shrewsbury and telford nhs trust · the nhs trust has not achieved the 4-hour a&e standard...

of 15 20190110 SaTH UoR Interim combined rating use of resources report.docx

Shrewsbury and Telford NHS Trust

Use of Resources assessment report NHS trust Headquarters, Royal Shrewsbury

Hospital, Mytton Oak Road

Shrewsbury, Shropshire

SY3 8XQ

Tel: 01743 261000

www.sath.nhs.uk

Date of publication:

29 November 2018

This report describes our judgement of the Use of Resources and our combined rating for quality and

resources for the trust.

Ratings

Overall quality rating for this trust Inadequate

Are services safe? Inadequate

Are services effective? Requires improvement

Are services caring? Good

Are services responsive? Requires improvement

Are services well-led? Inadequate

Our overall quality rating combines our five trust-level quality ratings of safe, effective, caring, responsive and well-led. These ratings are based on what we found when we inspected, and other information available to us. You can find information about these ratings in our inspection report for this trust and in the related evidence appendix. (See www.cqc.org.uk/provider/RXW/reports)

Are resources used productively? Requires improvement

Combined rating for quality and use of

resources Inadequate

We award the Use of Resources rating based on an assessment carried out by NHS Improvement.

Our combined rating for Quality and Use of Resources summarises the performance of the trust taking into account the quality of services as well as the trust’s productivity and sustainability. This rating combines our five trust-level quality ratings of safe, effective, caring, responsive and well-led with the Use of Resources rating.


Use of Resources assessment and rating

NHS Improvement are currently planning to assess all non-specialist acute NHS trusts and

foundation trusts for their Use of Resources assessments.

The aim of the assessment is to improve understanding of how productively trusts are using their

resources to provide high quality and sustainable care for patients. The assessment includes an

analysis of trust performance against a selection of initial metrics, using local intelligence, and

other evidence. This analysis is followed by a qualitative assessment by a team from NHS

Improvement during a one-day site visit to the trust.

Combined rating for Quality and Use of Resources

Our combined rating for Quality and Use of Resources is awarded by combining our five trust-level

quality ratings of safe, effective, caring, responsive and well-led with the Use of Resources rating,

using the ratings principles included in our guidance for NHS trusts.

This is the first time that we have awarded a combined rating for Quality and Use of Resources at

this trust. The combined rating for Quality and Use of Resources for this trust was inadequate,

because:

• The Princess Royal Hospital, Telford and Royal Shrewsbury Hospital, Shrewsbury were rated as inadequate overall.

• In four services, safe and well-led was rated as inadequate.

• In many services, overall, safe, effective, responsive and well-led were rated as requires

improvement.

• The trust was rated requires improvement for use of resources. Full details of the

assessment can be found on the following pages.


Shrewsbury and Telford NHS Trust

Use of Resources assessment report

NHS trust Headquarters, Royal Shrewsbury

Hospital, Mytton Oak Road

Shrewsbury, Shropshire

SY3 8XQ

Tel: 01743 261000

www.sath.nhs.uk

Date of site visit:

03 September 2018

Date of NHS publication:

29 November 2018

This report describes NHS Improvement’s assessment of how effectively this trust uses its resources. It is based on a combination of data on the trust’s performance over the previous 12 months, our local intelligence, the trust’s commentary on its performance, and qualitative evidence collected during a site visit comprised of a series of structured conversations with the trust's leadership team.

Are resources used

productively? Requires improvement

How we carried out this assessment

The aim of Use of Resources assessments is to understand how effectively providers are using

their resources to provide high quality, efficient and sustainable care for patients. The

assessment team has, according to the published framework, examined the NHS trust’s

performance against a set of initial metrics alongside local intelligence from NHS

Improvement’s day-to-day interactions with the NHS trust, and the NHS trust’s own

commentary of its performance. The team conducted a dedicated site visit to engage with key

staff using agreed key lines of enquiry (KLOEs) and prompts in the areas of clinical services;

people; clinical support services; corporate services, procurement, estates and facilities; and

finance. All KLOEs, initial metrics and prompts can be found in the Use of Resources

assessment framework.

