Slough Clinical Commissioning Group. Annual Report 2016/17

Transcription

1 Slough Clinical Commissioning Group Annual Report 2016/17

2 Contents INTRODUCTION BY THE CLINICAL CHAIR...3 Review of the Year.5 PERFORMANCE REPORT 18 Performance Overview...19 Performance analysis ACCOUNTABILITY REPORT...84 Corporate Governance Report 85 Members Report...85 Statement of Accountable Officer's Responsibilities...91 Governance Statement...92 Remuneration and Staff Report.121 Remuneration Report Staff Report Parliamentary Accountability and Audit Report ANNUAL ACCOUNTS.143 Page 2

3 Introduction by the Clinical Chair Dr Jim O Donnell This annual report covers the CCG s fourth year of operation and we continue to work with partner organisations to improve quality of care and our financial position while working towards delivering our vision. The values by which we continue to operate are: To be reliable, trusted and respected To be transparent and accountable To be innovative and deliver best practice To be community focused To be efficient and effective All GP practices in Slough are members of the CCG and the views of health professionals at these surgeries inform its priorities. Regular meetings of GPs and other practice staff ensure this continued engagement and we are seeking to engage different clinicians in commissioning work so that we can be confident in sustaining the clinical leadership for the future and ensure they are involved in the decisions that affect their patients. Our spirit of collaboration has underpinned the development of a cohort of future clinical leaders who remain focused on working with others, including patients, to ensure that the right services are commissioned for our local population. Our Accountable Officer, John Lisle, joined us from Chiltern CCG during the year at an exciting time. We have seen our local acute hospital move from a position of being considered unviable by the Care Quality Commission to being awarded Good following their last inspection. We have worked closely with our neighbouring CCGs for Bracknell and Ascot, and Windsor, Ascot and Maidenhead. Together we have strengthened our joint working. This was recognised by NHS England which confirmed its assessment of us as Good, despite inevitable uncertainties with not having a substantive Accountable Officer for the year before John arrived. Working together in collaboration with our neighbouring CCGs brings greater efficiencies, reduces duplication and enables economies of scale. We have embraced a phrase which lives within our own CCG values and describes the approach to our work between CCGs Thinking Locally, Working Together. This means we are still very much focused on our CCG, the local communities and the GP practices that serve our patients. At the same time, we know many of the things we want to improve are shared by our neighbours and by working together we can make a bigger difference, sharing our resources. The CCG annually reviews the Governing Body s and related committees performance. Assessment of their effectiveness is based on The UK Corporate Governance Code. The three Healthwatch organisations for Bracknell Forest, Slough, and Windsor, Ascot and Maidenhead are members of our joint Quality Committee. They collaborate to send a representative to meetings on behalf of all. Together with the clinical members of the committee, they ensure the voice of patients is heard. Page 3

4 We have a hands-on approach to monitoring quality and make regular visits to hospital wards and other care settings to talk to staff and patients about the care being provided. Together with other performance monitoring data and feedback from patients, this enables us to understand where there is need for change and where we have good practice. We are conscious of the challenges we face: increasing population; rising life expectancy (and so increasing number of older people); the growing numbers of people living with one or more long-term conditions; and the limited resources available to us. We know that we will need to take advantage of the opportunities to do things differently. We need to embrace technology, share data and provide care differently so care is truly integrated. We need to shift our focus from reactive to proactive and invest in prevention. We need to do more in the community to support people in their efforts to stay healthy and independent for as long as possible. This means working across health and social care to support local people in a way that we call a New Vision of Care. At the same time, we need to recognise that demand on urgent care services has increased more than would have been expected, as is the case in the rest of the country. While we are directing resources to managing demands in emergency departments, this means less for the areas we know will make the biggest difference for our patients now and in the future. We have been working hard to provide more services and improve access to primary care to persuade people to stop going to A&E for minor conditions, and to keep people well enough that they don t need to be admitted to hospital as an emergency. In this vein, extending opening hours for GP practices was a notable achievement this year. Nationally, we were the quickest to make more appointments available and working well. Feedback from patients has been positive and this scheme will continue into the next financial year. In the previous financial year, we were approved to enter into primary care co-commissioning with NHS England. This gives us more say in local decisions about how primary care services are commissioned locally, ensuring patients, communities and clinicians have more involvement in determining their local health care services for the future. Relationships with our key partners, Slough Borough Council, Frimley Health NHS Foundation Trust and Berkshire Healthcare NHS Foundation Trust, are hugely important to us. We have worked hard on them and believe that they are stronger now than they were at the start of the year. We believe we have continued to build a solid foundation of all key partners and have a joint ambition to improve the health and wellbeing of residents across Slough and beyond. Finally, working with our local authority, developing the Better Care Fund, and liaising with local GP practices on improving access to primary care, supported by the Prime Minister s Challenge Fund, have all led to improvements in care for patients. Dr Jim O Donnell Clinical Chair Slough Clinical Commissioning Group Page 4

5 Review of the year Once again, we have had a busy year full of challenges and achievements, building further on our decision to work more collaboratively with colleagues in Bracknell & Ascot and Slough. During the year we identified four key areas of focus. Grip ensuring we are on track to deliver what we set out to do and that we act quickly if anything starts to slip. Transformation our challenges ahead are significant and we are determined to make improvements that transform health and social care to meet the demands of our growing population consistently in the years ahead. People we can only deliver the improvements we want by ensuring we recruit the best people and retain them. This means investing in them and building strong organisations. Money our budgets are set for us and we must live within our means. This means making the most of every pound we spend to get good value for local residents and balance the books. Below are some examples of our work during the year. Sustainability and Transformation Partnership The Frimley Health and Care Sustainability and Transformation Partnership (STP) was developed by NHS organisations and local authorities across East Berkshire, Surrey Heath and North East Hampshire and Farnham, who together make up the catchment area for hospitals run by Frimley Health NHS Foundation Trust. The plan outlines how we aim to improve local services and was submitted to NHS England in October. You can see it here: along with a plain English FAQ document and a video about the national programme. We have set up seven work streams: Prevention and self-care General Practice transformation Integrated care decision-making hubs Social care support Unwarranted variation Shared care record Support workforce East Berkshire CCGs are leading on integrated care decision-making hubs, building on our New Vision of Care work on supporting coordinated care and telling your story only once. We will make sure there is more access to General Practices and that health and social care teams will working together more seamlessly. Page 5

6 The five main priorities under the STP are: Improve wellbeing and increase prevention, self-care and early detection Improve treatment planning for patients with long-term conditions, including greater selfmanagement and proactive management across all providers Provide proactive management for people who have multiple, complex and long-term physical and mental health conditions, to reduce crises and prolonged hospital stays Redesign urgent and emergency care, including integrated working and primary care models providing out of hospital responses to reduce hospital stays Reduce variation and health inequalities to improve outcomes and maximise value for citizens across the population, supported by evidence The CCG has submitted bids (with partners) for additional funding for mental health, diabetes, learning disabilities and cancer projects and are putting every effort into maximising resources for this patch. Future plans for closer working with local authorities and integration This year more than ever, East Berkshire Clinical Commissioning Groups and local authority partners committed to working together and had a mandate to do so. Successful joint working can improve and streamline services for residents and enable them to be less dependent on NHS and social care services. Our New Vision of Care work underpins this. The three East Berkshire local councils and CCGs are looking at shared functions and projects, as well as how joint planning can be even better. Currently we sit on local authority boards and they sit on ours, and there are ways we can achieve efficiency savings without adversely affecting service delivery. Governance In 2016 we started reshaping the CCGs governance processes and decision-making committees. Staff who work across the three CCGs have now been reorganised into a central team, who are Dr Lalitha Iyer (Medical Director), Fiona Slevin-Brown (Director of Strategy and Operations), Nigel Foster (Director of Finance and Performance), Sarah Bellars (Director of Nursing and Quality) and John Lisle (Accountable Officer). We also carried out a governance review to assess how well we are working together in the light of these changes, as well as the governance implications of STP-wide working. CCG Assurance NHS England met with the CCGs each month to assess their performance. Every three months they rate our performance, using a number of categories that together provide an overall assurance rating. We are delighted that we continue to be rated good across all three CCGs. 360 Stakeholder Survey Every year, NHS England and Ipsos Mori organise a survey of CCG stakeholders. It takes place at the same time across the country and questions are mostly the same each year to enable us to monitor changes in attitudes. The survey includes questions about the way the CCG communicates, engages and involves its stakeholders, about the CCG s plans and priorities, its finances, governance and its leadership. Page 6

7 Stakeholders are identified by the CCG using a template with defined numbers for each group and include member practices, local authority and local NHS trust colleagues, other local providers, Healthwatch and patient groups and voluntary sector representatives. The 2016 survey provided useful feedback to the CCG that was used to improve its engagement with member practices and its communication of key plans and priorities. The 2017 survey took place during January and February. Overall, there were some really encouraging results on which to build for next year. The overall response rate was 65%, which was higher than the national average of 62%. The full results are published on the CCG website. Operating Plans We developed our commissioning plans for 2017/19 following a health needs analysis for each CCG (the joint strategic needs assessment), outcomes benchmarking using NHS Right Care and talking to member practices and the public about our 2017/18 work programme. These fed into the 2017/19 operating plan, which was signed off in December Primary Care Our CCGs are committed to establishing a federation of practices to support transfer of care out of hospital and strengthening resilience in individual general practices. In supporting general practice infrastructure, we were successful in bids to the Estates Technology Transformation Fund in 2016/17 for capital investment in premises and technology. We achieved extensive improvement in outcomes from the Care Quality Commission (CQC) process during 2016/17, working in partnership with NHS England. The General Practice Outcome Framework (GPOF) has extended the scope of services delivered in practices, increased investment in our practices and pulled together a complex set of services and quality improvements. Our Community Education Provider Network (CEPN) initiative goes live in 2017/18, with workforce analysis, career development pathways and aligning education providers to the wider strategy, thus providing a pipeline for future primary care services. Our HealthMakers programme has been reviewed and extended to Slough, and Windsor, Ascot and Maidenhead CCGs for 2017/18, linking up wider mental health and social prescribing initiatives. Primary care transformation The Prime Minister s Challenge Fund (PMCF) programme is continuing to explore better access to primary care services in Slough CCG area.. Patient participation groups led open days to celebrate Patient Participation Group Awareness Week in June This was an opportunity to explore extended access beyond the PMCF pilots and encourage the patient groups to get more involved in shaping local services. This links strongly with the STP work stream on GP transformation. The General Practice Forward View implementation plans submitted in December 2016 supports the Primary Care Vision used in the development of the STP work stream during 2016/17. The key elements for sustaining general practice services include: Page 7

