Further metrics and additional considerations which boards may find useful to provide insight into their trust’s performance.

I. Strategy

Trust’s own strategic objectives

What to consider when developing and using indicators:

• Boards should ensure patient and service user experience shapes the organisation’s strategic objectives.
• Indicators should be specific, measurable and time bound. Every 6 months minimum, the board should review these to monitor delivery of the strategic objectives.
• The board should use quarterly Board Assurance Framework updates to identify risks in year that threaten delivery and focus their attention on them.

Local system objectives including forward plans

What to consider when developing and using indicators:

• Boards should understand the system-wide priorities and how their trust’s services support delivery of the joint plan they have agreed with partner trusts and their integrated care board (ICB), ensuring they meet their shared responsibility for system financial balance.
• To understand performance against local objectives, and how it compares to their peers, organisations should look at the scope for benchmarking and reporting within their provider collaborative – for instance benchmarking against peers to understand whether agreed shared objectives are being delivered.

Service and business development 

What to consider when developing and using indicators:

• Boards should ensure their organisation understands how their local population uses the trust’s services. Local geodemographic data can be used to identify groups that may have a lower-than-expected uptake of services. If health inequalities are identified, further work should be carried out to understand the causes and to develop solutions, working together with system partners.
• Boards should ensure their organisation understands access and referral patterns and the drivers for these. Understanding benchmarking analysis, for example using Getting it Right First Time (GIRFT) and the Model Health System, will help to plan future demand and areas for improvement.
• Trusts should collaborate within systems to ensure the best service is delivered for the health of the population.
• Boards need to understand the implications for their organisation in meeting their shared responsibility for system financial balance.
• Boards need to be assured they have appropriate visibility of estate and capital and their requirements are aligned to the integrated care system (ICS) infrastructure strategy. The frequency of reporting is likely to reflect the nature of the risks and whether the organisation is undertaking major capital transformation projects.

Trends and forecasts      

What to consider when developing and using indicators:

• Boards should understand the organisation’s income and expenditure by service and business unit for the previous financial year and current year-to-date.
• Understanding variances from budget including the recurrent nature of income and expenditure/run rate analysis will help the organisation to develop robust financial forecasts and a sustainable approach to delivering services.
• The board should be assured that activity data is robust and up to date. Waiting lists should be well understood alongside the expected income and associated costs to deliver to expected targets and standards. Significant issues arising from this analysis should be reported to the board.

National priorities

For example:

• quality improvement
• national planning guidance
• reducing health inequalities
• NHS Net Zero

What to consider when developing and using indicators:

• Board members should understand national priorities and standards in guidance such as the annual planning and contracting guidance and specific targets such as Net Zero.
• Health inequalities: the Healthcare Inequalities Improvement Dashboard brings together strategic indicators, cut by deprivation and ethnicity, in one place to measure, monitor and inform actionable insights. This can be used when determining local strategic priorities and establishing how they will be monitored.
• Net Zero: In 2020 the NHS made a public commitment to get its estate to net zero by 2040, with an 80% reduction by 2032. The NHS Net Zero Building Standard will help organisations achieve this ambition.

Boards and committees should receive:

• a summary of investment requirements to achieve these targets, alongside a summary of investment made
• an annual report on progress

Compliance with regulatory requirements

What to consider when developing and using indicators:

• Boards need to be assured their organisation complies with all regulatory requirements or working to do so, and issues are escalated where there is a risk of – or actual – non-compliance with the licence. 
• In such instances boards should:
  • work with their improvement team to develop and deliver a recovery plan
  • monitor progress against their recovery plan
  • review whether their ‘exit date’ is still accurate

External developments 

What to consider when developing and using indicators:

• Boards need to ensure their organisation has appropriate mechanisms for monitoring and evaluating the impacts of policy, technology and other changes in the external environment. The board should receive periodic assessments of the potential strategic risks and opportunities arising, which could include:
  • advancements in artificial intelligence
  • digital developments and enablers
  • medical research breakthroughs

Estates compliance        

What to consider when developing and using indicators:

Compliance with legislation is essential to sustain safe, legal and compliant services and avoids costly remedial actions and disruptive urgent intervention across organisations. Compliance failures can lead to fines and prosecutions, and contribute to postponed appointments, and infrastructure and procedural failures.