We visited the NHS trust on 3rd September 2018 and met the NHS trust’s executive team

(including the chief executive), a non-executive director (in this case, the chair) and relevant

senior management responsible for the areas under this assessment’s KLOEs.

https://improvement.nhs.uk/resources/use-resources-assessment-framework/

https://improvement.nhs.uk/resources/use-resources-assessment-framework/


Summary of findings

Is the trust using its resources productively to

maximise patient benefit? Requires improvement

We rated the NHS trust’s use of resources as requires improvement.

The NHS trust has high vacancy rates across its workforce and is heavily reliant on

temporary staffing to deliver its services, which is driving high agency spend. Areas such as

emergency department (ED) and nursing workforce are particularly challenged. Compared

with other NHS trusts, the trust’s initiatives to address the high vacancy situation have not

been as effective in improving recruitment rates and reducing reliance on temporary staffing.

The NHS trust did not achieve its control total for 2017/18 and its underlying financial

position deteriorated from previous years, this taken together with the workforce situation, if

not addressed, could have an adverse impact on the NHS trust’s future use of resource

ratings.

• For 2017/18, the NHS trust reported a deficit of £21.3 million excluding STF which was worse than the control total of £15.4 million. This was mainly due to slippage against its Cost Improvement Programme (CIP) and high agency spend. For the period April to June 2018, the NHS trust achieved its control total excluding PSF and was delivering slightly above its CIP plan, however it continues to incur high agency costs with this period with spend significantly higher than the agency ceiling set by NHS Improvement.

• The NHS trust’s underlying deficit, which was £20.5 million (5.8% of turnover) in 2017/18, worsened from previous years. The NHS trust’s analysis indicates that split site working, agency costs and investment in fragile services are the key drivers of the deficit. The NHS trust has a longer-term strategy to regain financial balance by 2023/24 which will involve rationalising the estate and reconfiguring services.

• There have been some initiatives undertaken to control agency spend which have delivered reduced spend on agency nursing. However, this has been offset by rising medical staff agency costs. The NHS trust spends more on consultants (and medical staffing overall) to deliver activity than other NHS trusts nationally but did not demonstrate existence of a workforce management system required to optimise their output.

• Other areas where the NHS trust did not compare well include estates maintenance, where the NHS trust has a high maintenance backlog which presents an infrastructure risk and, performance against the 4-hour A&E target, which has been below standard since 2013.

• There are, however, individual areas where the NHS trust’s productivity compared particularly well. Productivity in clinical services is better than most NHS trusts in England, with the Did Not Attend (DNA) and readmission rates benchmarking in best quartile nationally. The NHS trust has also progressed well in achieving its top ten medicines targets.

• The NHS trust has lower non-pay costs per weighted unit of activity (WAU) compared to other NHS trusts nationally. The NHS trust provides shared payroll and some procurement services to neighbouring NHS trusts and GP practices. It has effective procurement processes which drive down cost of purchases and its soft facilities management services are good value for money.


How well is the NHS trust using its resources to provide clinical services that operate as

productively as possible and thereby maximise patient benefit?

Productivity in clinical services is better than other NHS trusts nationally with improvement

across most areas. The NHS trust however, has consistently failed to meet the 4-hour A&E

standard with performance reported below national average.

• At the time of the assessment in September 2018, the NHS trust was meeting the constitutional operational performance standards for 18-week referral to treatment target, cancer 62-day wait target for NHS cancer screening service and the diagnostic 6-week wait target. The NHS trust was not meeting the constitutional targets for Cancer 62-day wait for urgent GP referrals and 4-hour A&E target.