8 Workforce development Reduction in workload Redesign of care Effective and sustainable infrastructure Delegated primary care commissioning The CCGs are moving to fully delegated status, taking on leadership and responsibilities from NHS England for commissioning primary care. This was discussed with member practices at GP member meetings and required constitutional changes and signing of MoU documents with NHS England. Urgent and Emergency Care The ten Thames Valley CCGs collaborated on developing a regional NHS 111 integrated urgent care service, using a most-capable-provider, three-stage procurement model. The original preferred provider, Care UK, withdrew in November 2016, therefore, in line with the published procurement process, the CCGs invited the reserve bidder, South Central Ambulance Service (SCAS), to co-produce a new integrated urgent care system for Thames Valley. This involved talking to everyone with an interest in the service GPs, clinicians, urgent and emergency care providers, and patients to decide what the improved service will look like and how it will work. As part of the Thames Valley Urgent and Emergency Care Network, our CCGs took part in a number of network events and continue to support the workstreams across Thames Valley. The Thames Valley re-procurement of an integrated 111 service including a clinical hub has resulted in a preferred provider being selected and recommendation to take forward this provider went to all Thames Valley CCG governing bodies in April The new service is expected to start in September We agreed contracts until March 2018 for our Slough walk in centre and extended out of hours service, to work alongside our new NHS 111 service. We saw improvements in patient discharges and our new Patient Transport Service was in place from April More patients are being treated on the day and not being admitted to hospital overnight, as South Central Ambulance Service continued to develop its use of hear & treat and see & treat. Further work continues in 2017/18 on these developments. Integrated Care and Better Care Fund Our three CCGs and three unitary authorities appointed a joint Associate Director of Integrated Care to work across East Berkshire to strengthen integration of health and social care for local people. We continued to work collaboratively through the Better Care Fund on system integration to support more people to live well at home and prevent unnecessary admissions to hospital. We achieved a significant reduction in unplanned hospital admissions for falls, complex cases, child asthma, end of life care and admissions from care homes. The CCG and the Better Care Fund programme had significant success in the prevention of falls during 2016/17, which fell by more than the planned 9% reduction. The falls prevention programme is continuing as part of a wider self-care and prevention remit. We established Page 8

9 integrated hospital teams at Wexham and Frimley Park hospitals with onsite social care. This dramatically cut social care related delays for our patients. Relationships between social care and the hospitals have significantly improved as a result of the teams working together. From April 2017, we will have a new end of life care and support service for people who are dying and their carers. The new service will support people to plan ahead about how they are cared for when they are coming to the end of their lives. Our practices are also identifying patients nearing end of life so that plans can be made in advance with the involvement of the patient, carer, and family. Our CCGs have established an East Berkshire-wide care homes quality group to drive up standards and safety, and develop meaningful relationships and innovative care with the homes. Together with the local authorities, we have also agreed a joint appointment for a care home quality delivery manager to take forward improvements and new care models. The integrated care team are actively supporting and embedding with the STP programme team to help shape the delivery of integrated decision making hubs and the social care market development strategy. The team have been chosen as an early adopter for an STP logic model. New Vision of Care During 2016/17, New Vision of Care (NVoC) focused on supporting the Frimley Health and Care Sustainability and Transformation Programme and has been a key influence in defining priorities and projects. Through collaboration between commissioners, providers, local authorities, public and voluntary sector, NVoC has supported the East Berkshire system in defining STP projects and ensuring NVoC principles are embedded in local design and delivery for local projects. Given the wide representation in the Steering Group, NVoC now plays a key role in unlocking barriers for projects and innovating in gaps to drive forward solutions for: a system-wide approach for analytics the launch and design of the 2020 leadership programme delivering care centred on people living with frailty improving the way our system partners with voluntary sector organisations Mental Health and Learning Disabilities The East Berkshire CCGs have continued to invest in developing local mental health services some of the highlights are below. Perinatal mental health service to ensure delivery of a NICE compliant specialist service that meets the needs of local people. The service includes: assessment by a clinician with perinatal mental health knowledge, skills and experience community intervention with routine and some intensive support for women at home support to clinicians maternity and health visiting training in for partner agencies, such as Community Support Centres, Homestart, Children s Centre staff and other professionals coming into contact with women during this time Page 9

10 The Berkshire Early Intervention in Psychosis (EIP) service launched in April 2016, working across the whole of Berkshire to support people experiencing psychosis for the first time, or with at risk mental states. For people in the early stages of a psychotic illness, the service offers three core functions: 1. Early detection 2. Acute care during and immediately following a crisis 3. Recovery-focused continuing care, to enable people to maintain or regain their social, academic, or career objectives. For more information, view our video produced with people using the service, their families, the EIP provider and commissioners: Street Triage a mental health clinician works with the police when they come into contact with people experiencing mental health problems, in order to avert crises and get them the right support. Crisis more funding for crisis response and home treatment teams since Improving access to psychological therapies expansion East Berkshire has a high performing service and received national funding as a pilot site to increase access for people with anxiety and depression to therapies. This includes people with long term conditions. Enhanced mental health liaison service to provide more access to mental health liaison in hospitals. GP education our GP mental health lead, Dr Katie Simpson, led education sessions for practice staff on a number of topics, including suicide prevention, dementia, children s mental health services and perinatal mental health. Young People with Dementia The CCG supported a 3 day a week service that provides support for young people with dementia and their families. Child and Adolescent Mental Health Service Transformation The CCGs in East Berkshire and local Health and Wellbeing Boards have worked together to implement real improvements through the development of local plans for children and young people in East Berkshire. The shared vision is: Children and young people will have good mental health and grow up being resilient Children and young people will get the right support at the right time In October a conference was held to raise awareness of children and young people s mental health and wellbeing. It brought together professionals, carers and members of the community in a forum where they had the opportunity to listen to guest speaker Professor Tanya Byron a clinical psychologist specialising in working with children and adolescents, and ask questions about interventions. In March a conference was held to highlight services for children and young people with special educational needs and disabilities (SEND). The conference was aimed at professionals who Page 10

11 work directly with children and young people with special educational needs and disabilities, as well as parents/carers in East Berkshire The CCGs have invested more in services every year since 2015, resulting in a 50% reduction in waiting times over last year, in addition to additional autism and attention deficit hyperactivity disorder (ADHD) assessments to cut waiting times. Eating disorder: a fully NICE compliant service started in The transformation programme was set up to deliver recommendations made by Future in Mind and has funded: online counselling face to face counselling pre-diagnostic support, post diagnostic support groups, youth clubs, home visits and National Autistic Society seminars support for parents of children with ADHD, sleep issues, behavioural issues, or autism PPeP Care (psychological perspectives in education and primary care) training for teachers, teaching assistants, primary care staff and anyone working with children to enable them to recognise mental health issues and help children and young people crisis support provided by Berkshire Health Care Trust since the start of this service in October 2016 there has been a dramatic reduction in children s admissions to Berkshire Adolescent Unit and out of area placements Learning Disabilities The Berkshire Transforming Care Programme (TCP) has been running for over a year now. Set up to improve services for people with learning disabilities and/or autism, who display behaviour that challenges, including those with a mental health condition. The aim is to enable more people to live in the community, with the right support close to home. Progress in 2016/17 includes: Publication of TCP plan Secured 2016/2017 funding from NHS England for shared housing in Windsor and Maidenhead for up to three people from across Berkshire with complex learning disabilities and challenging behaviour Secured 2016/2018 funding from Department of Health for 10 HOLD (home ownership for people with long-term disabilities) schemes Co-opted Carer and Family Experts by Experience as members of various workstreams involved in the Voluntary Appointment Contracts programme Began an experience based co-design project with the Point of Care Foundation weekly Berkshire Healthcare Foundation Trust group for service users Started to map local authority and CCG workstreams already in place for children and young people, to avoid duplication in work Page 11

