Performance analysis

As part of the Annual Report, we are required to review key indicators that we used to measure performance and quality of delivered care during 2024/25. A summary of these measures is included below.

The Information is taken from our Quality and Performance Report focusing on those metrics that in April 2024 were agreed by the Executive Leadership Team as of priority and that would provide the Board and its committees with assurance, or otherwise that the Trust was providing effective and safe care.

Key issues and risks affecting the Trust’s delivery of objectives

We have outlined the key risks to achieving our objectives in the Annual Governance Statement.

Challenges to performance

It is important that we are open about the challenges that we have faced and the context in which we, and the wider NHS, are operating.

We have continued to see pressures across the Trust, particularly in our community and urgent care pathway. Patients are presenting to services in crisis with higher acuity of illness, and are often waiting in unsuitable environments for an inpatient admission. We are then seeing longer lengths of stay in our acute wards, which is further impacting capacity. Waiting lists across Community and Children and Young People’s services also remain a significant challenge that impacts on patients, carers and our communities.

We have continued to make significant progress on vacancies and retention, and we have reduced our reliance on agency staff. However, we need to reduce temporary staffing yet further.

While we have made progress on staffing, our use of private sector beds has seen us block purchase external beds in South West London which has deteriorated our financial position. While we met our financial targets, this will become increasingly difficult next year with our reliance on external bed use.

How do we monitor and manage performance?

The care of the people we serve is central to performance monitoring and management. Each of our Key Performance Indicators (KPIs) is only in place to directly ensure our patients and staff receive the right care and support, at the right time, in the right place.

Our performance is comprehensively monitored by external stakeholders such as NHS England, local commissioners, local authorities and joint management groups across a wide domain of performance areas.

Internally, we have a robust governance structure for managing performance from floor to Board. This includes monthly reviews by service lines. This year we have worked hard to improve our performance reporting across the Trust and at Board, committee and working levels. The Finance and Performance Committee scrutinise performance on behalf of the Board providing oversight and assurance as do the Quality and Safety Assurance and People Committees.

Reporting was adapted at the beginning of 2024/25 to align with priority KPIs set by the Trust Executive. The priority metrics are aligned to Operations, Quality, Workforce and Finance domains.

Quality and performance metrics are assigned a theme. Each theme is reported under a domain (see below) and reviewed by committees reporting to board.

Quality and performance themes

Domain	Theme
Two top priorities	Adult Patient Journey and Great Place to Work
Operations	Access and flow
Quality	Patient safety, patient experience and outcomes and fundamental standards of care
Workforce	Recruitment and attraction, staff skills and development, staff retention, support, and satisfaction
Finance	Length of Stay, Agency Costs and Productivity

 

We aim for high levels of performance to ensure we deliver the best care, and base our strategy on these principles:

·        Creating an improvement culture: Support the development of a culture of continuous performance improvement. The approach is integrated, action orientated and focused on delivering improved performance for the benefit of patients.

·        Integrated information: The overall performance of the organisation, directorates, departments, teams and individuals is assessed across a range of clinical and nonclinical operational performance metrics, quality indicators and outcome measures.

·        Health inequalities: To support our ambition to reduce health inequalities, particularly race inequality, we are working to ensure our data is available via ethnicity

·        Benchmarking: Wherever possible, performance is measured against external standards, internal and external benchmarks.

 

Below are a set of high level summaries of our performance, following by more detailed narrative reports into key areas (including operational, quality, workforce, environmental and health inequalities performance).

2024/25 year-end assessment: achievement of outcomes

Reporting on the top priorities has focused on delivery against outcomes and target metrics. The table below sets out full year performance against these priority metrics:

Two top priorities (narrative in Great Place to Work and Adult Patient Journey sections).

Mental Health Benchmarking:

The most recent benchmarking for London Trusts. Source: NHS Digital and NHS England

The Trust benchmarks well on 72 hour follow up and CAMHS ED non-urgent referrals seen within 4 weeks. First episode psychosis is above national and London average. Sickness rates are slightly above the London average and below national average.  Our trust positions below London and national average for Patient Friends and Family Test.

NHS Benchmarking Network

The NHS Benchmarking Network’s 2023/24 Inpatient and Community Mental Health Benchmarking Report was issued in November 2024 and allows Trusts to benchmark their performance against other participating Trusts throughout England and within their local region. Our Trust is highlighted red in the graphs below, London Trusts are highlighted green, and all other Trusts are highlighted blue.

We look at a number of areas to support us in measuring operational performance for our communities. This includes acute and crisis response, access, and flow. We also measure ourselves against a number of targets set by NHS England and others.

Although challenges have impacted our performance, we have seen some important improvements in key areas:

·        There has been a consistent upward trend in women accessing Perinatal Mental Health services, culminating with the target being consistently met in Q4 2024/25.  The target was amended in 2024/25 to 8%, in order to align with requirements.

·        Within 2024/25, the NHS committed to increasing the number of adults and older adults completing a course of treatment for anxiety and depression via NHS Talking Therapies. The Trust has subsequently implemented new metrics for reliable improvement and recovery.  Improvement has been seen in Reliable Recovery, with the (48%) target being met frequently in the year.