Robust reporting is required to ensure board members are sighted on their statutory responsibilities, accountabilities and risks for the trust estate. This can come in various forms (for example, performance dashboards or high-level data) but should provide a consistent framework that allows boards to review estates services in an integrated way.

Boards should receive:

• a summary of the latest mandated NHS Premises Assurance Model Self-Assessment
• main estates and facilities compliance risks, scored and RAG (red, amber, green) rated with mitigations. These should be detailed by areas of service/estate (as opposed to line item), such as fire, electrical
• a summary of the impact of non-compliance on clinical services

Estates risks (infrastructure failure and critical maintenance)          

What to consider when developing and using indicators:

In 2022/23 across the NHS there were more than 12,000 incidents where infrastructure failed and stopped clinical services. These incidents have a significant impact on patients, and on the trust’s finances and productivity.

Information should be triangulated with other quality metrics such as Patient-Led Assessments of the Care Environment (PLACE), NHS Premises Assurance Model and safety culture measures.

Boards should also:

• understand the main areas of vulnerability across the estate that without investment are likely to fail and disrupt services
• understand the true costs associated with putting right these areas of vulnerability
• track investment
• assure themselves their organisation monitors and understands performance. Comparisons with other organisations should be those in their benchmark group, for example, community trusts with community trusts

This could also be supplemented by the trust’s latest 6 facet/condition survey information about statutory compliance, shown as a percentage of the GIA at categories A to D for compliance with mandatory fire safety requirements and statutory health and safety legislation, as defined in a risk-based methodology for establishing and managing backlog. The organisation should aim to be at category B level, including performance against other peer groups using Estates Return Information Collection (ERIC) data where applicable.

II. Quality

Mortality

What to consider when developing and using indicators:

Mortality reporting should draw on and triangulate data from several sources, and standardised reporting should be used where possible.

Mortality reporting should look at variation and inequalities across different groups, including people with a learning disability and autistic people, children and young people, people with a serious mental illness (SMI), and people from black, Asian and minority ethnic communities.

As more patients are moved into community beds and managed via virtual wards, it may be appropriate to look at deaths after discharge.

Mental health trusts should also consider data on homicides.

Mandatory board information 

What to consider when developing and using indicators:

Certain types of quality data are nationally specified for mandatory reporting to the board:

1. Learning from deaths

Quarterly board reporting of certain Learning from Deaths mortality data is mandatory. 

The board should understand the trust’s investigations, learning and actions implemented in response to deaths. Particular attention should be paid to the deaths of autistic children and young people with a learning disability or mental health condition.

Mental health trusts should use the Royal College of Psychiatrists’ guidance to report on those circumstances which require further review, including the protected characteristics of people who are dying prematurely.

2. Safety incident reporting

In cases where a Patient Safety Incident Investigation (PSII) is mandatory, this information must be reported to the board.

3. Perinatal quality

The Perinatal Quality Surveillance Model requires the mandatory reporting of certain information to boards – see appendix 2 of implementing a revised perinatal quality surveillance model.

Safety incidents

What to consider when developing and using indicators:

Safety intelligence should be triangulated with other quality metrics such as clinical audit, patient experience and safety culture measures. Boards should review patient safety incident reporting data linked to their trust’s patient safety incident review plan priorities.

A variety of data should be used, which can be outcome or process based. This should reflect the needs and objectives of the services in question. There must be a clear rationale for why metrics are collected and used for patient safety incident response oversight.