12 Planned Care Stroke services From January 2017 stroke services began improving for more than 430,000 East Berkshire residents. The improvements were the culmination of two years planning by the three East Berkshire Clinical Commissioning Groups, involving local clinicians, patients, the public and the Stroke Association from the start. Now, anyone suspected of having a stroke is taken straight to the nearest hyper acute stroke unit by ambulance to receive the best possible care. Local hyper acute stroke units are sited at: Frimley Park Hospital, Camberley Royal Berkshire Hospital, Reading St Peter s Hospital, Chertsey Wycombe General Hospital, High Wycombe East Berkshire Clinical Commissioning Groups have also commissioned a stroke rehabilitation unit at Wexham Park Hospital for patients who need further rehabilitation in hospital after leaving a hyper acute stroke unit. These new arrangements, which provide clot-busting treatment (thrombolysis) and 24-hour specialist stroke care, are expected to save lives in the years ahead by improving people s quality of life and maximising their chances of remaining independent at home after a stroke. Diabetes In 2016, the CCG submitted a successful bid for 1 million for transformation of diabetes services as part of the Frimley Health and Care sustainability partnership, along with North East Hants and Farnham CCG, Royal Berkshire Healthcare Foundation Trust, and Frimley Healthcare Foundation Trust. This will be rolled out in 2017/18. The bid was successful in the following areas of treatment and care: Improved access to structured education programmes for diabetic patients Improved care planning to achieve treatment control targets of HBA1c, blood pressure and cholesterol Implementation of a multidisciplinary foot care team to reduce foot amputations among diabetic patients Inpatient diabetes specialist nursing service to support patients to reduce length of stay in hospital, as well as prevent readmissions. In 2016/17, the CCG also implemented the first phase of a locally commissioned service to support practices in delivering the Year of Care model to improve treatment targets. These were significant achievements for our work in diabetes. Right Care The CCG has adopted the NHS Right Care approach to enable us to prioritise plans that will deliver wide health benefits for the most people. Page 12

13 The CCG identified the following areas for improvement in 2016/17: Cardiovascular Neurology Respiratory Integrated care Cancer The CCG planned to improve early diagnosis for breast and gastrointestinal cancers, as well as encouraging more people to be screened for them. It also prioritised screening for colorectal cancer and increasing uptake of bowel screening, especially among black and minority ethnic communities, where uptake is low and outcomes worse than national averages. The CCG planned to: agree with hospitals which patients who were referred urgently (2 week wait referrals) should be test straight away rather than for an initial outpatient appointment agree mechanisms with hospitals for direct access to tests for GPs, including x-ray, ultrasound, brain MRI, CT and endoscopy review waiting times for direct access tests and agreement of when tests would be available within 2 weeks, as recommended by NICE review hospitals diagnostic capacity and agree investment/redirection of funding implement a phased plan for all cancer services to deliver the recovery package, as described in the National Cancer Survivor Initiatives. plan for holistic needs assessments and care planning at key points of treatment ensure treatment summaries were completed at the end of each session of hospital treatment (sent to patient and GP) have cancer care reviews completed by GPs or practice nurses to discuss patients needs support and educate patients, for example, at a Health and Wellbeing Clinic, to prepare them for looking after themselves, including advice on healthy lifestyle and physical activity The three CCGs have education plans in place for ensuring implementation of NICE guidelines, including adhering to clinical guidelines and using audit tools and dashboards to enable a sharing of expertise within primary and secondary care. Performance Through 2016/17 we sustained the improved performance in NHS Constitutional Standards reported the previous year. This was recognised by NHS England, which assessed the three CCGs in East Berkshire as Good against the new Improvement and Assessment Framework introduced in 2016/17. Our CCGs have continued to work collaboratively with key providers, in particular Frimley Health Foundation Trust, Berkshire Healthcare Foundation Trust and South Central Ambulance Service to maintain this strong performance. In particular, 18 weeks referral to treatment waiting times consistently remained above the 92% standard. Cancer waiting times at Frimley were achieved consistently throughout the year, along with 2 week and 62 day cancer waits standards. Page 13

14 Operations and System Resilience Following national guidance, the local Systems Resilience Group became the A&E Delivery Board as part of a plan to improve A&E performance across the country. This focuses on a standard approach to urgent and emergency care best practice, as set out in the NHS England report on transforming urgent and emergency care services: Safer, Faster, Better. This asks the NHS and its partners to implement five initiatives to improve performance: Introduce screening in emergency departments to establish which patients need hospital care and who can be treated and discharged on the same day Increase the proportion of NHS 111 calls handled by clinicians Improve ambulance response times to critically ill patients Cut down the time it takes to admit patients to hospital and then send them home after treatment Use best practice to reduce the time people spend in hospital when they are medically fit to go home A&E delivery boards monitor and manage emergency care, report progress and offer improvement support as needed. They are aligned with an urgent and emergency care review. Share Your Care Over the past year the CCG has been implementing a new system for sharing clinical information between health and social care organisations in Berkshire. This will allow professionals involved in your care to have instant, secure access to your health and social care records. Sharing your electronic records with the people who look after you gives them the most up-to-date information about you and makes your care safer and more efficient. The computer system used by health and social care professionals to see your shared record is called Connected Care. The system takes a regular snapshot of information held at GP surgeries, hospital departments and local authorities across Berkshire. These snapshots combine into a single, shared record all about you. Only those directly involved with your care and authorised to use the system can see your information. If you are present and able to answer, then you will be asked whether it is ok for the person looking after you to look up information about you on the computer system. The computer system reduces the time spent by professionals checking details from different health and social care organisations. It can also reduce delays to your treatment caused by a lack of information. The system went live in March 2017, with clinical staff at Berkshire Healthcare Foundation Trust having access to GP records. Already, 1,000 records a week are being accessed through the system and the implementation will continue in phases throughout The system will also allow patients to view their clinical records and, in time, enable remote monitoring of medical conditions, for example, through the use of wearable devices. Another benefit will be automated real-time alerts to clinicians, so, for example, your GP and community nursing staff could be alerted that you have been admitted to hospital or discharged. Further information about Share Your Care is available at Page 14

15 Equality and diversity All public bodies have a specific duty to promote equality, diversity and inclusion in the way they work. We are committed to upholding the NHS Constitution, which outlines a number of commitments and pledges to uphold patients entitlement to dignity, equality, diversity and human rights in all aspects of commissioning, employment, engagement and involvement. The senior lead for equality and diversity is Sarah Bellars, Director of Nursing. She chairs the Equality and Diversity Steering Group, which sought views from the public about setting objectives for 2016/17. A survey on Health Connect attracted 95 responses and a group of Patient Panel members will now work with us in developing action plans to ensure our objectives are delivered. Falls Prevention Slough Borough Council and the CCG together commission a community falls and home safety service with a focus on older adults at high risk of falling or who have already fallen. It is promoted through local community groups, GPs, the hospital, local optometrists and the Slough Services guide. It has initially been working with specific practices with community outreach to the Slough Seniors programme. Patients are seen at the practice, at home or in group exercise sessions. The service also has links to other health teams. Sessions include: advice on how to access the falls service work on falls prevention group and home based exercises review of medication blood pressure monitoring rapid referral for cataracts to a GP correct use of safety shoes A key feature of the service is access through the Falls Free 4 Life web page GPs and A&E can encourage self-referrals through a dedicated phone number or via to info@fallsfree4life.co.uk. Falls activity is monitored and the programme is reducing the number of people attending A&E or admitted to hospital as a result of a fall. Complex case management As part of our proactive care approach, Slough is using a risk stratification tool to identify patients who may benefit from more intensive support and regular appointments with a GP. We have integrated the complex case finding process with the extended access scheme under the Prime Minister s Challenge programme. We monitor these patients every month and there are signs of significant reduction in hospital admissions and A&E attendances. Currently, 568 patients see their GPs once every three weeks for a 20 minute appointment and we have seen a 28% reduction in non-elective admissions and A&E attendances, as well as a 37% reduction in new outpatients appointments. Page 15

16 Respiratory care for children and young people In response to a high number of hospital admissions among children with asthma and respiratory difficulties, we have been running a community respiratory service in Slough, led by Wexham Park Hospital. Two nurses follow up the children after they leave hospital, for additional education, training and support for them and their families. They also work with practices to support GPs and practice nurses with guidance on managing respiratory conditions. In the last quarter there have been 50 home visits, three nurse-led clinics and 14 GP clinics. Another initiative was the children s asthma bus, which visited 15 of the largest secondary schools in Slough in two weeks. Students, their parents and school workers were invited to board the bus to listen to advice about dealing with asthma. Children had their lung function tested and their inhaler technique reviewed, as well as learning about the impact of allergies on asthma. Telehealth Following a successful trial of telehealth devices trial across the borough, Slough CCG and the Council decided to extend it to other patients in 2016/17. The previous trial was funded through the Better Care Fund for patients with heart failure or respiratory diseases. The devices read and report patients conditions throughout the day. As a result, they have more independence and control, plus a better quality of life and fewer appointments or unplanned hospital admissions. Shared strategy and joint commissioning of voluntary/community services Slough Borough Council and the CCG have a joint strategy for working with voluntary and community services to deliver better health, social care and wellbeing outcomes for vulnerable adults in Slough. The Slough Prevention Alliance Community Engagement (SPACE) consortium is now providing a range of services and support, including support for carers, information and advices services, and community navigators. Local wellbeing hubs The CCG and Borough Council are building on the work of community hubs in Slough to strengthen relationships with people, communities, the voluntary sector and partners. We have an opportunity to create a circle of support for people in the heart of our communities, with the CCG, the Council and other partners supporting Slough residents to have independent lives for as long as possible. The programme is in three phases and is pursuing opportunities for multi-disciplinary working with GPs and community health colleagues. We also want to develop integrated care in clusters at a very local level. Community centres provide a focal point and facilities to foster greater communal activity and bring residents, businesses, neighbourhoods and smaller organisations together to improve quality of life in their areas. Page 16

17 Cardio prevention programme Slough has commissioned an integrated cardio prevention service which identifies people at risk of cardiovascular disease and those with diabetes and offers a range of support, such as exercise, healthy hearts, healthy eating, and physical activity programmes. Latent tuberculosis The CCG and Borough Council have been working together to highlight the effects of a sleeping form of TB. While prevalence is coming down in European countries, it remains high in the UK. The two organisations hosted a World TB day event in March to raise awareness of TB, as well as offering testing for people entering the UK from high risk countries. The high-risk country list is available here: Rates of TB in the South East of England (outside London) are highest in Slough and South Reading. A high percentage of TB in England comes from people who have the sleeping (latent) form of TB. They may have this for many years while feeling completely well. Illness, life stresses and certain medication can reduce their immunity and reactivate their sleeping form of TB. It is important to identify people who have this so it can be treated before it becomes active. Each untreated, infectious person could potentially infect a further 10 people a year. Early detection of active TB and tracing people who may have been in contact with it is key to treating people with the disease, as well as testing those they ve been in contact with it, because TB is treatable and curable. Page 17

