NHS Board Meeting. 28 January 2013 Paper 5. To inform Board members of progress in achieving the Waiting Times Targets

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1 NHS Board Meeting 28 January 2013 Paper 5 NHS Board Meeting Monday 28 January 2013 Subject Purpose Recommendation Waiting Times. To inform Board members of progress in achieving the Waiting Times Targets To review the Board s performance against its Waiting Time Targets To approve the Board s proposed actions against sustainable delivery of the patient access goals 1. Background 1.1 NHS Ayrshire & Arran is monitored by the Scottish Government Health Directorates (SGHD) against a number of national targets and standards from the Local Delivery Plan (LDP). This report measures and details performance against stage of treatment targets, ensuring patients gain access to and are seen by services within required timeframes. It also focuses on any necessary recovery measures and upon sustainability of delivery. 1.2 A paper is produced on Waiting Times and submitted to both the Corporate Management Team and the Board on a regular basis. 1.3 In light of the agreed development of NHS Ayrshire & Arran Performs, the waiting times data are presented in a Waiting Times summary scorecard format, which outlines RAG status (Red, Amber and Green) traffic light icons, current values and short and long term trend indicators against targets and standards. This is provided in Appendix 1 of this paper. 1.4 The Board is asked to note that the content and data within the Waiting Times reports presented to the Board will be reviewed in line with the Internal Audit Report on Waiting times published in December 2. Current situation 2.1 The Waiting Times summary scorecard supporting trend profiles are available on request from the Policy, Planning & Performance Team. These are updated monthly with the latest available information. 1 of 15

2 2.2 The current performance status for each indicator, as at the end of October, is summarised below. Of the 31 targets, 15 were Red (Alert) and the remaining 16 were Green (OK). The targets that changed in month were the 18 weeks Referral to Treatment and Performance and Other Specialty Waiting Time Finance (both of which moved from red to green). The undernoted table also provides a month on month trend from April. Table 1 Month Red Amber Green Total (Alert) (Warning) (OK) October September August July June May April The targets that are currently (Red) are outlined below: 2.4 Inpatients Inpatients and Day cases waiting more than 9 weeks; Inpatients and Day cases waiting more than 12 weeks; Outpatients (all source referrals) waiting more than 12 weeks; Emergency Access Accident & Emergency (A&E) 4 hours; Clinic Outcome Recording; Total Waiting Time List Finance; Orthopaedic Waiting Time Finance; Radiology Waiting Time Finance; Diagnostics (Endoscopy & Imaging) waiting more than 4 weeks (local target); Diagnostics (Endoscopy & Imaging) waiting more than 6 weeks; Consultant Specialty; Psychology Services; Child and Adolescent Mental Health Services (CAMHS); Primary Care Mental Health Teams (PCMHTs) (new model); and, Community Paediatrics. Within Inpatients and Day cases, a total of 302 patients breached the 9 weeks guarantee, of which 152 waited in excess of 12 weeks, 62 in excess of 15 weeks and 28 in excess of 18 weeks. Overall, this has been an improvement of 1 from the September position. In respect of patients waiting in excess of 12 weeks, the number increased by 2. Whereas, the number of patients waiting in excess of 15 and 18 weeks improved by 19 and 6 respectively. The specialties recording breaches over 9 weeks are within Orthopaedics (259), Vascular Surgery (25), General Surgery (14) and Ophthalmology (4). 2 of 15