• The NHS trust’s performance against the cancer 62-day wait target, for urgent GP referrals, has been variable across the last 12 months with performance for June 2018 being 82.6% against the national target of 85%, but above the national average of 79.2%. The NHS trust has not achieved the 4-hour A&E standard since July 2013 and its performance for July 2018 was 74.6% below the national average of 89.3%.

• The NHS trust’s readmission rates have consistently been better national averages. For April 2018 to July 2018 the NHS trust’s emergency readmission rates of 4.57% are significantly below the national median of 7.64%. This means patients are less likely to require additional medical treatment for the same condition at this NHS trust compared to other providers nationally.

• The NHS trust is working with partner organisations to improve pathways and provide care in appropriate settings. Examples of this include work with the ambulance NHS trust to avoid patients being brought to hospital where other care options are available and working with partners in community and social care to ensure frail patients receive appropriate care at home and avoid unnecessary admissions to hospital. The NHS trust is also using technology which allows some patients to self-monitor and be in contact with local care teams.

• For the period April 2018 to July 2018 fewer patients are coming into hospital for longer than necessary prior to treatment compared to most other hospitals in England. On pre-procedure elective bed days, at 0.09, the NHS trust’s performance is better than the national median of 0.11, and on pre-procedure non-elective bed days, at 0.69, the NHS trust is performance is the same as the national median.

• The Did Not Attend (DNA) rate for the NHS trust is low at 4.11% for the period April 2018 to July 2018 compared to the national median of 7.07%. This reflects the effectiveness of the NHS trust’s centralised booking team and its patient engagement through targeted text and phone reminders to encourage attendance.

• The NHS trust reports a delayed transfers of care (DTOC) rate that is lower than national standard. DTOC rates have been improving between April 2018 and June 2018 due to daily review of all patients at the NHS trust and the ‘check, chase, challenge’ approach adopted to ensure patient care and discharge is planned and efficient throughout their care. Additionally, the NHS trust implemented its ‘Sath2Home’ pathway which provides short term support for patients in their home to allow them to be discharged from hospital when they are medically fit.

• The NHS trust has started to engage with the national ‘Getting it right first time’ (GIRFT) programme with progress in some specialities such as ophthalmology.


How effectively is the NHS trust using its workforce to maximise patient benefit and provide high quality care? The NHS trust has a high level of vacancies across its workforce and is heavily reliant on temporary staffing to deliver activity which is driving the rise in agency spend. The NHS trust has undertaken some initiatives to reduce reliance on temporary staffing and agency spend, however more effort is required especially around recruitment initiatives.

• Although NHS trust had an overall pay cost per WAU of £2,157 (2016/17), which is the same as the national median, it does not indicate better workforce productivity nationally as the NHS trust is carrying high vacancy rates and is heavily reliant on temporary staff to deliver services, with increasing levels in 2017/18.

• At the time of the assessment, the NHS trust’s vacancy rates for medical staffing (16.8%), consultant workforce (10.4%) and registered nursing band 5/6 (19%), were all above 9.2% national average. Some specialities such as emergency care had vacancy rates as high as 50% for their consultant workforce. This has contributed to the NHS trust’s high agency spend which remains above the celling set by NHS Improvement.

• To control agency costs, the NHS trust is reconfiguring services to reduce the aggregate (Whole Time Equivalent) WTE required to deliver services and it has streamlined procurement processes for agency staff, introducing stricter controls on agency spend.

• The NHS trust also has some recruitment initiatives which include accelerating the recruitment process, advertising vacancies more widely and using technology to improve response rates. The NHS trust is working with the Virginia Masson institute to implement some of these processes however, compared to other NHS trusts there is still scope for improvement in this area.

• The NHS trust is developing some alternative workforce models and working in partnership with the Virginia Mason Institute to embed these roles. They include advanced clinical practitioners to work on clinical rotas, reporting radiographers, trainee nurse and physician associate roles to support ED. The NHS trust has several apprenticeship roles which stood at 160 in 2017/18.