18 PERFORMANCE REPORT John Lisle Accountable Officer Slough CCG 30 May 2017 Page 18

19 Performance Overview Statement from the Accountable Officer Slough Clinical Commissioning Group (CCG) is part of a collaboration of three CCGs with Bracknell and Ascot CCG, and Windsor, Ascot & Maidenhead CCG. While retaining a local perspective on healthcare commissioning, we have a joint administrative structure, which brings consistency, reduces duplication of effort and allows us to benefit from economies of scale. WAM CCG is the employing organisation for the shared administration and management team. The introduction of the Frimley Health and Care Sustainability and Transformation Partnership in the past year has encouraged closer working across the three CCGs, with opportunities for further joined-up working across health and local authorities. CCGs co-chair local health and wellbeing boards and local authority leaders have been non-voting members of the CCGs governing bodies, but we are always looking for ways to improve efficiencies and share resources. Slough CCG covers an area of 32.5 square miles, most of it urban. The population has a number of distinguishing features which present health challenges. Slough CCG is clear about what we need to achieve and confident of delivering the changes that are required to improve the health of our community. The CCG has 156,668 registered patients with almost 9% being over 65 and 23% being aged The population is diverse with a high turnover of newcomers to the area from abroad and from elsewhere in the country. The economy is strong but there are several areas of particular deprivation where health outcomes are directly affected. The CCG has 16 General Practices in the area. Our services are commissioned from more than 300 providers, but our main providers are: Acute hospitals: o Frimley Health Foundation Trust o Royal Berkshire Foundation Trust o Ashford and St Peters Foundation Trust Mental health/community trust Berkshire Healthcare Foundation Trust South Central Ambulance Service A range of private and other providers Slough Borough Council provides the majority of social care to the CCG s residents. We also have a vibrant voluntary and community sector. We have worked hard, along with our partner organisations, to improve quality of care and our financial position while working towards delivering our vision: We have monitored all the key areas of performance and any areas of concern have been brought to the attention of the governing body for action to be taken. Page 19

20 Statement of the purpose and activities of the organisation Slough Clinical Commissioning Group was established on 1 April 2013 following the passing into law of the Health and Social Care Act This legislation resulted in a change in commissioning health services. Across England, CCGs took on many of the responsibilities of primary care trusts. They are independent bodies run by GPs who plan, buy and oversee health services from a range of NHS, voluntary, community and private sector providers. CCGs put clinicians, who are attuned and responsive to the health needs of local people, at the forefront of commissioning. In the past two years, we have been a lead partner in improving health and care for people with complex illnesses or conditions. Our work has fed into the Frimley Health and Care Sustainability and Transformation Partnership(STP) and is an essential part of its integrated care decision-making hubs work stream. The challenges this programme is addressing include: practical issues for integrating NHS and local authority care services technology for sharing information workforce issues such as care coordination and breaking down some of the barriers between services better information for patients, carers, families and care professionals so it is easier to get the right care at the time it is needed STP work streams are picking up this work and the CCG has ensured its two-year operating plan and contracts are all in line with STP priorities across the Frimley Health and Care system. The CCG has been developing further its partnership working with Slough Borough Council and its neighbouring CCGs, as well as further developing clinical engagement with GPs and other local clinicians. Slough Wellbeing Board is the partnership body which decides on strategic priorities for the health and wellbeing of local people. The CCG s performance and delivery of its strategy is discussed with the Wellbeing Board, including the annual report. Dr Jim O Donnell is a member of the Wellbeing Board. The strategic direction and Sustainability and Transformation Partnership discussions are taken to the Wellbeing Board. Our shared plans and strategic direction are discussed at the Health Priority Delivery Group (sub group of the Wellbeing Board). The Health Priority Delivery Group is the vehicle for agreeing joint health and social care priorities and these have bene discussed at Wellbeing Board level as we revisit our joint Wellbeing Strategy Its strategy includes five overarching priorities to help make Slough a better place to live, work and visit by 2028: Health - Slough will be healthier with reduced inequalities, improved wellbeing and opportunities for our residents to live positive, active and independent lives. Economy and Skills - Slough will be an accessible location, competitive on the world stage with a sustainable and varied business sector and strong knowledge economy, supported by a local workforce that has the skills to meet local businesses changing needs. Page 20

21 Housing Slough will possess a strong, attractive and balanced housing market which recognises the importance of housing in supporting economic growth. Regeneration and the environment - Slough will be distinctive from our competitors, harnessing the diversity and creativity of our people and our customers and physical fabric to create an attractive local environment for our residents and businesses. Safer communities Slough will have levels of crime and disorder that are not significantly higher than any other town in the Thames Valley. Key issues and risks The CCG Governing Body regularly reviews its key risks and publishes an assurance framework which describes these and the mitigation actions in place. During the year key risks that were identified included: o the strategic relationships with the CCG providers o the right leadership skills, knowledge and capacity of the management team o the right skills, workforce capacity in primary, social, community and secondary care o having effective performance and quality governance structures in place o effective corporate governance, decision making structures, member engagement and patient involvement in place o acceleration and embed the adoption of technology and information sharing in clinical and corporate areas o development and utilisation of the local health and local authority estate in the most effective way o achievement of our QIPP savings and service transformation plans o the right information to be assured we are meeting the NHS constitutional standards, statutory standards and other key performance targets o the right financial, activity and performance information o anticipation and responding to future individual health needs o having the right information about the impact of legislation and regulatory requirements on health and social care o appropriately manage and stimulate the healthcare market o partnership working arrangements to identify and uncover any threats to the financial sustainability of our local NHS providers and local authorities Performance Summary Constitutional Standards Performance Summary 2016/17 Through 2016/17 the improved performance in NHS Constitutional Standards reported the previous year has been sustained. This has been recognised by NHS England who has assessed the three CCGs in East Berkshire as Good against the new IAF Improvement and Assessment Framework introduced during 2016/17. The IAF consists of 4 domains including Better Health, Better Care, Sustainability and Leadership. The CCGs are assessed against these 4 domains by NHSE who reference a suite of indicators under each domain. The CCGs performance against the IAF is also published on mynhs and updated quarterly. The assessment of the CCGs performance against the IAF indicators is undertaken at quarterly and year end IAF assurance meetings with NHSE. During this face to face assessment the CCGs are scrutinised on its performance against the 4 domains and the underlying IAF indicators and given a rating of Good. Page 21

22 One area if the IAF is chosen at each quarterly meeting for a deep dive where the CCGs are required to demonstrate how their programmes of work are designed to improve performance, illustrating this with outcome data. Many of these IAF indicators are Constitutional Standards and performance in these standards are outlined below. These ratings are also reflected on mynhs for each CCG. Within the framework there are also 6 clinical priorities including, Cancer, Dementia, Diabetes, Maternity Learning Disabilities and Mental Health. Performance against these clinical priorities is determined for each CCG and is published on mynhs. This initial baseline assessment of the 6 Clinical Priorities provides the CCGs with a snapshot & useful starting point for future assessments. The methodology for the clinical priority assessment comes from the underlying IAF indicators published in June Independent panels for each priority area have defined approaches to combining individual indicators in the IAF to reach a composite banding for each Clinical Priority. The CCGs programmes of work are designed to address areas where performance is requiring improvement. It is expected that the ratings assigned to each clinical priority will be published annually. Initial ratings indicate the CCGs require to focus on Maternity, Cancer and Dementia with Mental Health overall performing well. Our CCGs have continued to work collaboratively with key providers in particular Frimley Health Foundation Trust (FHFT), Berkshire Healthcare Foundation Trust (BHFT) and South Central Ambulance Service (SCAS) within our health system to maintain this strong performance. In particular 18 weeks RTT (Referral to Treatment) waiting times have consistently remained at above the 92% standard. Cancer waiting times at our main provider FHFT including the 2 week wait and 62 day wait cancer standards have been achieved consistently throughout the year. This good performance is also reflected in the published IAF indicators against the Better Care domain on mynhs. Performance in A&E 4hr waits has in the latter half of the year been very challenging. With increased demand and acuity of patients, FHFT has struggled to maintain the 95% standard of patients arriving at A&E being seen within 4 hours. Robust cross system working overseen by the A&E Delivery Board is addressing the causative factors that might be driving this reduced performance. Improvement plans are being implemented at pace to turn this performance around. This has been a national picture and despite this Frimley Health at both sites remains in the top 25 performing Trusts in the country with regard to A&E. Performance in 6 weeks diagnostics waits has also been very strong at FHFT despite a blip at Frimley Park in January and February due to staff shortages but performance was recovered very swiftly. Berkshire Healthcare Foundation Trust (BHFT) has delivered strong performance in improving IAPT (Access to Psychological Therapies), with achievement of the standard throughout the year. Equally performance in delivering the relatively new EIP standard (Early Intervention in Psychosis) has been outstanding with Berkshire leading the way nationally in the provision of this service. Performance in Dementia diagnosis rates particularly in Slough CCG remains a challenge. Improvement plans are in place to address the disparity in performance when compared to the other two CCGs. To date performance has not seen an improvement and as such new approaches are being sought by Slough clinicians to address this. Page 22