3 The detail of why performance is not at the expected level and the remedial actions in place to address these issues for those specialities recording the highest number of breaches are as follows. Orthopaedics The service is continuing to work with colleagues in Nursing, Theatres and TSSU in the implementation of the agreed recovery plan. The plan will provide more ongoing capacity for Orthopaedic surgery. The service continues to re-utilise internal lists wherever possible and is also continuing to arrange weekend theatre lists. In addition, the service is utilising Carrick Glen and the Golden Jubilee National Hospital (GJNH). Vascular Surgery With the appointment and commencement in post in early October of a Locum Vascular Surgeon the backlog of patients has reduced. The Service is ensuring that all lists are being fully utilised to ensure full capacity and the service envisages being on track by around the end of November and into December. General Surgery The service s attempts to undertake extra waiting list sessions has proved problematic due to challenges in securing and co-ordinating theatre space and medical and nursing team availability to offer patients a date with their consultant. The service has secured clinical input at Crosshouse to assist with the outstanding cases, however the identification of sessions with cover continues to improve problematic. Ophthalmology The service experienced a number of theatre cancellations as a result of a shortage of theatre staff. Additional theatre sessions have been scheduled in order to address backlog and reduce waiting time to endeavour not to book patients close to their guarantee date. 2.5 Outpatients Within Outpatients, a total of 295 outpatients breached the 12 weeks guarantee, of which 177 waited in excess of 15 weeks. This is an improvement of 9 from the September position. The highest figures were recorded in General Medicine (170), of which 1 was a scope. This is a decrease of 5 breaches from the previous month, with Respiratory Medicine attributable for 152 patients of the General Medicine total. Within Orthopaedics, there are 48 patients, which is a decrease of 52 from previous month. For Dermatology there are 39 patients, no recorded breaches in previous month. Neurology had 30 patients which was an increase of 11 from the previous month. Details of why performance is not at the expected level and the remedial actions in place to address these issues for those specialities recording the highest number of breaches, is as follows. General Medicine Additional demand in Respiratory services together with the service being one consultant under establishment continues to prove challenging. A retrieval plan based on existing consultants undertaking Waiting List Initiative sessions has been initiated with effect from October with a view to eliminating or reducing the backlog by end of December. 3 of 15

4 Orthopaedics The service continues to experience outpatient pressure in specific areas, predominantly for foot surgery assessment and for one specific consultant s clinics. Additional clinics have been being scheduled, where possible, to help address this in the short term. In the longer term, increased capacity for see and treat at GJNH has been requested, but has not yet been confirmed. Furthermore, recent changes in vetting practice at Ayr Hospital are expected to impact on the allocation of referrals and minimise pressure points, although it may be February or March before the effect of this is seen. Dermatology The service experienced a high volume of urgent referrals, combined with a reduction in staffing (a replacement specialty doctor is still to commence post and there is a consultant on paternity leave). Extra clinics are scheduled for the period November to January The Clinical Director, in conjunction with the consultants, is undertaking a review of number of patients seen at additional clinics in an attempt to increase throughput. A replacement for a specialty doctor has been appointed and is scheduled to take up post early in the new year. A review of service redesign to maximise the use of outpatient treatment space, led by the Health Care Manager, is scheduled to be undertaken by February Neurology - In the short term, Waiting List Initiatives are on-going with the service utilising visiting Ayrshire consultants where possible. In addition ongoing stringent monitoring of the waiting list position and daily contact with appointments continues. The main limiting factor in the reduction of the waiting times is the number of consultants willing to undertake additional sessions in Ayrshire. 2.6 Diagnostics Endoscopy Within Endoscopy, the position at the end of October showed that there were 15 patients waiting over the National 6 week standard, which is an improvement of 59 from the September position of 74. This demonstrates the ongoing improvement in Endoscopy waiting times as verified by the 97% improvement from the June position of 446. In respect of reporting against the 4 week Local standard, there were 37 Endoscopy patients waiting. This is a reduction of 261 from the September position of 298. The service has secured Locum Gastroenterologist cover through to the end of December. Reliance on locum cover to fill the gastroenterology gap means the situation remains subject to risk. The improved position reflects the substantial investment in resource both from within NHS Ayrshire & Arran and the Golden Jubilee National Hospital. The success of this investment is demonstrated in the month on month improvement in the overall waiting times. A high level Demand/Capacity/Activity/Queue (DCAQ) exercise was completed in October which indicated that if capacity is provided in full there would be sufficient 4 of 15

