

NHSP/Agency less Sickness Cost 

Potential Retirees(HC) 

Training - Child Protection 

Training - Mandatory 

Training - BLS 

Training - Manual Handling 

March April May June July August September October November December January February 

5791.39 5795.26 5901.83 5916.34 5912.62 5902.61 5872.79 5887.97 5884.82 5876.36 5876.63 5877.08 

5430.27 5447.73 5446.87 5459.67 5454.35 5479.14 5489.47 5478.19 5464.5 5430.14 5402.96 5391.13 

451.64 499.43 493.21 465.87 452.38 406.98 418.58 404.09 420.32 446.22 473.67 485.95 

6416 6445 6434 6448 6447 6479 6498 6480 6460 6426 6395 6379 

10.44 10.17 10.16 10.19 9.96 9.68 9.49 9.72 9.44 9.58 9.61 9.43 

73.33 74.42 74.91 77.45 80.29 80.81 79.74 76.53 74.78 72.92 75.61 76.93 

5.09 4.01 4.14 4.17 4.32 3.63 4.11 4.37 4.55 5.19 4.89 3.91 

505139.89 402479.82 409832.68 399269 433239.46 370940.99 386867.28 432607.5 450065.38 534131.09 491539.31 350237.36 

930 922 907 894 849 828 813 798 740 759 742 705 

1110830.72 830315.62 840006.36 991000.95 1107168.13 969422.91 638846.67 724136 640906 627794.11 707724.95 617503.32 

605690.83 427835.8 430173.68 591731.95 673928.67 598481.92 251979.39 291528.5 190840.62 93663.02 216185.64 267265.96 

1203 1192 1187 1190 1196 1216 1221 1219 1225 1227 1228 1229 

94 94 95 

96 96 98 

98 96 98 

97 97 98 

81 85 85 

85 86 86 

85 86 86 

87 86 81 

77 84 84 

86 84 90 

88 86 87 

87 87 79 

88 89 90 

90 91 92 

91 92 90 

91 94 91 

Private & Confidential 

15 March 2011 

Page 52

PHT Public Trust Board Papers March 2011.pdf - Plymouth Hospitals

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