23 This lower than expected performance is also reflected in the published IAF indicators against the Better Care domain on mynhs. Performance in ambulance response times has improved against agreed trajectories and achieved the standards in February 2017 for RED1 8 minutes, RED2 8 minutes and CAT A 19 minutes. Pressure on ambulance services is a national picture as a result of increased demand and issues with staff shortages, particularly in specialised paramedics roles. The CCGs have worked closely with the Trust and other Commissioners in Thames Valley to resolve this poor performance with focus on innovative ideas for retaining and attracting paramedic staff and increased use of hear and treat and see and treat thus reducing conveyances to acute hospitals. Monitoring of performance of our main Providers take place monthly at Clinical Quality Review Meetings and Contract Review Meetings. These take place between Commissioners and the Trust where the CCGs are provided with assurance of action being taken to improve performance where is it required. The Governing Bodies receive and discuss a Quality and Performance Report that explains achievement against all NHS constitutional standards and other relevant quality outcome metrics. NHS Constitutional Standards Performance Summary 2016/17 URGENT & EMERGENCY CARE A&E Waits 12 Hr Trolley Waits Indicator Patients should be admitted, transferred or discharges within 4 hours of their arrival at an A&E Department. Trolley waits in A&E no longer than 12 hours Threshold Frimley Health FT YTD at M12 Frimley North M12 Frimley South M12 95% 91.5% 88.3% 93.8% Zero 4 URGENT & EMERGENCY CARE Mixed sex accommodation Category A Ambulance calls Indicator Breaches of mixed sex accommodation Category A calls resulting in emergency response arriving within 8 minutes (Red 1) Category A calls resulting in emergency response arriving within 8 minutes (Red 2) Category A calls resulting in an emergency response arriving within 19 minutes Threshold BA CCG YTD at M12 Slough YTD at M12 WAM CCG YTD at M12 Zero % 74.5% 85.2% 72.4% 75% 74.5% 85.2% 72.8% 95% 95% 98.2% 96.5% Page 23

24 PLANNED CARE Referral to Treatment waiting times for non-urgent consultant-led treatment Diagnostic test waiting times Cancer Waiting Times Indicator Patients on Incomplete nonemergency pathways (yet to start treatment) should have been waiting no more than 18 weeks. Number of patients waiting more than 52 weeks for incomplete pathways. Patients waiting for a diagnostic test should have been waiting less than 6 weeks from referral. Maximum 2 week wait (2WW) for first outpatient appointment for patients referred urgently with suspected cancer by a GP Maximum 2 week wait for the first outpatient appointment for patients referred urgently with breast symptoms (where cancer was not initially suspected) Maximum one month (31 day) wait from diagnosis to first definitive treatment for all cancers. Maximum 31 day wait for subsequent treatment where the treatment is surgery. Maximum 31 day wait for subsequent treatment where the treatment is an anti-cancer drug regimen. Maximum 31 day wait for subsequent treatment where the treatment is a course of radiotherapy. Maximum 2 month (62 days) wait from urgent GP referral to first definitive treatment for cancer. Maximum 62 day wait from referral from an NHS screening service to first definitive treatment for all cancers. Threshold 92% Zero BA CCG YTD at M12 Slough CCG YTD at M12 WAM CCG YTD at M % 93.15% 93.12% <1% 0.75% 0.15% 0.31% 93% 95.4% 96.6% 95.6% 93% 98.3% 97.1% 96.4% 96% 98.9% 99.1% 99.5% 94% 97.3% 100% 98.4% 98% 99.2% 100% 100% 94% 95.2% 95.8% 95.2% 85% 86.4% 87.6% 89.5% 90% 100% 100% 100% Page 24

25 MENTAL HEALTH Indicator Threshold Dementia Diagnosis rate Diagnosis rate for people with dementia, expressed as a percentage of the estimated prevalence BA CCG M12 Slough CG M12 WAM CCG M % 67.0% % MENTAL HEALTH Indicator Threshold BHFT Q3 2016/17 EIP Early Intervention in Psychosis People with first episode of psychosis started treatment with a NICE recommended package of care treated within 2 weeks of referral 50% 91% (BHFT figure for Berkshire wide) MENTAL HEALTH Indicator Threshold Care Programme Approach CPA Improving Access to Psychological Therapies % of service users under adult mental illness specialities on CPA who were followed up within 7 days of discharge from psychiatric in-patient care IAPT access - the proportion of people with depression and/or anxiety disorders that have entered psychological therapies % of Service Users referred to an IAPT programme who are treated within six weeks of referral % of Service Users referred to an IAPT programme who are treated within 18 weeks of referral IAPT recovery rate. The % of people who finished treatment within the reporting period, have attended at least 2 treatment contacts, coded as discharged, and assessed as moving to recovery BA CCG Q3 Slough CG Q3 WAM CCG Q3 95% 95.7% 97.5% 100% 3.75% quarterly 4.0% 4.0% 5.0% 75% 99% 98% 98% 95% 100% 100% 100% >= 50% 55% 57% 54% Page 25

26 HEALTHCARE ASSOCIATED INFECTIONS Infection Control (HCAI) Infection Control (HCAI) Indicator Number of MRSA Bacteraemia Number of Clostridium Difficile Threshold BA CCG YTD (to M12) Slough CCG YTD (to M12) WAM CCG YTD (to M12) Zero B&A (18) Slough (22) WAM (33) Performance analysis Slough CCG is part of a collaboration of three CCGs who, while retaining a local perspective on healthcare commissioning in their area, operate within a joint administrative structure, which brings consistency, reduces duplication of effort and allows us to benefit from economies of scale. The CCG is the employing organisation for these shared staff. The CCG regularly monitors and reviews its performance, including finance, quality and areas such as A&E attendances and non-elective admissions, benchmarking them against guidance, such as admission avoidance pathways and referral management advice. Reports to the Governing Body ensure the focus remains high throughout the year. Monitoring of performance of our main providers takes place monthly at clinical quality review meetings and contract review meetings between commissioners and Trusts, at which the CCGs are provided with assurance of action to improve performance as required. Governing Bodies receive and discuss a quality and performance report that explains achievement against all NHS constitutional standards and other relevant quality outcome metrics. NHS England assesses the performance of all CCGs through its Assurance Process, which assesses the CCG against the following framework: Page 26

27 Better Health: this section looks at how the CCG is contributing towards improving the health and wellbeing of its population and bending the demand curve. Better Care: this principally focuses on care redesign, performance of constitutional standards and outcomes, including in important clinical areas; Sustainability: this section looks at how the CCG is remaining in financial balance and is securing good value for patients and the public from the money it spends; Leadership: this domain assesses the quality of the CCG s leadership, the quality of its plans, how the CCG works with its partners and the governance arrangements that the CCG has in place to ensure it acts with probity, for example, in managing conflicts of interest. The CCG has been rated good against all of the four domains throughout 2016/17 up to and including Q4. Our assurance rating for Q4 will be awarded in early May but all indications are that we will maintain this good status across the four domains. Performance across the Constitutional Standards has been strong and leadership has been strengthened with appointment of permanent Accountable Officer and the embedding of the restructure of the CCGs. This has been recognised by NHS England in the rating awarded to the CCGs in East Berkshire. Delivering NHS Constitution standards The following section summarises our performance for the year in meeting the NHS Constitution standards. The performance of each of the three East Berkshire CCGs is included for comparison. Urgent & Emergency Care A&E A&E performance for Frimley Health was outstanding in the first quarter of 2016/17. However, 2016/17 has been challenging, with significant demand and increased attendances, coupled with high acuity patients. July and August were particularly challenging, with high numbers of frail and elderly patients with complex needs and the need for significant planning in discharging them. At times, lack of capacity in community beds has impacted on the hospital, exacerbating performance in A&E. Performance began to recover in September 2016, but dropped again as winter pressures began. January was particularly challenging, with unprecedented numbers attending A&E and high acuity patients. This fits with the national picture, but despite this FHFT remains in the top 25 performing Trusts in the country with regard to A&E. A&E performance, along with other urgent and emergency care performance metrics, is reviewed monthly at the A&E Delivery Board, attended by cross-system partners, including NHSE. This forum is proactive in resolving issues and overcoming barriers to improving performance across the patch. In addition to actions to address winter pressure, a number of initiatives are in progress to ease pressure and demand on A&E, including: extension of ambulatory care unit to 7 days a week and 12 hours a day expansion of the frailty units in ambulatory care at FHFT implementation and acceleration of discharge-to-assess model at Wexham Park Hospital Page 27

28 development of multi-agency, trusted assessor role to aid discharge to onward care across East Berkshire increased mental health support at the front door acceleration of plans for diuretics lounge and bed reconfiguration following changes to stroke pathway at Wexham Park Hospital increased senior nursing presence in A&E twice daily system operational calls attended by all partners in the East Berkshire & Bucks health and social care system, using real time data to manage demand and flow integrated urgent care commissioning through reprocurement of NHS 111 to increase number of patients clinically triaged, decreasing number of referrals and decreasing ambulance response from 111 increased ambulance hear and treat and see and treat to reduce ambulance conveyance Fig: Frimley Health Foundation Trust A&E 4hr standard Performance 2016/ % FHFT A&E 4hr Standard 94.00% 90.00% 86.00% 82.00% Frimley Health Frimley North Frimley South Threshold Mixed sex accommodation (MSA) As a result of pressures and high demand in A&E, at times it is not always possible to ensure single sex accommodation in bays, especially in acute medical units while patients are waiting for assessment prior to admission. The Royal Berkshire Foundation Trust (RBFT) reported significant numbers of breaches during 2016/17. The Trust puts patient safety first and if a breach is inevitable, screens and curtains are used to maintain dignity and privacy and patents are informed of the decision to breach and reasons why. Commissioners are kept informed of reasons for the breaches and each is investigated to ensure no harm to patients has occurred. Ambulance waits As mentioned earlier in this report, South Central Ambulance Service underperformed in emergency response calls throughout the year. Commissioners and the Trust developed a recovery plan to reach these standards by March SCAS met the standards in M11 (February 2017) and met 2 out of the 3 standards in M12 (March 2017). This improved performance was in the main due to a drop in demand during this period however SCAS is still one of the top performing Ambulance Trusts in the country. Page 28