• Although the above initiatives undertaken delivered some improvements such as reductions in nursing agency spend, temporary staffing levels remain high and medical staffing agency spend continues to increase, in particular with in the emergency service and Trauma and Orthopaedics.

• The NHS trust’s medical staffing cost per WAU at £550 benchmarks above (worse) the national median of £529, and it also spends more on consultants per unit of activity than the national average but was not able demonstrate effective utilisation of their consultant workforce.

• The proportion of consultants with a current job plan at 71% was below the national median of 89% for 2016/17. The number of Programmed Activities (PAs) is variable with high levels of extra duty payments. The NHS trust does not have visibility of actual utilisation of their consultant workforce but has recently invested in job planning software to strengthen its medical workforce planning and optimise their output.

• The NHS trust’s overall retention rates were in the highest (best) quartile nationally however, it has some departments and workforce areas with high turnover rates and has recently experienced an increase in turnover for nursing and midwifery workforce. The NHS trust secured additional funding from Health Education England (HEE) to support ED staff retention initiatives.


• The NHS trusts sickness rates deteriorated in the second half of 2017/18 reaching a high of 5.2% in January 2018 but have since reduced to 4.14% in April 2018 (latest data available). This is still above the national average of 3.99%. The NHS trust is targeting management of sickness at care group level with interventions such as support for mental health wellbeing and physio services being made available for staff.

• The NHS trust has implemented e-rostering for most non-medical staff groups within in-patient ward areas and therapies. Plans are in place to implement e-rostering for radiology and Allied Health professionals (AHPs).

How effectively is the NHS trust using its clinical support services to deliver high quality, sustainable services for patients?

The NHS trust was able to demonstrate good value for money in some areas of its clinical

support services, for instance low cost per test in pathology and a low cost per imaging report. It

is also delivering well against its top ten medicines target. There are however, opportunities for

productivity improvement within its imaging workforce and medicines management.

• For the period January 2018 to March 2018, the NHS trust’s overall pathology cost per test at £1.38, benchmarks in the lowest (best) quartile nationally compared to a national median £1.95. The NHS trust is not part pathology network but is considering financially viable options for pathology collaborations with partners.

• Imaging services compare well in some productivity metrics, for instance the cost per imaging report of £15.66 places it in the best quartile nationally, above an average of £50 per report. The NHS trust however has a high level of consultant vacancies in radiology and high agency and outsourcing costs. The NHS trust has introduced a consultant radiographer role to provide additional capacity.

• There are opportunities for productivity improvement within the NHS trust’s pharmacy services. The NHS trust’s staff and medicines cost per WAU at £368, is in the second highest (worst) quartile nationally above the median of £354 (2016/17). The high cost medicines at £117 per WAU are more expensive than both national [£109] and peer median [£106], and non-high cost medicines at £210 per WAU are also above the national average of £202. The NHS trust has recently invested in a medicines management system to reduce duplication within medicines procurement and achieve stock reduction.

• The NHS trust delivered 108% of its Top Ten Medicines savings target in 2017/18 and has made good progress in delivering savings opportunities for 2018/19 where it has achieved £488,076 compared to national upper benchmark of £326,900 so far for 2018/19.

• The NHS trust is using some technology to improve patient care and avoid unnecessary admissions. Examples include creating an App for Oncology patient which facilitates self-monitoring and reduces clinician facing time. This innovation won an Health Service Journal (HSJ) patient safety award in 2017.

How effectively is the NHS trust managing its corporate services, procurement, estates and facilities to maximise productivity to the benefit of patients?

The NHS trust’s non-clinical support services productivity compares well nationally. The NHS

trust has demonstrated collaborative working with local partners in back office functions and has

been able to achieve good value on purchases. The NHS trust however, has a high

maintenance backlog which presents an infrastructure risk.


• For 2016/17 the NHS trust had an overall non-pay cost per WAU of £1,074, compared with a national median of £1,301, placing it in the lowest (best) cost quartile nationally.