5 capacity to meet demand. A more detailed DCAQ is scheduled for January In addition, a series of audits are being undertaken to determine any service improvements. Imaging Within Imaging, the end of October position showed that there were 3 patients waiting over 6 weeks, all of whom were for Magnetic Resonance Imaging (MRI). In respect of waits over 4 weeks, the total number of breaches was 28. This is an improvement of 90 from the September position. The 28 breaches in October comprised of 23 for MRI 3 Ultrasound and 2 Computed Tomography (CT). Medical Imaging continues to experience pressure as a result of continually increasing demand across all modalities. The service is continuing to provide additional evening and weekend sessions to meet demand. 2.7 Referral to Treatment (RTT) In respect of the 18 weeks Referral to Treatment Performance, the October position improved to 90.75% from 89.50% in September and is once again achieving the target of 90%. Although the overall target of 90% was achieved, there are a number of specialities who recorded below 90% in October: Audiology 76.4%, which is an improvement from 69.48% in previous month; Urology 88.70%, an improvement from 75.2% in previous month; Vascular Surgery 82.46%, an improvement from 79.46% in previous month,; Orthopaedics 86.22%, a decrease from 88.04% in previous month; and, Cardiology 88.96%, a decrease from 92.41% in previous month. Improvement work is on-going within each of these services to address the situation. 2.8 Emergency Access Accident & Emergency (A&E) 4 hours The Emergency Access Accident & Emergency (A&E) 4 hour standard showed a worsening position at 92.35% in October, compared to 94.05% in September, against a target of 98%. Patient Flow Capacity Management and Escalation Procedures have been reviewed and updated and escalation triggers agreed last year have been updated to include new escalation triggers for both managers and clinicians. Proactive patient flow management arrangements are in place on both Acute sites which aim to support the 4 hour standard and delivery of elective waiting time targets. This is supported by a designated Duty manager for daily patient flow meetings, with triggers for additional meetings earlier and later each day as required. The Associate Medical Director is leading on bringing forward workforce and service redesign changes which can be delivered in advance of the Building for Better Care investments, for which an outline business case has recently been 5 of 15

6 approved by the Board and submitted to the Scottish Government. This includes consultant expansion and increasing the consultant contribution to the A&E middle grade rotas, which encompasses the out of hours period. There are a number of patient flow improvement programmes, with additional Programme Support being provided by the Programme Manager, Service Futures. Whole System Review of Bed Management Requirements Pan Ayrshire; Direct GP Admissions (Ayr Hospital); Surgical Flow; Review Consultant Allocation (Crosshouse Hospital); Standardisation on Wards; CDU Pathways (Ayr); Discharge Pathways; and, Pilot of Acute Physician Assessment of GP expected patients in the Emergency department. 2.9 Cancer Waiting Times Performance was above the overall target of 95% in both elements of the cancer waiting times In terms of Suspicion of Cancer Referrals (62 days), the October position decreased to 95.2% from the September figure of 96.1%. The cancer types below target were Colorectal (88.2%) and Upper GI (83.3%). All other cancer types recorded 100%. In respect of All Cancer Treatment (31 days), the October position decreased slightly to 98.3% from the September figure of 100%, the only cancer type below target was Colorectal (91.3%) Mental Health The breakdown of patients waiting in excess of 18 weeks was: 127 patients for Primary Care Mental Health Team (New Model) Services; 234 for Psychology Services, the services contributing to this are Community Mental Health (93), CAMHS (3), Community Paediatrics (45), Pain Clinic (41), General Medicine (35), Cardiac (10), Multiple Sclerosis (4) and Non Epileptic Seizure/Acquired Brain Injury (3); 22 for Child & Adolescent Mental Health Services; and, 10 for Consultant Specialty Services General Psychiatry (3), Psychiatry of Old Age (6) and Child & Adolescent Psychiatry (3). Although Mental Health Services are not currently required to report to 18 weeks, this measure has been adopted and is the target being worked to locally. The service has adopted a number of remedial actions to strive to achieve this target. Primary Care Mental Health Team (PCMHT) The recruitment of counsellors is progressing and the service anticipates that this should start to show in a reduction of waiting times in the next quarter. A current vacancy together with sickness absence has seen a slight increase in waits over 6 of 15