29 This issues challenging SCAS in achieving the ambulance response times targets include workforce pressures and shortages of trained paramedics, increased demand in both 999 and 111 calls for emergency response and increased acuity of patients. SCAS has put considerable effort into reversing the recruitment issue, with innovative ideas to overcome loss of specialist paramedics to other healthcare sectors. Progress against the recovery action plan is discussed by all Commissioners in Thames Valley region with the Ambulance Trust at monthly contract and quality review meetings. Development and implementation of the ambulance response programme (ARP) will bring new metrics for 2017 that allow more time for triage prior to conveyance. Fig: RED1 Ambulance (SCAS) Performance in East Berkshire 2016/ % 95.0% 90.0% 85.0% 80.0% 75.0% 70.0% 65.0% 60.0% East Berkshire CCGs Ambulance RED 1 (8 mins) 2016/17 SCAS Overall B&A Slough WAM Threshold Fig: RED2 Ambulance (SCAS) Performance in East Berkshire 2016/ % 90.0% 85.0% 80.0% 75.0% 70.0% 65.0% 60.0% East Berkshire CCGs Ambulance RED 2 (8 mins) 2016/17 SCAS Overall B&A Slough WAM Threshold Page 29

30 Fig: RED19 Ambulance (SCAS) Performance in East Berkshire 2016/ % East Berkshire CCGs Ambulance CAT A (19 mins) 2016/ % 90.0% SCAS Overall B&A Slough WAM Threshold Planned care Referral to treatment (RTT) for elective care During 2016/17 East Berkshire CCGs consistently met the 92% Incomplete RTT standard. Our main provider, FHFT, maintained performance despite a challenging environment, with increased referrals. This was achieved by smarter working across the three FHFT sites, offering patients more choice. Utilisation of the elective facilities at Heatherwood Hospital improved, as did more efficient clinical pathways and the attraction of additional consultants to a successful Trust. There was pressure in some specialties, due to consultant shortages and recruitment issues, but the Trust had plans in place to address and cover the shortfalls with locums. Pressure at Royal Berkshire Foundation Trust (RBFT) affected Berkshire East patients, particularly in ophthalmology and dermatology, but recovery plans have now delivered compliance in 18-week wait times. Some patients have waited over 52 weeks for treatment. The main issue was in ophthalmology at RBFT, where a hidden waiting list was discovered that was not visible on the patient tracking system. Patients were waiting for minor eye procedures and have now been treated or discharged. No harm was identified. In addition, a couple of cases of patients have waited more than 52 weeks for plastic surgery by Imperial College Healthcare in London. The Trust is experiencing a huge backlog in 52-week waits. NHS Improvement is overseeing the recovery plan. No patients waited more than 52 weeks at FHFT as a result of increased focus by the Trust on early identification of patients with long waits and instigating the appropriate actions to eliminate this. Page 30

31 Fig: East Berkshire CCGs 18 Weeks RTT Incomplete Performance 2016/ % East Berkshire CCGs RTT Incomplete 2016/ % 91.00% B&A Slough WAM Threshold Diagnostic waiting times Performance in diagnostic waiting times at FHFT dipped during month 9 and 10 in 2016/17 due to a loss of capacity in the endoscopy unit, due to sickness of key senior booking staff. The Trust had an action plan in place to regain compliance, which was achieved as expected at end March The issue was predominantly at the Frimley South site and as such did not affect the performance in Slough CCG. Performance in waiting times for diagnostic tests has been consistently compliant for Wexham Park Hospital site throughout 2016/17. Performance has been at 100% for Slough CCG in consecutive months. Fig: East Berkshire CCGs 6 Weeks Diagnostics Waits 2016/ % East Berkshire CCGs 6 Weeks Diagnostic Waits 1.00% 0.00% B&A Slough WAM Threshold Page 31

32 Treatment for cancer Cancer performance was good in 2016/17, with only a few areas of underperformance as a result of patients receiving treatment at multiple providers and patient choice to delay. Frimley Health reported strong performance in wait times throughout the year and 2-week wait times for all cancers and breast symptoms was consistently above the 93% threshold. B&A CCG dipped in July, due to data issues, but refreshed quarterly figures report compliance across the patch. Fig: East Berkshire CCGs 2 Weeks Cancer Waits 2016/ % East Berkshire CCGs Cancer 2 Weeks Wait 98.00% 96.00% 94.00% 92.00% 90.00% Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 B&A Slough WAM Threshold Fig: East Berkshire CCGs 2 Weeks Cancer Waits BrEast 2016/ % East Berkshire CCGs Cancer 2 Weeks Wait Breast 98.00% 96.00% 94.00% 92.00% 90.00% Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 B&A Quarterly Slough Quarterly WAM Quarterly Threshold The 31-day wait times are compliant for all East Berkshire CCGs, with the exception of surgery (B&A CCG in Q2 2106/17) and radiotherapy (B&A CCG in Q1 and Q3 and Slough CCG in Q4). The surgery breaches related to cases in May 2016 among several providers. No theme was identified and recovery was reported the following and subsequent months. The radiotherapy breaches were predominantly due to patient choice. Radiotherapy patients at RBFT chose to pause treatment to take a holiday. Commissioners are assured that sufficient and suitable appointment slots are offered by the Trust. Page 32

33 Fig: East Berkshire CCGs 31 Day Waits All Cancers 2016/ % East Berkshire CCGs Cancer 31 Day Wait All Cancers 98.00% 96.00% 94.00% Q1 2016/17 Q2 2016/17 Q3 2016/17 Q4 2016/17 B&A Quarterly Slough Quarterly WAM Quarterly Threshold Fig: East Berkshire CCGs 31 Day Waits Surgery 2016/ % East Berkshire CCGs 31 Day Wait Surgery 96.00% 92.00% 88.00% Q1 2016/17 Q2 2016/2017 Q3 2016/17 Q4 2016/17 B&A Quarterly Slough Quarterly WAM Quarterly Threshold Fig: East Berkshire CCGs 31 Day Waits Radiotherapy 2016/ % East Berkshire CCGs 31 Day Wait Radiotherapy 96.00% 92.00% 88.00% 84.00% 80.00% Q1 2016/17 Q2 2016/17 Q3 2016/17 Q4 B&A Slough WAM Threshold Page 33

34 The 62-day waits marginally failed the quarterly threshold of 85% in Q3 for Slough CCG. There was no particular theme. Breaches in the main were as a result of late tertiary referral, complex diagnostics, complex cases referred between specialties, and patient choice. Commissioners work closely with the Trust to identify any themes for breaches and implement actions where appropriate. All 3 CCGs achieved the standard overall for final month 12 YTD figures. Fig: East Berkshire CCGs 62 Day Waits 2016/ % East Berkshire CCGs Cancer 62 Day Wait 92.00% 88.00% 84.00% 80.00% Q1 Q2 Q3 Q4 B&A Quarterly Slough Quarterly WAM Quarterly Threshold Mental Health Dementia Slough CCG continues to struggle to meet the dementia diagnosis rate (DDR) standard. Performance was at 60% for some months, despite initiatives and refreshed action plans to increase this. Cultural issues remain a barrier to dementia diagnosis, with English often not being the first language and a lack of awareness of Dementia diagnosis and knowledge of how to access the help available in some groups. Slough CCG has instigated a number of schemes to address this and has been working hard with local community groups to raise awareness of dementia. Such initiatives include targeted visits to GP surgeries with the lowest DDR, proactive clinical case finding in primary care and care homes. The Alzheimer's Society dementia information worker has been visiting Slough GP practices to raise awareness, taking a dementia exhibition stand and speaking to patients to raise awareness in waiting rooms, especially targeting BME groups. Dementia awareness leaflets and were sent to all Slough GP practices in March 2016 and frontline practice staff are now Dementia Friends. Slough CCG is working closely with the national dementia lead to find a way forward in increasing the DDR. Page 34

35 Fig: East Berkshire CCGs Dementia Diagnosis Rates 2016/ % East Berkshire CCGs Dementia Diagnoses 68.00% 64.00% 60.00% 56.00% B&A Slough WAM Threshold National EIP (early intervention in psychosis) The Early Intervention in Psychosis (EiP) service launched in 2016 and has been exceeding the access standards of 50% of people with an EiP to be seen in 2 weeks since its launch. The service has been recognised regionally as exemplar with passionate and enthusiastic team who are dedicated to early intervention in its truest form. The team also focus on physical as well as mental health which is a key component for recovery. This is a standalone service with strong links to other mental health services, including a single point of access team, who screen, triage and assess people who have been referred with suspected or first episode psychosis community mental health teams transitioning people once an initial assessment has been completed The service runs a performance dashboard that provides up to date information as to where people are in their journey and helps to see at a glance whether they are being seen within the two week wait standard. For more information on the service please see our video Gays9PXpP IAPT (Improving Access to Psychological Therapies) IAPT services in the 3 CCGs in East Berks are high performing with >15% of people with anxiety & depression accessing IAPT provision. There has been good performance in the delivery of the access and recovery targets for some time now. The teams at our local Provider Berkshire Healthcare foundation Trust (BHFT) work hard to accommodate the individual needs of every patient offering online (Silvercloud), telephone and face to face support. There is also the ability for people to drop in to the IAPT clinic in Slough to support the uptake of the service. The service is consistently well led and the teams are able to access an internal training programme to maintain and update skills. Page 35