• The cost of running its Finance and Human Resources departments are lower than the national average for 2016/17. Finance function costs per £100m turnover are in the best quartile nationally at £422,660 compared to a national average of £635,300. The Human Resources function is £783,280 per £100m turnover compared to a national average of £942,830.

• In terms of consolidating corporate service functions, the NHS trust hosts a shared service payroll function offering payroll services to two other local NHS trusts and it provides some procurement services to other local NHS trusts and GP Practices. The NHS trust shares a finance ledger with the whole local healthcare economy which reduces vendor costs.

• The NHS trust’s procurement processes are efficient and tend to successfully drive down costs on the things it buys. This is reflected in the NHS trust’s Procurement Process Efficiency and Price Performance Score of 72.2, which placed it in the best segment when compared with a national average of 66.5. The score of 5.4% variance from median price, for the top 100 products, also suggests that the NHS trust is getting the best prices from its procurement operations.

• The NHS trust catalogue is fixed and held by the procurement department which ensures usage and wastage levels are controlled centrally. This department also takes responsibility for stock replenishment at ward level and monitors which products are used the most. Nurses on wards are responsible for monitoring and reporting wastage of products.

• The NHS trust also has clinical engagement in its procurement decisions and processes. For instance, the Medical Director chairs the NHS trust’s Purchasing Working Group which has oversight of purchasing decisions and it has recently appointed a Clinical Procurement Nurse Specialist to support standardisation of clinical products purchasing.

• At £303 per square metre in 2016/17, the NHS trust’s estates and facilities costs benchmark significantly below the national average of £351 per m². Hard Facilities Management benchmarks slightly higher at £87 per m² compared to £82 per m² national average.

• Total critical infrastructure risk stood at £30.35 million in 2016/17 with backlog maintenance being high at £462 per m² compared to national median of £226. Work has been undertaken in key areas such as fire safety and infrastructure but due to deterioration in other areas in this time, the overall backlog is broadly staying the same.

• Soft facilities management services are partially outsourced. Food cost per meal benchmarks lower than national average at £2.96 compared to a national average of £3.71 for 2016/17. Food also scores well in the patient-led assessments of care environment (PLACE) with a score of 93.3% compared to a national average of 90.5%.

• Laundry cost per item is 32p compared to a national benchmark of 33p per item for 2016/17. Cleaning is delivered in-house and represents good value for money per square metre at £26 per square metre compared to a national median of £41 for 2016/17. Cleanliness also scores well in PLACE with a score of 99.7% compared to 98.7% national average.

• The NHS trust has undertaken a survey of clinical and surplus land and identified land at the Shrewsbury site that could be released. This will be addressed with the wider estates rationalisation plans.


How effectively is the NHS trust managing its financial resources to deliver high quality, sustainable services for patients? The NHS trust did not meet its control total for 2017/18 and its deficit position has deteriorated from the previous year. This was due to slippage in the CIP schemes and continued workforce challenges. The NHS trust is not able to meet its financial obligations without additional cash support.

• For 2017/18, the NHS trust reported a deficit of £21.3 million excluding STF which was worse than control total deficit of £15.4 million. The deterioration in position resulted mainly from slippage on key CIP schemes and agency costs, meant that the NHS trust was not eligible to receive the full STF funding. The NHS trust’s reported deficit including STF, at £17.4 million, was therefore £11.3 million worse than the planned £6.1 million deficit.

• For 2018/19 the NHS trust’s control total was £18.4 million excluding PSF and £8.6 million including PSF. At the time of the assessment, the reported position including PSF was slightly better than plan, but the position excluding PSF was worse than plan and the NHS trust was forecasting a full year deficit of £11.6 million including PSF. This was due to non-delivery of A&E performance which resulted in reduced PSF funding.

• The NHS trust has an underlying deficit of £21.3 million which has worsened from previous years (£20.5 million in 2017/18 and £15.9 million in 2016/17). The NHS trust’s analysis indicates that 50% of this deficit is attributable to split site working, with the rest resulting from agency spend and additional investments in services which it identifies as fragile. The NHS trust has plans to rationalise the estate and reconfigure its services, and its long-term financial plan indicates that it will achieve financial balance in 2023/24.