Irrespective of the choice of metrics, the board (either directly or through its subcommittees) should be able to note outlier specialties or pathways and trends and to understand the learning taking place, and the impact of changes implemented following incidents. It must be possible to identify emerging themes from investigations and to understand if these continue to be an issue across the organisation, regardless of whether individual action plans are being developed and implemented.

As well as monitoring safety intelligence to identify early warning signs of risk, boards need to assure themselves the actions taken / being taken are leading to improvement. The Patient Safety Incident Response Framework is firmly embedded in quality improvement, and boards should expect to see patient safety learning reflected in their quality improvement priorities.

Low numbers or proportions of reported incidents (both in absolute terms and relative to peers or internal benchmarking) may indicate underreporting.

Care Quality Commission (CQC)

What to consider when developing and using indicators:

CQC provides insight reports and flags early concerns. Boards should note these will often be more time sensitive than ratings.

Clinical and internal audit outcomes and the outputs of independent reviews

What to consider when developing and using indicators:

Findings and recommendations from internal audits and reviews (including commissioned clinical reviews) can indicate quality issues and should always be reported promptly to the board and analysed thematically. Their nature will drive whether the outputs (such as themes, recommendations or findings) should be reported by exception or on a periodic basis.

The commission of internal reviews should not in itself be seen as a warning sign – on the contrary, the lack of internal reviews can reveal leadership and cultural concerns/issues. When considering audit and review, boards must be assured that their scope has not been unduly limited (for example, to exclude certain causes) and explores all potential avenues of concern. Recommendations must be SMART with a realistic action plan for implementation.

The board should receive routine (ie quarterly) thematic updates on learning and actions from independent investigations, including gaining assurance that the actions have been implemented.

When considering the outputs of independent investigations, boards need to understand if there are common themes behind them (for example, staff concerns about speaking up), even if the context or outcome of the incidents or topics in question are different.

Trusts must evidence participation in national, statutory and local clinical audit and patient outcome programmes (NCAPOP), with evidence of actions taken – especially where outliers have been identified (as reported by CQC).  This should be reported annually in NHS Quality Accounts.

Staff feedback indicators on quality

What to consider when developing and using indicators:

Staff survey data will highlight trends, variation and themes, for example, about leadership, staff engagement, bullying and harassment, and safety sub-scores. The data should be analysed by and across different staff groups and role seniority.

Where there are known concerns about culture it may be appropriate to look in detail at compassionate leadership, bullying and harassment, staff engagement and safety sub-scores.

Feedback from students and trainees can also be a sensitive indicator of early warning signs.

Board members should ensure reporting information is supplemented by observations, for example, walkabouts and regular presence on wards. 

Experiences of care        

What to consider when developing and using indicators:

Patient stories support strategic and operational (board to ward) quality improvement discussions. In addition, a high proportion of patients must be invited to complete the Friends & Family Test (FFT) and the board should set a suitable level of ambition for numbers completing it.

FFT data should be part of the quality dashboard and will highlight services, wards or sites which are outliers. Boards should understand the explanation for such differences and why scores deteriorate. FFT should also be used to measure progress against overall improvement priorities (for example discharge rates).

The NHS patient survey programme focuses on areas such as cancer, inpatient, maternity and emergency care. Boards should be assured their organisation is comparing results over time (including against similar trusts) and is reviewing variation among population groups (for example by ethnicity).

Analysis of national and local patient surveys will show trends in patient experience metrics. NHS.uk ratings and reviews can also offer a source of feedback in real time which should be considered as part of experience of care data triangulation, along with complaints.

Mental health

The board should review approaches to gathering and acting on patient experience measures in inpatient mental health settings. The patient and carer race equality framework can be used to improve ethnic minorities’ experiences of mental health services.

The way we clean our facilities and provide food, nutrition and logistical operations is essential to the patient experience. Boards should review PLACE data and assure themselves that the environment and EFM service represents the operation they aspire to achieve. Boards should consider if PLACE provides sufficient detail to identify poor performance and whether additional measures and reports are necessary.