36 A key strength of the service is its working with other IAPT services across Thames Valley and the Academic Health Science Network to share best practice and focus on recovery. The service & CCGs have been approved as a nationally funded pilot site to increase access to from 15% to 25%, including people with long term condition. As part of this expansion we are rolling out the Bracknell HealthMakers project East Berks wide on a one year pilot. This is peer led support for patients with long term conditions which is supervised by Berkshire Health Care Foundation Trust Talking Therapies team. Also as part of this IAPT expansion we are expanding the Psychological Therapies in Nursing Care patients (PINC) which is a home visiting psychological therapy for housebound patients with long term conditions as a one year pilot. Fig: East Berkshire CCGs IAPT Access 2016/17 East Berskhire CCGs IAPT Access 2016/17 6% 5% 4% 3% 2% 1% 0% Q1 Q2 Q3 B&A Slough WAM Threshold Fig: East Berkshire CCGs IAPT Recovery 2016/ % East Berkshire CCGs IAPT Recovery Rate 2016/ % 40.00% 20.00% 0.00% B&A Slough WAM Threshold Qtr 1 Qtr 2 Qtr 3 Page 36

37 Financial Performance for Slough CCG Clinical Commissioning Groups are expected to manage expenditure within the resources allocated by NHS England, and deliver a minimum 1% surplus (which can be carried forward to future years). This requires not only careful management of the finances but also strong internal control mechanisms to ensure the resources of the CCG are handled in a way which is up to public standards and can be sustained year on year. The CCG spent almost 173.9m in 2016/17 (net operating costs), which equates to 1,104 for every person registered with our practices. NHS Slough CCG have reported a surplus of 3.7m for the year. As set out in the 2016/17 NHS Planning Guidance, CCGs were required to hold a 1 percent reserve uncommitted from the start of the year, created by setting aside the monies that CCGs were otherwise required to spend non-recurrently. This was intended to be released for investment in Five Year Forward View transformation priorities to the extent that evidence emerged of risks not arising or being effectively mitigated through other means. In the event, the national position across the provider sector has been such that NHS England has been unable to allow CCGs 1% non-recurrent monies to be spent. Therefore, to comply with this requirement, NHS Slough CCG has released its 1% reserve to the bottom line, resulting in an additional surplus for the year of 1.7m. This additional surplus will be carried forward for drawdown in future years. Just over half of our expenditure ( 104m) is spent on acute services. Our main provider is Frimley Health NHS Foundation Trust. In 2016/17 we spent 82m with Frimley Health. Our next largest provider is the Royal Berkshire NHS Foundation Trust 5.5m who provide ophthalmology services from the King Edward VII Hospital in Windsor. Then there are range of smaller contracts with other hospitals such as Ashford & St Peters, Buckinghamshire Healthcare and Oxford University Hospitals. This category of expenditure (acute services) also includes Ambulance costs. The majority of our community and mental health services are provided by Berkshire Healthcare NHS Foundation Trust 23.8m. Page 37

38 We also meet the cost of drugs prescribed by our local GPs (about 17.3m) and pay for the GP out of hours service. But for 2016/17 the majority of GP costs are funded through contracts held directly by NHS England and not Slough CCG. This will change in 2017/18 when the CCG assumes full delegated responsibility for Primary Care (GP) budgets from NHS England. The CCG has received 0.9m of additional funding to provide improved access to primary care and in addition the CCG has allocated 1.0m of its 2016/17 budget to support this initiative. In common with many CCGs across the country during 2016/17 Slough CCG experienced significant financial pressure on its acute hospital contracts, particularly in the cost of emergency admissions. Other cost pressures included expenditure on independent acute hospital contracts, additional costs of Continuing Healthcare (CHC) for clients awaiting assessment, appeals and joint funded learning disability clients and Funded Nursing Care costs (which have increased by 60%) These financial pressures and unexpected costs have been funded from the financial contingencies the CCG established at the start of the year. NHS England adopted a new funding formula for CCGs in 2014/15 which allocated the overall national funding based on the needs of the local population, and calculates a target allocation. Over time actual funding levels will be moved closer to the target (this is sometimes referred to as the pace of change ). Slough CCG is funded at about this target level, and for 2016/17 the CCG received an increase of 5.1m in its programme funding allocation. Looking to 2017/18, the CCG has received a lower funding increase of 4.1m which is required to cover inflation, population growth, a range of new national policy pressures and local service developments. The CCG also has to replace the contingency budgets it used in 2016/17. It has therefore been necessary to develop a substantial QIPP (Quality, Investment Productivity and Prevention) programme looking to mitigate the impact of these pressures by 3.4m. We have approached this through using the NHS Right Care approach to identify opportunities where evidence indicates unwarranted variation in outcomes and/ or financial value. We have used this approach to drive a robust plan of clinical and wider stakeholder engagement in the generation and development of new ideas for QIPP projects. These include projects for respiratory services, neurology and end of life care. About 8.4m of the CCG s funding allocation will be spent in partnership with the Slough Borough Council via the Better Care Fund. This is supporting greater integration across health and social care services. We are also planning to continue our scheme for extended access to primary care (GP) services. Since the formation of the CCG in 2013, we have been working in close partnership with the other two CCGs in the East of Berkshire, and this includes sharing the financial risks on some areas of our budget. As already mentioned elsewhere in this Annual Report, we are also part of the Frimley Health and Care Sustainability and Transformation Partnership, which includes the other two CCGs in the East of Berkshire, Surrey Heath CCG, North East Hampshire & Farnham CCG, local health providers and our local authorities. In the year ahead we will be working together to tackle the challenges of increasing demand for healthcare caused by an ageing population, ensuring that acute services are configured in the most clinically and cost effective way, and that where appropriate patients are cared for at home or in community settings rather than in expensive hospital beds. Over the medium term the increases in CCG funding only covers the costs of inflation, not the demographic impacts so effectively we have to meet tomorrow s demand with today s funding. Page 38

39 Further details about our expenditure in 2016/17 are available in our Financial Statements. These statements have been prepared in accordance with the Directions issued by NHS England under the National Health Service Act 2006, and are audited by BDO LLP. Our external audit for 2016/17 costs us 46,350 plus VAT. Sustainable Development As an NHS organisation, and as a spender of public funds, we have an obligation to work in a way that has a positive effect on the communities for which we commission and procure healthcare services. Sustainability means spending public money well, the smart and efficient use of natural resources and building healthy, resilient communities. By making the most of social, environmental and economic assets we can improve health both in the immediate and long term even in the context of rising cost of natural resources. Spending money well and considering the social and environmental impacts is enshrined in the Public Services (Social Value) Act (2012). We acknowledge this responsibility to our patients, local communities and the environment by working hard to minimise our footprint. As a part of the NHS, public health and social care system, it is our duty to contribute towards the level of ambition set in 2014 of reducing the carbon footprint of the NHS, public health and social care system by 34% (from a 1990 baseline) equivalent to a 28% reduction from a 2013 baseline by It is our aim to meet this target by reducing our carbon emissions 28% by 2020 using 2013 as the baseline year. Modelled Carbon Footprint The majority of the environmental and social impacts are through the services we Commission. Therefore, the following information uses a scaled model based on work performed by the Sustainable Development Unit (SDU) in 2014/15. More information available here: Resulting in an estimated total carbon footprint of tonnes of carbon dioxide equivalent emissions (tco₂e). The majority of this impact is from the services we commission. Proportions of Carbon Footprint 90% 0% 1% 9% Energy Travel Procurement Commissioning Page 39

40 Category % CO 2 e Energy 0% I Travel 1% n Procurement 9% Commissioning 90% Policies In order to embed sustainability within our business it is important to explain where in our process and procedures sustainability features. Area Commissioning (environmental) Commissioning (social impact) Suppliers' impact Business Cases Travel Is sustainability considered? Yes Yes Yes Yes Yes One of the ways in which we as an organisation can embed sustainability is through the use of a Sustainable Development Management Plan (SDMP). We will be putting together an SDMP in the near future for consideration by the Governing body. We do not currently use the Good Corporate Citizenship (GCC) tool or run awareness campaigns promoting sustainability. Climate change brings new challenges to our business both in direct effects to the healthcare estates, but also to patient health. Examples of recent years include the effects of heat waves, extreme temperatures and prolonged periods of cold, floods, droughts etc. The organisation has identified the need for the development of a board approved plan to include adaptation for future climate change risks affecting our area. We have not assessed the social and environmental impacts for the CCG. Slough CCG fully supports the Government s objectives to eradicate modern slavery and human trafficking but does not met the requirements for producing an annual Slavery and Human Trafficking Statement as set out in the Modern Slavery Act Partnerships As a commissioning and contracting organisation, we will need effective contract mechanisms to deliver our ambitions for sustainable healthcare delivery. The NHS policy framework already sets the scene for commissioners and providers to operate in a sustainable manner. Crucially for us as a CCG, evidence of this commitment will need to be provided in part through contracting mechanisms. Page 40