• The NHS trust’s 2017/18 CIP target at 1.94% of expenditure is lower than most other NHS trusts. The NHS trust explained that this due to non-inclusion of income and non-recurrent schemes. For 2017/18 the NHS trust had a shortfall against CIP because of slippages in some of the main schemes, but for 2018/19, the NHS trust CIP programme is 2.91% of expenditure and it was meeting the year to date plan (July 2018).

• The NHS trust is not able to meet its financial obligations and pay its staff and suppliers in the interim without additional cash support. This position has been worsened by the non-achievement of PSF targets and commissioner challenges.

• The NHS trust ensures it charges for all its activity through its current processes and commissions additional assurance from audits and independent coding reviews. It has also undertaken training for clinical coders. The income contracts are primarily payment by results with only a few services on block contracts e.g. pathology direct access. The NHS trust has minimal non-clinical and non-contract income.

• The NHS trust uses costing data and service line reporting across its service lines. The NHS trust has Patient Level Information Costing systems (PLICS) and service line reporting (SLR) reporting at care group and organisational level.

• The NHS trust has used management consultants to review productivity in clinics,

theatres and diagnostics, and expects to deliver a recurrent benefit of £750,000 in the

2018/19 CIP as a result of this work. The NHS trust is also using management

consultants for scoping work and developing a business case for the Future Fit

Programme which is the longer-term plan to address its service and financial

challenges.


Areas for improvement

• The NHS trust should continue to strengthen its workforce management systems to maintain the favourable retention rates, improve recruitment rates and reduce reliance on temporary staffing

• The trust should work at pace to embed systems that will optimise output from its medical workforce.


Ratings tables

Key to tables

Ratings Inadequate Requires

improvement Good Outstanding

Rating

change since

last inspection

Same Up one rating Up two

ratings

Down one

rating

Down two

ratings

Symbol *

Month Year = date key question inspected

* Where there is no symbol showing how a rating has changed, it means either that:

• we have not inspected this aspect of the service before or

• we have not inspected it this time or

• changes to how we inspect make comparisons with a previous inspection unreliable.

Ratings for the whole trust

Service level Trust level

Safe Effective Caring Responsive Well-led Use of

Resources

Inadequate

Nov 2018

Requires

improvement

Nov 2018

Good

Nov 2018

Requires

improvement

Nov 2018

Inadequate

Nov 2018

Requires

improvement Nov 2018

Overall quality

Inadequate

Nov 2018

Combined quality and use

of resources

Inadequate Nov 2018


Use of Resources report glossary

Term Definition

18-week referral to treatment target

According to this national target, over 92% of patients should wait no longer than 18 weeks from GP referral to treatment.

4-hour A&E target

According to this national target, over 95% of patients should spend four hours or less in A&E from arrival to transfer, admission or discharge.

Agency spend Over reliance on agency staff can significantly increase costs without increasing productivity. Organisations should aim to reduce the proportion of their pay bill spent on agency staff.

Allied health professional (AHP)

The term ‘allied health professional’ encompasses practitioners from 12 diverse groups, including podiatrists, dietitians, osteopaths, physiotherapists, diagnostic radiographers, and speech and language therapists.

AHP cost per WAU

This is an AHP specific version of the pay cost per WAU metric. This allows trusts to query why their AHP pay is higher or lower than national peers. Consideration should be given to clinical staff mix and clinical staff skill mix when using this metric.

Biosimilar medicine

A biosimilar medicine is a biological medicine which has been shown not to have any clinically meaningful differences from the originator medicine in terms of quality, safety and efficacy.

Cancer 62-day wait target

According to this national target, 85% of patients should begin their first definitive treatment for cancer within 62 days following an urgent GP referral for suspected cancer. The target is 90% for NHS cancer screening service referrals.