·        Sustained compliance on cardio metabolic assessments with target consistently met in 2024/25.

·        The Trust is currently reviewing NHS Benchmarks publications (including the most recent publication 2024/24 for Adults, Older People and CAMHS) to inform future focus and highlight good practice and value for money. 

Overall, our performance remains stable, although improvements are required across a number of areas, particularly length of stay in adult acute services and waiting times, i.e., 52-week breaches.

Access:

Non-urgent referrals seen within 28 days (Adult and older people and Community Mental Health Teams): There has been variation throughout the year, with the target being met in 7 of 12 months.  Performance has been impacted by the variation in practice within SPAs, demand increases, and staffing challenges. Mitigations have included the development of a SPA policy to standardise practices (this was presented to QGG in April 2025) and implementing an action plan to address backlogs within Wandsworth SPA. Staffing challenges impacted older people’s services in quarter 4, and a temporary resource was deployed to support.

Liaison Services: People waiting over 12 hours for a bed: All three liaison services have seen increases in the number of people waiting over 12 hours for a bed, although this has reduced over the last four months of the year. Delays are linked to reduced flow, increased length of stay, and increased numbers of people who are clinically ready for discharge.  In the year, mitigations included using additional external beds and continued system meetings with acute hospitals to prioritise patients for beds.  As part of the Adult Patient Journey programme, we are developing a process for tracking patient status. This will lead to standardising referrals to Liaison Psychiatry and better demand oversight.  Length of stay improvement work has seen some easing of this pressure over recent months.

Referral to treatment 52-week breaches: There has been a significant increase in levels of 52-week breaches.  This has principally been driven by demand and capacity issues within the ADHD pathway (both in adults’ and children’s services).  In the adult ADHD service, the lack of a discharge pathway is leading to cases staying on the caseload for annual review once they have received a diagnosis of ADHD, reducing overall capacity.

Mitigations have included discussions with ICB about support from primary care and employment of Non-Medical Prescribers (NMP) to undertake some of the annual review requirements.

CAMHS wait times have increased in the neurodevelopment pathway for screening and for ADHD medication titration in Tier 3. Mitigations have included the employment of Non-Medical Prescribers and a digitalised solution for ADHD.

52-week breaches have also occurred within Adult Eating Disorders (AED) and CAMHS Learning Disability services due to demand and capacity issues and case complexity.

Expected population need met by Talking Therapies (numbers entering treatment): The Trust was below its cumulative access requirements in 2024/25 in all five of its Talking Therapies services. In the past year, mitigations have included using third-party providers to undertake assessments. Towards year-end, we have focused on the numbers completing treatment, which aligns with the national position. The ICB has confirmed that no access targets will be set in 2025/26.

Perinatal Access: Access to perinatal services has steadily improved in recent years, with the revised 8% target (implemented in line with ICB reporting) exceeded throughout 2024/25. 

CAMHS ED – non urgent referrals who begin treatment within 4 weeks: There has been frequent compliance in year (average performance 95.8% above target).

CAMHS Tier 3 – non urgent referrals assessed within 8 weeks: Average performance for the year has been below target at 65.8%.  Most delays have been linked to waits for ADHD medication commencement, and there have also been delays for psychiatry appointments. Mitigations include the recruitment of a Non-medical Prescriber (NMP) and a GP with special interest in ADHD.

Dementia diagnosis within 6 weeks of referral to a memory assessment service (%): There has been a downward trend in performance, with targets being met on only two occasions.  Deterioration has been linked to demand and staffing challenges, leading to a backlog of cases, particularly in Richmond and Wandsworth teams.  Merton's performance significantly deteriorated, and this is being addressed and is expected to improve early in 2025/26.  Additional mitigations have included medical cover being put in place in Richmond, whilst Wandsworth and Merton have a six-month improvement trajectory in place.

Number of adults and older adults receiving 2+ contacts in the new integrated model across the core and dedicated service provision: This measure aligns with the Long-Term Plan ambition for increasing access to adult community services.  Access levels have steadily increased, although there was a slight drop-off in older people’s services at year-end, which is under review.  Mitigations have included setting clinical staff contact targets, which are now being embedded across the Trust.

Flow

Percentage of adult acute patients length of stay over 60 Days: This metric was new in 2024/25 and is a key metric in the NHS Performance Assessment Framework. The previous Length of Stay metric (based on adult acute discharges) is still reported to the Quality, Safety and Assurance Committee. 

Length of Stay is impacted by multiple factors, such as high acuity, complexity of patients, i.e., physical and mental health issues, patients who are Clinically Ready for Discharge, variation by ward, and medicine optimization. 

Mitigations have included a fortnightly review of patients with a length of stay over 90 days. As part of the Adult Patient Journey, purposeful admission structures are being embedded across the wards whilst monthly ‘learning events’ are now established to review and support the discharge of Patients Clinically Ready for Discharge.   