Information should be triangulated with other quality metrics such as PLACE, Premises assurance model and safety culture measures.

Boards should, for example:

• understand their star rating against the national cleaning and food and drink standards
• review their PLACE data against quality standards and ensure robust action plans are evident to seek improvement

Complaints, concerns and compliments  

What to consider when developing and using indicators:

The number of complaints alone is not a sign of poor care – unusually low numbers can be a warning sign. Boards should oversee good complaint management (such as time taken to respond), however their most important role is to demonstrate learning from complaints.

Boards need to understand the nature of complaints, concerns and compliments, and the actions delivered as a result. Complaints’ response time is not a good indicator, as the timeframe is negotiable. Data on upheld / partially upheld / not upheld should not be looked at as the national data collection has ceased.

It is helpful to reflect on the CQC’s ‘Responsive’ domain on complaints. This shouldn’t just be tested at inspection but also by boards.

NEDs may want to meet PALS staff directly to understand the process and how the organisation responds to complaints.

III. People

Headcount, salary bill, skill mix         

What to consider when developing and using indicators:

Many NHS staff work part-time – when benchmarking against comparable peers, it is important to consider gross headcount and whole-time equivalents, and the effective workforce (such as those not on career breaks or maternity leave).  

Use of agency / bank      

What to consider when developing and using indicators:

Sudden increases in agency / bank staff use can provide an early warning of problems.

If bank staff also have substantive roles, for example, they are working full /almost full time and taking on multiple bank shifts, this can highlight potential staff burnout issues.

Understanding the demographics of bank / agency staff can also indicate whether there may be an unmet need in the substantive workforce, for example, flexible working needs aren’t being supported.

Staff health and wellbeing       

What to consider when developing and using indicators:

Like staff turnover, health and wellbeing is an important measure of the health and culture of an organisation and should be reviewed at least quarterly by boards. Boards should consider:

• the relationship between vacancy rates and staff engagement scores
• high or low staff turnover and the underlying reasons for it
• sickness absence figures:
  • may provide warning indicators about organisational culture and patient safety, for example, patterns in short term absence (Mondays off), may also be cause for concern
  • low figures can mask high presenteeism, which impacts productivity and may have longer-term impacts on absence

Vacancies   

What to consider when developing and using indicators:

Vacancies can be an indicator of organisational culture and sustainability. High / increasing levels of vacancies are a predictor of rising levels of future sickness absence.

Boards should understand: the areas which are difficult to recruit to and why (for example, market, location); the average length of time to recruit by post-type; and roles with a small number of – or zero – applicants.

This should be considered in detail at the appropriate subcommittee and reported to and understood by the board.

Staff turnover and leaver rates           

What to consider when developing and using indicators:

A turnover rate that appears too high and (arguably) too low can be an indicator of a poor organisational culture, and in combination with sickness absence, it is important to consider why people are leaving. 

Boards should monitor and make a distinction between ‘positive’ and ‘negative’ attrition as a marker of a trust’s ability to develop its workforce and provide career pathways to staff.

Diversity      

What to consider when developing and using indicators:

A diverse workforce that is representative of the communities it serves can support the organisation to address the health inequalities in those communities. Diverse and inclusive environments provide psychological safety for individuals and teams. In turn this creates better quality and safer patient care and more efficient and productive organisations. The board should consider the national NHS equality, diversity and inclusion improvement plan and the trust’s progress in delivering the actions in it.

Staff speaking up (freedom to speak up)    

What to consider when developing and using indicators:

The board must ensure there is a healthy culture which enables staff and volunteers to report concerns, as well as promoting national requirements such as the Fit and Proper Persons Test (FPPT), where concerns may be identified around senior individuals.

Data can be used to identify where reporting levels may be a cause for concern, whether within certain teams or by specific staff groups. 