7 18 weeks for the Primary Care Mental Health Nurse (PCMHN). The review of Do Attends (DNAs) and Could Attends (CNAs) to improve efficiency is scheduled to be completed by the end of December. Psychology Services Some vacant posts, previously on hold for possible efficiency savings, have now been released and advertised. However, it will take some months for there to be a full impact on waiting times. The service is currently skilling up other staff to increase the resource available to manage the waiting lists. Discussions are taking place with referrers to review and prioritise patients on waiting lists, and involving the Service Improvement Team for further advice in Physical Health and Community Paediatrics by December. A Psychologist commenced in early October to provide maternity cover within Community Paediatrics and, although waiting times have started to reduce, it will take time for the new clinician to build their caseload. However, despite the above, the current resource will not meet demand and therefore will not be on trajectory without an increase in resource. Child & Adolescent Mental Health Services The service continues to progress towards reducing their waiting times, with a decrease in the longest waiting times. The return of nursing staff from development opportunities will ensure that the staffing complement will return to full capacity by January A new Psychologist commenced in post in November and will pick up cases on waiting lists. The service envisages that performance will be back on track by December. Consultant Specialty Services The service is undertaking an analysis of the increasing number of Did Attends (DNAs) with the objective of quantifying and determining actions to resolve this issue. Training and support for staff inputting to PMS will be undertaken by December. It is envisaged that Psychiatry of Old Age performance will be back on track by end of January Clinic Outcome Recording The October position for new or return outpatient appointments to have a recorded outcome code was 82.44%. This has been an increase from the September position of 80.34% Community Paediatrics At the end of October, there were 25 patients waiting more than 18 weeks, within the Occupational Therapy Service. This is a decrease of 10 from the September position of 35. The service continues to experience a higher than average number of urgent referrals, which have impacted on the ability to respond to routine referrals. To address this situation, a number of staff increased their hours back to full-time 7 of 15

8 from October. Approval has been received to proceed with external recruitment for Daldorch School Waiting List Finance The Access Spend figures as at October outline that the Radiology monthly spend increased to 111.7K from 94.6K in September, which resulted in the cumulative overspend increasing to 103K, previously 44.9K. The Endoscopy monthly spend of 59.4K for October has resulted in the cumulative overspend remaining unchanged at 16.5K. The Orthopaedics cumulative overspend increased at the end of October to 170.8K from 117.8K in September. This increase together with other overspends has resulted in the overall cumulative overspend at end of October increasing to 252.6K from 173.7K in September Treatment Time Guarantee From the beginning of October, NHS patients requiring planned inpatient or day case treatment were covered by a Treatment Time Guarantee (TTG) enshrined in law. The guarantee means that patients have a legal right to receive treatment within a maximum of 12 weeks from the day when they agree to the care. The guarantee is one of the rights in the Charter of Patient Rights and Responsibilities which brings together, in one place, a summary of the rights and responsibilities that patients have when using NHS services. Within NHS Ayrshire & Arran service managers have been using countdown reports which highlighted the patients who have waited longest for appointments. Alerts are also now being built into the Patient Management System (PMS) to highlight patients who have waited more than 7 weeks and who do not yet have an appointment for their Impatient or Day Case procedure. The initial focus was on patients added to the waiting list on 1 st October, who were due to have had their treatment before 24 th December. The guarantee is now rolling forward and is a fundamental consideration when scheduling clinical activity. The reporting of performance against this legal right is in addition to the stage of treatment and 18 week goals that are extant. Operational focus is on bringing forward waiting times, for inpatient and day case procedures, to around 9 weeks to ensure on-going achievement of the TTG since by setting this primary time a contingency window is created for any unforeseen circumstances. The first performance data for the Board s TTG activity will be presented to the next Board meeting Proposal The NHS Board notes the current waiting times as at the end of October against current operational activity. 8 of 15

9 3.2 The Waiting Times summary scorecard will continue to be presented to the NHS Board on a routine basis. 3.3 The Board uses the attached appendix to scrutinise and challenge performance against these targets. 4. Engagement and consultation on development of the proposal 4.1 This report is compiled by summarising information from a variety of sources and other NHS Ayrshire & Arran reports. 5. Resource implications and identified source of funding 5.1 The management of this process is core business for Performance staff in the Department of Policy, Planning and Performance; however the accuracy of the Waiting Times Scorecard at a glance report depends on the accuracy and timeliness of data provided by various other departments. 6. Risk assessment and mitigation 6.1 There is significant risk to the organisation in failing to ensure that accurate data and trajectories are used in the management of performance against waiting times targets. This is a particular concern in areas where local targets have been set, i.e. Community and Mental Health Services. 6.2 Risks remain that exigencies of the service such as unforeseen circumstances, e.g. ward closures due to illness could adversely affect the present recovery programme. As all internal relevant staff and facilities are already committed to this effort no contingency plans are possible. Risk mitigation is being delivered by close scrutiny and management of the scheme. 6.3 There is also significant risk to the organisation in failing to improve against the waiting times targets and in failing to monitor progress at the highest management and governance levels. 7. Impact assessment and consequential changes proposed to mitigate adverse impacts identified 7.1 This paper does not require impact assessment. 8. Conclusion 8.1 The Board is asked to consider the current position for Waiting Times as shown in the Waiting Times summary scorecard. Professor R G Masterton, Executive Medical Director [Kirstin Dickson, Andy Mathie, Fraser Doris] 21 December 9 of 15