It should be noted that we are an outlier on adult acute average length of stay nationally (see NHS Benchmarks section), and there has been a focus on length of stay, and a key milestone for the Adult Patient Journey will be to reduce length of stay in the longer term.  Towards year-end, the Trust started focused work on safely expediting discharges of patients with longer lengths of stay, where clinically appropriate.  This has reduced very long length of stay and reduced reliance on external beds (external contract for 41 beds reducing to 27 beds in April) and created better flow within the system. 

% Older people’s length of stay over 90 Days: This metric was new in 2024/25 and is part of the NHS Oversight Framework. There has been some variation over the period around the mean length of stay of 33.8 for a 2-year period. Recent months have shown a positive decline (although not significant) in proportions above 90 days.  Length of stay is impacted by multiple factors, including behavioural and psychological symptoms of dementia and availability of suitable care or nursing homes for placement. There has also been a challenge within some local authorities to allocate social workers. Length of stay issues are being addressed through transformation work.

Inappropriate out-of-area placement bed days: Out-of-area usage has fluctuated in the year.  Acute services have consistently had a high bed occupancy rate (96.2%). In 2024/25 and during peak times, the Trust has opened surge beds, which have allowed it to keep out-of-area use to a minimum. The Trust negotiated the use of 41 external beds in area, which enables us to have a strong relationship with the provider to support good care coordination for our patients. The key to decreasing out-of-area provision is to reduce the average length of stay and levels of Clinically Ready for Discharge days within adult acute services. Mitigations are noted further above.

Clinically Ready for Discharge:  There have been challenges in year, with the position consistently above the 2.5% target.  Delays are often beyond the control of the Trust and are reliant on Local Authority engagement and resources.  Staffing issues in social services (although improved) have at times impacted.  In terms of mitigations, joint ‘events’ have been held, and at year end, this moved to monthly with a focus on patients that are clinically ready for discharge. For further mitigations, see the length of stay update above.

For full details about the Trust's quality agenda, reporting, and outcomes can be found in the annual Quality Account.

In terms of quality metrics, the Fundamental Standards of Care were reviewed by Senior Nursing and Performance & Information leading to more streamlined measures and reducing the reporting burden on services.

·        The Trust has met its local activity requirements for 2024/25.

·        Talking Therapies' recovery rate was compliant with the national 50% target across all services, and reporting has now moved to Reliable Recovery with the Trust above the 48% target.

·        Cardiometabolic assessment compliance for community and early intervention services (EIS) has consistently been above target in the year.

Fundamental Standards of Care

Cardiometabolic Assessment: Performance has been consistently above target for cardiometabolic assessment recording, with average performance at 83.8% against a 75% target. 

Safe Staffing: Trust performance has consistently been above the safe staffing target. This is linked to acuity and the use of extra staff to support observations within inpatient settings. Mitigations include weekly audits by Clinical Service Leads on constant and enhanced observation, where complex cases are reviewed around the continuity of maintaining observation. Ward managers, Clinical Service Leads, and matrons attend monthly roster meetings to review and approve completions.

Patient Friends and Family Tests: Performance averaged 84% and remained below the 92% target.  Challenges include low patient engagement, accessibility (for older adults), and staff not proactively seeking feedback.

Further, the CAMHS community team offers a different feedback system.  Efforts to increase overall feedback rates included utilisation of waiting areas, displaying QR codes in wards, and distributing laminated cards.  In community services, well-being administrators support and lead in gaining feedback in the Integrated Recovery Hub waiting areas.

Patient Experience and Outcomes:

Talking Therapies Recovery Rate: All four services exceeded the 50% National Recovery Rate target in 2024/25. Clinical leads complete data quality checks before monthly audits, review outcomes, and implement action plans. Additionally, recovery rates are shared in supervision with staff to enhance learning. Training support is provided to clinicians with treatment, focusing on improving diagnostic accuracy.

We moved to reporting Reliable Recovery Rate (a national metric that has replaced the Recovery Rate metric). Trust performance averaged 48.8%, which is above the 48% national target.

Patient safety:

Suspected suicide: Each suspected suicide is a tragedy and something that the Trust takes very seriously. The number of suspected suicides reported each month remains low, with an average of 2.5 for 2024/25. Suspected suicides are discussed in Quality Matters, and an appropriate response/review is allocated to identify areas of improvement and good practice. Such cases are also subject to review via the monthly Learning and Improvement Group.  Each suspected suicide has a response type in line with the Patient Safety Incident Response Framework (PSIRF) and the Trust’s Patient Safety Incident Response Plan.  Guidance on Thematic Reviews has been developed for staff and safety learning events, which addresses incident themes and learning is shared across service lines.

Paired DIAOG: There has been significant improvement in paired DIALOG completion in the year, but performance has remained below target.  A transition to DIALOG+ care planning has begun and has been piloted in year, with a fuller roll out to be completed by September 2025/26.

Productivity:

Activity vs WTE: There has been low-level variation in performance.  The challenge is that not all clinical activity is recorded in the clinical diary (RiO or clinical contacts section (IAPTus or CYP IAPTus).  Mitigations include the embedding of job planning (individual targets for activity are set in supervision) for some clinical staff and training has also been provided.