Access the Freedom to Speak Up (FTSU) guide on how to interpret FTSU data:  

• indicators of concern – page 32
• triangulating data and being curious about your data – page 18

The number of concerns raised with guardians needs triangulating with other data – for example, the number of those who speak up internally versus the number who go direct to external bodies such as NHS England or CQC; and what promotional campaigns have there been to raise awareness and understanding of speak up?

Data should be sliced in several ways, including by division / directorate as well as by protected characteristic.

 Note:

• some trusts promote anonymous reporting – so taken in isolation, high anonymity may not be an issue
• high levels of or spikes in reporting may not be a cause for concern if they follow a communications campaign to encourage staff to speak up
• persistent low numbers can be as worrying as high numbers

Triangulate FTSU information with other metrics including:

• grievances
• exit interview themes
• sickness rates
• patient complaints
• patient safety incidents
• bullying /grievance / number of suspensions (time suspended)

Staff engagement            

What to consider when developing and using indicators:

NHS Staff Survey and National Quarterly Pulse Survey (NQPS) results cannot be directly compared due to differences in methodology, seasonal differences, etc. However, NQPS can be used as a trend indicator for staff engagement scores. 

NQPS runs in quarters 1, 2 and 4. The NHS Staff Survey runs in quarter 3 with results available the following spring.

Employee experience    

What to consider when developing and using indicators:

Survey results should be used at an organisational, directorate, team, etc level to effect change.

Boards should be assured their organisation monitors and understands performance over time. Comparisons with other organisations should be with those in their benchmark group, for example community trusts with community trusts.

Organisations should understand their training provision and impact, for example, the uptake by students post-graduation and why the organisation may not be their preferred option.

Lived experience workforce     

What to consider when developing and using indicators:

Boards may find it helpful to consider the provision of lived experience leadership roles.

IV. Access and targets

Acute           

What to consider when developing and using indicators:

Elective recovery targets

Elective recovery targets are applicable except where patients choose to wait longer or in specific specialties.

To understand elective waiting times better and their impact on patients, further analysis can be undertaken by population grouping and Index of Multiple Deprivation quintile to identify and address inequalities.

Trusts should discuss with their ICB their contribution to all national elective recovery targets.

Mental health

What to consider when developing and using indicators:

Boards may also wish to consider other metrics on access to services including:

• number of people accessing NHS Talking Therapies for anxiety and depression as a percentage of trajectory
• number of adults and older adults with severe mental illness accessing community mental health services as a percentage of trajectory
• recovery of the dementia diagnosis rate
• access to perinatal mental health services

Community           

What to consider when developing and using indicators:

Benchmarking is more challenging for community trusts as nationally available data for community and out of hospital provision is more limited. Work is taking place nationally to improve this and boards should ensure their organisations are keeping abreast as more data and comparison sources become available.

Ambulance

What to consider when developing and using indicators:

Boards should be aware of the category 2 30 minutes target, which is a central focus of the UEC recovery plan. Other indicators are useful to ensure wider performance does not decline over time. These include:

• See and Treat rates
• Hear and Treat rates
• Category 1, 3 and 4 response time

Prevention and health inequalities improvement            

What to consider when developing and using indicators:

Boards should ensure their organisation is working with their ICB to establish and monitor progress against wider population health targets.

V. Productivity

The Model Health System contains the latest productivity and efficiency metrics and their methodologies, guidance and resources, and the ability to benchmark performance with peers and against national averages. Boards should use this information combined with local intelligence to assess their drivers of productivity.

Headline productivity

What to consider when developing and using indicators:

Implied Productivity Growth (year-to-date compared to 2019/20) (percentage)

A negative value implies decreased productivity while positive implies productivity growth. The target is to see positive year-on-year change in this value and reduce or eliminate any negative distance from the same value calculated for the same period in 2019/20.

The headline productivity metric offers a measure of current productivity by looking directly at costs and activity. However, how some of the other metrics link to productivity can be more nuanced; they should therefore be seen as guides and be combined with further local intelligence to help present a fuller picture of overall performance.