Capital service capacity

This metric assesses the degree to which the organisation’s generated income covers its financing obligations.

Care hours per patient day (CHPPD)

CHPPD measures the combined number of hours of care provided to a patient over a 24 hour period by both nurses and healthcare support workers. It can be used to identify unwarranted variation in productivity between wards that have similar speciality, length of stay, layout and patient acuity and dependency.

Cost improvement programme (CIP)

CIPs are identified schemes to increase efficiency or reduce expenditure. These can include recurrent (year on year) and non-recurrent (one-off) savings. CIPs are integral to all trusts’ financial planning and require good, sustained performance to be achieved.

Control total Control totals represent the minimum level of financial performance required for the year, against which trust boards, governing bodies and chief executives of trusts are held accountable.

Diagnostic 6-week wait target

According to this national target, at least 99% of patients should wait no longer than 6 weeks for a diagnostic procedure.


Did not attend (DNA) rate

A high level of DNAs indicates a system that might be making unnecessary outpatient appointments or failing to communicate clearly with patients. It also might mean the hospital has made appointments at inappropriate times, eg school closing hour. Patients might not be clear how to rearrange an appointment. Lowering this rate would help the trust save costs on unconfirmed appointments and increase system efficiency.

Distance from financial plan

This metric measures the variance between the trust’s annual financial plan and its actual performance. Trusts are expected to be on, or ahead, of financial plan, to ensure the sector achieves, or exceeds, its annual forecast. Being behind plan may be the result of poor financial management, poor financial planning or both.

Doctors cost per WAU

This is a doctor specific version of the pay cost per WAU metric. This allows trusts to query why their doctor pay is higher or lower than national peers. Consideration should be given to clinical staff mix and clinical staff skill mix when using this metric.

Delayed transfers of care (DTOC)

A DTOC from acute or non-acute care occurs when a patient is ready to depart from such care is still occupying a bed. This happens for a number of reasons, such as awaiting completion of assessment, public funding, further non-acute NHS care, residential home placement or availability, or care package in own home, or due to patient or family choice.

EBITDA Earnings Before Interest, Tax, Depreciation and Amortisation divided by total revenue. This is a measurement of an organisation’s operating profitability as a percentage of its total revenue.

Emergency readmissions

This metric looks at the number of emergency readmissions within 30 days of the original procedure/stay, and the associated financial opportunity of reducing this number. The percentage of patients readmitted to hospital within 30 days of discharge can be an indicator of the quality of care received during the first admission and how appropriate the original decision made to discharge was.

Electronic staff record (ESR)

ESR is an electronic human resources and payroll database system used by the NHS to manage its staff.

Estates cost per square metre

This metric examines the overall cost-effectiveness of the trust’s estates, looking at the cost per square metre. The aim is to reduce property costs relative to those paid by peers over time.

Finance cost per £100 million turnover

This metric shows the annual cost of the finance department for each £100 million of trust turnover. A low value is preferable to a high value but the quality and efficiency of the department’s services should also be considered.

Getting It Right First Time (GIRFT) programme

GIRFT is a national programme designed to improve medical care within the NHS by reducing unwarranted variations.

Human Resources (HR)

This metric shows the annual cost of the trust’s HR department for each £100 million of trust turnover. A low value is preferable to a high value but the quality and efficiency of the department’s services should also be considered.


cost per £100 million turnover

Income and expenditure (I&E) margin

This metric measures the degree to which an organisation is operating at a surplus or deficit. Operating at a sustained deficit indicates that a provider may not be financially viable or sustainable.

Key line of enquiry (KLOE)

KLOEs are high-level questions around which the Use of Resources assessment framework is based and the lens through which trust performance on Use of Resources should be seen.

Liquidity (days) This metric measures the days of operating costs held in cash or cash equivalent forms. This reflects the provider’s ability to pay staff and suppliers in the immediate term. Providers should maintain a positive number of days of liquidity.