10 Waiting Times summary scorecard Appendix 1 Report Author: Andy Mathie Generated on: 20 December PI Status Alert Warning OK Unknown Long s Improving No Change Getting Worse Short s Improving No Change Getting Worse Data Only PI Code & November Short Name 2011 HEAT HNS.1a 62-day Cancer: Suspicion-ofcancer referrals (62 days) HEAT HNS.1b 31-Day Cancer: All Cancer Treatment (31 days) December 2011 January February March April May June July August September 97.1% 97.4% 96.6% 94% 95% 95% 94.3% 95.8% 94.6% 96.4% 96.1% 95.2% 100% 100% 99% 100% 99.4% 100% 97.1% 100% 99.2% 100% 100% 98.3% October Short Long 10 of 15

11 PI Code & November Short Name 2011 HEAT HNS.2 New Outpatients: Maximum 12 weeks from referral HEAT HNS.3 18 weeks Referral To Treatment - Performance HEAT HNS.3a 18 weeks Referral To Treatment - Completeness HEAT HNS.6 A&E waits to be a maximum of 4 hours HEAT HLS.5 Inpatients & Day Cases: Maximum 12 weeks December 2011 January February March April May June July August September 1,652 1, % 91.19% 91.83% 92.69% 92.21% 92.39% 93.34% 92.06% 91.52% 90.37% 89.56% 90.75% 74.7% 73.95% 78.05% 84.26% 90.49% 91.42% 92.01% 92.55% 92.75% 92.44% 93.08% 85.84% 97.72% 94.43% 94.38% 95.38% 95% 93.7% 90.55% 93.3% 96.44% 94.15% 94.05% 92.35% October Short Long 11 of 15

12 PI Code & November Short Name 2011 HEAT HLS.6 Inpatients & Day Cases: Maximum 9 weeks HEAT WT3.001 Patients waiting more than 6 weeks for Diagnostic checks HEAT WT3.002 Patients waiting more than 4 weeks for Diagnostic checks AS10.a 10/11 18 weeks RTT: Admitted Performance AS10.b 10/11 18 weeks RTT: Admitted Completeness December 2011 January February March April May June July August September % 72.74% 73.91% 77.35% 76.12% 78.83% 81.44% 81.41% 80.37% 75.74% 73.79% 77.44% October 71.5% 69.94% 75.05% 99.77% 99.77% 98.65% 97.43% 98.79% 98.4% 98.32% 97.44% 97.41% Short Long 12 of 15

13 PI Code & November Short Name 2011 AS10.c 10/11 18 weeks RTT: Nonadmitted Performance AS10.d 10/11 18 weeks RTT: Nonadmitted Completeness WT1.7 Clinic outcome recording WT2 Total waiting list finance (cumulative) WT7.01 Inpatients - Detox WT7.02 Consultant Specialty WT7.03 Psychology Services December 2011 January February March April May June July August September 92.9% 95.01% 95.23% 96.05% 95.78% 95.47% 96.07% 94.67% 94.33% 93.76% 93.17% 93.86% 75.5% 74.83% 78.65% 81.49% 88.66% 89.91% 90.85% 91.14% 91.43% 91.17% 92.14% 83.52% 79.8% 79.7% 80.66% 79.95% 80.49% 79.41% 80.09% 79.65% 77.76% 77.87% 80.34% 82.44% 2, , , , , , , , October Short Long 13 of 15

14 PI Code & November Short Name 2011 WT7.04 Child & Adolescent Mental Health Services WT7.05 Adult Community Mental Health Teams WT7.07 Primary Care Mental Health Teams (New model) WT7.08 Elderly Community Mental Health Teams WT7.09 Addiction Services WT7.10 Learning Disabilities Service December 2011 January February March April May June July August September October Short Long 14 of 15

15 PI Code & November Short Name 2011 WT2.001 Orthopaedic waiting time finance (cumulative) WT2.002 Radiology waiting time finance (cumulative) WT2.003 Other specialty waiting time finance (cumulative) WT8.01 Children Womens & Sexual Health Services WT8.02 Community AHP Services WT8.03 Community Paediatrics December 2011 January February March April May June July August September , , , , , , , October Short Long 15 of 15