For example, reductions in the average length of stay for non-elective spells should improve productivity by freeing up beds and allowing greater elective through-put. However, there could be wider factors constraining further elective work, for example, temporary theatre closures, meaning productivity does not rise as might have been expected from the reduction in average length of stay.

Operational and clinical productivity           

What to consider when developing and using indicators:

Average Length of Stay (ALOS) – non-elective (1+ days)             

The purpose of the data is to show how activity volumes are recovering and whether ALOS are returning to normal levels following Covid.

Bed occupancy classed as clinically ready for discharge for hospital (percentage)

This metric allows the tracking of the proportion of patients who do not meet the criteria to reside and therefore are clinically ready for discharge but are inhibited by other contributing factors. A decrease in this proportion can be seen to release much-needed capacity in acute hospital settings.

Capped theatre utilisation (percentage) / Touch time within planned session vs planned session time     

This indicator helps understand the effectiveness of the operation scheduling processes of the organisation in comparison to other organisations.

This metric represents theatre time utilisation on actual surgery, and touch time represents the time where the theatre team were actively engaged in operating. A high level of touch time utilisation could represent effective use of theatre time as well as efficiency in non-surgery activities such as set up and logistics. Touch time utilisation over 85% is considered good practice.

‘Capped Utilisation’ refers to the touch time being calculated on the total volume of time the surgical team was operating, within the planned session time only. This means any touch time occurring within an unplanned session extension (after the planned session end time) is excluded from the calculation. This can be used to build understanding alongside the un-capped utilisation percentage and this metric should also be interpreted alongside other supporting measures such as early starts, late finishes and unplanned session extensions. This figure in normal circumstances should not be above 100% although data quality issues with the start time can cause it to be higher.

Day case rates (percentage)

Trusts may wish to adopt benchmarks proposed by the British Association of Day Surgery (BADS) for the proportion of cases that could safely be seen as a day case (including procedure room and zero night stays).

Rates lower than the BADS benchmark might indicate an opportunity to reduce inpatient stays and improve productivity, while maintaining or improving clinical quality and patient experience. On the Model Health System a day case will be counted if the spell was pre-planned with day surgery intent only.

Workforce productivity  

What to consider when developing and using indicators:

Implied workforce productivity growth (year-to-date compared to 2019/20)

A negative value implies decreased productivity while positive implies productivity growth. The target is to see positive year-on-year change in this value and reduce / eliminate any negative distance from the same value calculated for same period in 2019/20.

Non-elective admissions per clinical whole-time equivalent (WTE)

Increasing this value means outputs (non-elective admissions) relative to inputs (clinical WTEs) are improving and more non-elective admissions are being treated per clinical WTEs.

Outpatient per consultant WTE    

Increasing this value means outputs (total first and follow-up outpatient attendances and outpatient procedures) relative to inputs (consultant WTEs) are improving and more outpatient attendances are being carried out per consultant WTEs.

Elective admissions per clinical WTE      

Increasing this value means outputs (elective admissions) relative to inputs (clinical WTEs) are improving and more elective admissions are being treated per clinical WTEs.

A&E attendances (Type 1 and 2) per emergency medicine consultant           

Increasing this value means outputs (A&E attendances (Type 1 & 2)) relative to inputs (emergency medicine consultants) are improving and more A&E attendances (Type 1 & 2) are being attended per emergency medicine consultant. This includes substantive, bank and agency staff.

Workforce drivers

What to consider when developing and using indicators:

Overall temporary staff spend as a percentage of total spend            

This metric is intended to highlight to organisations where they may be spending more on temporary staffing than others and should consider reducing the usage of temporary staffing as a whole, if possible. Temporary staffing includes a combination of agency and bank.

Registered nurses: Sickness absence rate (percentage)          

Reducing rates of sickness absence reduces costs and has a positive impact on the wider workforce, the efficiency of an organisation and patient care. Evidence shows that poor health can be caused by several work-related factors, including lack of management support, heavy workload, job insecurity, perceived organisational injustice, sense of lack of control and work-home conflict.