Model Hospital The Model Hospital is a digital tool designed to help NHS providers improve their productivity and efficiency. It gives trusts information on key performance metrics, from board to ward, advises them on the most efficient allocation of resources and allows them to measure performance against one another using data, benchmarks and good practice to identify what good looks like.

Non-pay cost per WAU

This metric shows the non-staff element of trust cost to produce one WAU across all areas of clinical activity. A lower than average figure is preferable as it suggests the trust spends less per standardised unit of activity than other trusts. This allows trusts to investigate why their non-pay spend is higher or lower than national peers.

Nurses cost per WAU

This is a nurse specific version of the pay cost per WAU metric. This allows trusts to query why their nurse pay is higher or lower than national peers. Consideration should be given to clinical staff mix and clinical staff skill mix when using this metric.

Overall cost per test

The cost per test is the average cost of undertaking one pathology test across all disciplines, taking into account all pay and non-pay cost items. Low value is preferable to a high value but the mix of tests across disciplines and the specialist nature of work undertaken should be considered. This should be done by selecting the appropriate peer group (‘Pathology’) on the Model Hospital. Other metrics to consider are discipline level cost per test.

Pay cost per WAU

This metric shows the staff element of trust cost to produce one WAU across all areas of clinical activity. A lower than average figure is preferable as it suggests the trust spends less on staff per standardised unit of activity than other trusts. This allows trusts to investigate why their pay is higher or lower than national peers.

Peer group Peer group is defined by the trust’s size according to spend for benchmarking purposes.

Private Finance Initiative (PFI)

PFI is a procurement method which uses private sector investment in order to deliver infrastructure and/or services for the public sector.

Patient-level costs

Patient-level costs are calculated by tracing resources actually used by a patient and associated costs


Pre-procedure elective bed days

This metric looks at the length of stay between admission and an elective procedure being carried out – the aim being to minimise it – and the associated financial productivity opportunity of reducing this. Better performers will have a lower number of bed days.

Pre-procedure non-elective bed days

This metric looks at the length of stay between admission and an emergency procedure being carried out – the aim being to minimise it – and the associated financial productivity opportunity of reducing this. Better performers will have a lower number of bed days.

Procurement Process Efficiency and Price Performance Score

This metric provides an indication of the operational efficiency and price performance of the trust’s procurement process. It provides a combined score of 5 individual metrics which assess both engagement with price benchmarking (the process element) and the prices secured for the goods purchased compared to other trusts (the performance element). A high score indicates that the procurement function of the trust is efficient and is performing well in securing the best prices.

Sickness absence

High levels of staff sickness absence can have a negative impact on organisational performance and productivity. Organisations should aim to reduce the number of days lost through sickness absence over time.

Service line reporting (SLR)

SLR brings together the income generated by services and the costs associated with providing that service to patients for each operational unit. Management of service lines enables trusts to better understand the combined view of resources, costs and income, and hence profit and loss, by service line or speciality rather than at trust or directorate level.

Supporting Professional Activities (SPA)

Activities that underpin direct clinical care, such as training, medical education, continuing professional development, formal teaching, audit, job planning, appraisal, research, clinical management and local clinical governance activities.

Staff retention rate

This metric considers the stability of the workforce. Some turnover in an organisation is acceptable and healthy, but a high level can have a negative impact on organisational performance (eg through loss of capacity, skills and knowledge). In most circumstances organisations should seek to reduce the percentage of leavers over time.

Top Ten Medicines

Top Ten Medicines, linked with the Medicines Value Programme, sets trusts specific monthly savings targets related to their choice of medicines. This includes the uptake of biosimilar medicines, the use of new generic medicines and choice of product for clinical reasons. These metrics report trusts’ % achievement against these targets. Trusts can assess their success in pursuing these savings (relative to national peers).

Weighted activity unit (WAU)

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

shrewsbury and telford nhs trust · the nhs trust has not achieved the 4-hour a&e standard...

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