All staff: NHS turnover rate (percentage)              

A percentage of all staff who left an organisation to join another NHS organisation, or left the NHS, over the previous 12 months.

A high turnover rate may indicate a number of opportunities to identify reasons for staff leaving and allow management the chance to introduce staff retention schemes to lessen the impact of staff leaving. The turnover rate includes a certain amount of expected turnover for normal transition of staff, including career advancement, promotions and voluntary reasons for leaving. This can also be affected by region and geographical dependencies.

Care hours per patient day              

A measure of ward level productivity and transparency on variation in staff to patient ratios across wards, specialties and organisations.

Very low rates may indicate a potential patient safety risk. Very high rates may suggest the organisation has several unproductive wards or inefficient staff rostering processes.

Non-pay efficiency – medicines (cost)     

This metric allows providers to identify the total monthly value of the delivered savings for the combined top medicines in the current financial year as well as the value of any potential additional savings that have not been delivered.

Non-pay efficiency          

What to consider when developing and using indicators:

Non-pay efficiency – estates and facilities cost (£ per m2)      

The total estates and facilities running cost is the cost of running an NHS estate, including staff and overhead costs. In-house and out-sourced costs, including PFI costs, are included.

The cost of estates and facilities services may reflect the size of the estate. However, this relationship is frequently affected by other factors. For example, cleaning costs are relative to the floor area being cleaned, but are also affected by how often the cleaning occurs and the type of cleaning. Clinical areas will be cleaned more thoroughly than office areas.

The total running costs consist of 4 parts: hard FM, soft FM, management (Hard and Soft FM) costs and financing costs. Changes to this metric can be the result of movements in these elements year-on-year.

Non-pay efficiency – estates and facilities cost (£ per m2)      

Total estates and facilities running costs is the cost of running an NHS estate, including associated staff and overhead costs. It also includes in-house and out-sourced costs, including PFI costs.

Many services related to the NHS estates and facilities may be fully or partly related to the size of the estate. However, this relationship is frequently affected by other factors. For example, cleaning costs are relative to the floor area being cleaned, but are also affected by how often the cleaning occurs and the type of cleaning. Clinical areas will be cleaned more thoroughly than office areas.

The total running costs consist of 4 parts: hard FM, soft FM, management (Hard and Soft FM) costs and financing costs. Changes to this metric can be the result of movements in these elements year-on-year.

Estates        

What to consider when developing and using indicators:

Estates failure           

Boards need to understand the quantum, severity and cost of infrastructure failure and the impact it has on clinical services, staff morale and productivity.

Ambulance, mental health and community trusts – productivity considerations

An individual trust’s performance is impacted by its wider system partners, including acute, community, ambulance and mental health trusts, as well as primary and social care providers.

The list above covers productivity-related metrics on the Model Health System for acute and specialist trusts. Work is underway to produce a similar list and section of the Model Health System with productivity-related metrics for all other trusts. This will cover metrics and indictors similar to those below.

Operational productivity          

What to consider when developing and using indicators:

Ambulance providers:

• conveyance rate
• see and convey rates
• average response times for category (CAT) 1,2,3 and 4 calls
• emergency ambulance handover delays (for example, over 30 minutes)

Mental health providers:

• 12-hour mental health breaches in A&E
• acute adult long length of stay (60+ days)
• older adult acute long length of stay (90+ days)
• percentage of acute adult bed occupancy

Community providers:

• virtual ward occupancy and length of stay
• number of delayed discharges
• average length of stay

VI. Finance

Organisational performance:

What to consider when developing and using indicators:

• income and expenditure
• cash flow

Financial stability and efficiency are defined in the NHS planning guidance. Boards should ensure they receive quantitative and qualitative overviews of financial performance including variance analysis and any known risks and mitigations. 

Boards should understand the organisation’s current performance versus forecast outturn (FOT) and year-to-date (YTD).

Boards should understand current run rate versus what is required to deliver the year end plan and the differences between each. This assures boards as to the likely deliverability of a plan and the extent to which performance may need to change to deliver its financial plan.

Liquidity       

What to consider when developing and using indicators:

Liquidity metrics demonstrate the trust is able to meet its financial obligations. Liquidity (days) measures the days of operating costs held in cash or cash equivalent forms, which reflects the trust’s ability to pay staff and suppliers in the immediate term. Liquidity is a key metric of an organisation’s financial health and is particularly important in an environment with financial challenges and pressures.

Financial run-rate

What to consider when developing and using indicators:

Considering the run rate will give the board a view of how the recent month’s activity will impact the year-end position relative to plan, when extrapolated out for the year.

Run rate analysis should also look at the underlying financial position of the organisation, adjusted for non-recurrent material items which may distort the underlying future forecast. This will help the board to be aware of financial issues which may be managed in-year but could result in longer term recurrent financial challenge. Effective run rate and underlying analysis improves board assurance of organisational grip and control.

Risk and mitigations       

What to consider when developing and using indicators:

In a complex organisation there will be financial uncertainties that need to be captured in the ledger to understand the implications. The board should be sighted on a range of risks that are most likely to become issues so they can be considered and managed. Managing these effectively will help to reduce the risk of unexpected changes to the financial position and can support decision making by giving broader financial context than ledger information alone.

Phasing of efficiency schemes           

What to consider when developing and using indicators:

To support board assurance that local plans are phased realistically, phasing should be considered against historical performance and in-year delivery should be risk rated. If efficiency savings are not yet identified, these should be appropriately phased and monitored closely, to avoid unexpected movements from planned position.

Capital         

What to consider when developing and using indicators:

The availability of capital funding and the trust’s capital plan supports delivery of the organisation’s strategic and operational plans. Decisions on allocation of capital resources are often based on a limited understanding of the risks to the trust from the estate. Aging equipment and building fabric is often overlooked at the expense of new equipment or new developments. Board representation from well informed members would contribute to discussions at that level so that decisions are based on the whole picture and not an unrealistic perception.

Boards should review, for example:

• a summary of risk areas that require capital investment
• a summary of progress against the trust’s capital programme, including the overall capital budget, itemised into sub-allocations, which incorporate the main projects that comprise the trust’s capital programme with the proposed outcomes. Variances to plan and slippages in delivery should be highlighted to the board and relevant mitigating actions provided
• a clear understanding of the next 5 years capital requirements and likely gap to allocation

Linkages to non-financial domains should also be made where relevant, for example, patient experience where buildings are in a poor state of repair.

System financial performance           

What to consider when developing and using indicators:

Trusts have a duty under the provider licence to deliver the system’s overall financial plan. The board should understand how their organisation contributes to the overall plan, especially where decisions may need to be taken locally in support of the broader organisational duty to the system, in particular where it has an adverse effect on the trust’s underlying position.

Productivity           

What to consider when developing and using indicators:

Another metric for boards to consider is weighted activity per substantive WTE (a comparison to own performance over time)

Estates and facilities management (EFM) running costs         

What to consider when developing and using indicators:

Typically 10% of a trust’s overall budget is allocated to EFM. The Model Health System provides trusts and systems with a picture of how each organisation compares with its peers on EFM running costs. The costs in the Model Health System are provided by the organisations themselves on a mandated yearly collection called ERIC.

Day-to-day levels of risk are not all reported at board level. Routine board level reporting of estates running costs, achievable financial efficiencies and maximisation of the estate helps ensure the board is sighted and understands the severity of issues and impact limited investment has on patient quality. 

Maintaining this oversight also helps to quantify investment requirements to maintain services, address backlog and aid greater understanding of impact, while providing trajectory and forecasting for improvements in the future estate.

Boards should:

• review and sign off their annual ERIC returns to ensure accurate data is supplied
• obtain a summary of data errors flagged by NHS England’s EFM data team