41 For commissioned services here is the sustainability comparator for our providers: Organisation Name SDMP On track for 34% reduction GCC Healthy travel plan Adaptation SD Reporting score Berkshire Healthcare NHS Foundation Trust Frimley Health NHS Foundation Trust Ashford And St. Peter's Hospitals NHS Foundation Trust Royal Berkshire NHS Foundation Trust South Central Ambulance Service NHS Foundation Trust Buckinghamshire Healthcare NHS Trust Yes No Yes No Yes No 1. On track to meet target 4. No Sustainable Development Management Plan or Carbon reduction Plan 2. Target included but not on track to be met 4. No Sustainable Development Management Plan or Carbon reduction Plan 2. Target included but not on track to be met 4. No Sustainable Development Management Plan or Carbon reduction Plan Yes Yes Yes Good No Yes No Good No Yes Yes Good No Yes No Poor No No No Poor No No No Good Note: Sustainable Development Management Plan (SDMP), Good Corporate Citizenship (GCC) More information on these measures is available here: Performance Organisation As a part of the NHS, public health and social care system, it is our duty to contribute towards the level of ambition set in 2014 of reducing the carbon footprint of the NHS, public health and social care system by 34% (from a 1990 baseline) equivalent to a 28% reduction from a 2013 baseline by It is our aim to meet this target by reducing our carbon emissions 10% by 2015 using 2007 as the baseline year. Here's how we have done: Travel We can improve local air quality and improve the health of our community by promoting active travel to our staff, through our providers and to the patients and public that use the services we commission. Page 41

42 Every action counts and we are a lean organisation trying to realise efficiencies across the board for cost and carbon (CO 2 e) reductions. We support a culture for active travel to improve staff wellbeing and reduce sickness. The CCG manages business travel and encourages staff to use technology for meetings and to travel by public transport and or travel together when attending meetings off site. Energy The CCG actively encourages staff to reduce energy consumption where ever possible. The CCG has single site for its Head quarter (HQ-King Edward VII Hospital). The table below shows the energy usage by CCG at the King Edward VII Hospital for 16/17. Resource 2016/17 Gas Electricity Use (kwh) 3,098 tco 2 e 1 Use (kwh) 29,134 tco 2 e 15 Total Energy CO 2 e 16 Total Energy Spend 5,780 Table Energy used for 16/17 Waste The CCG has actively supported and encouraged staff on recycling of paper waste and other consumable items at the HQ site. Waste 2016/17 Recycling/ reuse Other Landfill (tonnes) 0 tco 2 e 0.01 (tonnes) 2 tco 2 e 0.04 (tonnes) 0 tco 2 e 0.00 Total Waste (tonnes) 2 % Recycled or Re-used 14% Total Waste tco 2 e 0.05 Page 42

43 Improve quality The CCG has a quality strategy for , which sets out how it works collaboratively to endeavour to ensure high quality and the provision of safe care for patients and their carers to experience good services. In December 2016 the National Quality Board published shared commitment to quality, a national definition. The model below illustrates the three components of quality. The 5 domains of the NHS Outcomes Framework form part of NHS England s mandate to deliver the priority outcomes for each domain. These outcomes are key drivers for the CCGs local priorities for quality commissioning. Each indicator is captured in a quality schedule. All providers of services commissioned by the CCGs have a quality schedule mapped against the 5 Domains. The indicators are standards to support the monitoring of safety, effectiveness and patient/carer experience. Quality is reviewed at regular clinical quality review meetings (CQRM) with each provider with a standard NHS Contract. There are a number of contractual levers that can be used if the provider does not meet the standard the CCG has commissioned, including contract performance notices, which enable commissioner and provider to work together to meet care standards. Page 43

44 In 2016/17, contract performance notices were issued to a number of providers, which improved their quality of care following implementation of agreed specified actions. The CCG was issued with a contract query notice from SCAS Patient Transport Service in relation to higher than expected bookings on a particular day from acute hospitals, following a new contract award. The CCG is supporting SCAS with working to reduce numbers of on-the-day bookings to improve patients discharge planning. The CCG s approach to contracting concentrated on the following key areas. Patient experience: The aim is to have measurable ambitions to reduce poor patient experience and understand and assess the quality of care experienced by vulnerable groups of patients. The evidence base is information gathered from the friends and family test, complaints, safe staffing levels, incidents and NHS Choices. The CCG strives to ensure providers deliver on the NHS Constitution, patients rights and commitments given to patients. For FHFT and Berkshire Healthcare NHS Foundation Trust in 2016/17 there was improvement in patient experience, for example, in the Family and Friends test. Safety of clinical services: the CCG has worked with providers to increase the reporting of harm to patients, targeting areas of concern raised by external or local intelligence, including proactive assurance of performance against national standards and ensuring that action from lessons learned were taken effectively and monitored through clinical quality review meetings. In 2016/17 the CCG set up a mortality review group, a thematic review of deaths of service users with learning disabilities, following the Mazars Report into deaths at Southern Health NHS Foundation Trust. Deaths involving people with learning disabilities are reviewed to identify: key themes which may deliver learning or shape future planning of care pathways for people with learning disabilities themes which increase knowledge as to common causes of death cases which give rise to concerns about care provided with follow-up action and communication with families, in keeping with principles of candour and openness if cases meet the criteria of NHS serious incidents guidance, action will be taken to ensure the relevant trust investigates thoroughly findings to contribute to broader reviews, to optimise learning and contribute to recommendations Good clinical practice: The CCG works with providers to ensure clinicians and services are systematically working to accepted best practice guidelines, and that there are systems of clinical communication which are timely, accurate, relevant and systematic. At clinical quality review meetings, providers are requested to thoroughly examine different services to highlight good practice or any concerns. Agree pathways of care: The CCG has worked with primary, community and secondary care services ensuring effective adoption by of agreed care pathways, with indicators that measure the quality of a whole pathway of care and are evidence based. When new care pathways are developed following agreed CCG commissioning intentions, there is a quality review. A new quality impact assessment has been developed this year and is being piloted. Page 44

45 Staff satisfaction is an important indicator of quality and there is good evidence that happy, well-motivated staff delivers better care and their patients have better outcomes. NHS staff work hard, often under great pressure, and the CCG worked with providers of NHS services to make it possible for them to do the best job they can. The CCG used results from staff surveys and the staff Friends and Family Test to improve the quality of services being commissioned. The CCG surveyed its own staff to have an understanding of the needs of its workforce. Safeguarding: The CCG publishes a separate mandatory safeguarding annual report, published on the CCG website. The 5 domains fit well into the themes of personal care and patient experience, safety and clinical effectiveness. Quality care is the core of what we do, and is part of every step in the commissioning cycle, identifying and setting quality standards against local and national priorities, evaluating quality against standards and status with trajectories towards stretch goals. Care and treatment reviews have continued as part of the NHS England response to Transforming Care and the Winterbourne Concordat. These reviews supported people in planning the next stage of their care from hospital into the community or by supporting people at home, rather than being admitted into hospital. Developments and improvements in quality for primary care The CCG has been working with NHS England on the quality of primary care through cocommissioning. There continues to be a monthly quality improvement meeting for primary care, focusing on quality issues and ways for improvement using local intelligence and relationships. A quality tracker has been developed to cover the main issues of infection control, Care Quality Commission (CQC) compliance, general issues, incidents and Friends and Family Test. The meeting has had representation from primary care, Healthwatch, NHS England and the CCG. The quality team, alongside NHS England, is supporting practices that have had an inadequate or requires improvement rating from the CQC. This has involved regular meeting to support practices with their CQC action plan and undertaking mock CQC visits. Practices are then visited again by the CQC after 6 months. All practices so far have improved on their original ratings. These practices have been supported under the NHS England vulnerable practice scheme. A risk management system called Datix has been piloted by a number of practices, this system records all incidents that occur in Primary care and if it is a patient safety incident uploaded to the national reporting and learning system which looks at themes and trends nationally. This will also allow for the CCG to look at any local themes and trends. As part of the quality premium for 2016/17 the quality team has been working with practices on improving access to a GP as outlined in the GP patient survey report. The target is for a 3% point increase from the GP patient survey on the number of patients that had a good overall experience of making a GP appointment. There were a number of practices that were offered a meeting to discuss improving access within the surgery and patient satisfaction with making an appointment. They were selected based on the results from the previous publications of the GP patient survey. Page 45

46 The practices were offered support and a meeting to discuss recent data, the process within the surgery for making an appointment and to go through the improving access guide to determine whether efficient improvements could be made. A number of options were composed for each practice with follow ups also arranged to determine if there is anything the surgery would like to pilot. The GP patient survey was repeated in January 2017 but the results are not yet available for this annual report. Nursing Vision In 2015 a Nursing Vision across East Berkshire was developed with participation from the CCG Frimley Health, Berkshire Healthcare NHS Foundation Trust, Spire Thames Valley, BMI Healthcare The Princess Margaret Hospital and St Marks Nursing Home. The Nursing Vision was launched on National Nurses Day in May 2016 with the Associate Director of Nursing Quality and Safety in attendance for a number of provider events. The vision is about how we can work together on sharing best practice, celebrating success and also sharing skills and knowledge with the workforce across Berkshire. In September 2016 the CCG held a nursing conference, all the local health providers sent representatives. This was a forum to share best practice. A follow up session has been planned to look at patient discharges. The Nursing Vision work and the Community Education Provider Network (CEPN) are becoming aligned. A new system of revalidating nurses by the Nursing and Midwifery Council came in to force on 1 t April The purpose of revalidation is to improve public protection by making sure that nurses and midwives continue to practise safely and effectively throughout their career. Nurses and midwives should stay up to date in their professional practice. They need to develop new skills, keep informed on standards and understand the changing needs of the public they serve and fellow healthcare professionals with whom they work. Revalidation provides nurses and midwives with the opportunity to reflect on their practice against the standards in the Code and demonstrate that they are living these standards. For those nurses and midwives who are professionally isolated from their peers, revalidation will encourage them to engage in professional networks and discussions about their practice. Thames Valley was successful in bidding to pilot the Nursing Associates Training, there will be 38 trainees across Berkshire in a number of different providers and 2 are planned in Primary care in East Berkshire, these 2 Nursing Associates will be supported by the CCG. The creation of the Nursing Associate is a landmark innovation for the nursing and care professions. The introduction of this new role will ensure a highly trained support role to help Registered Nurses deliver effective, safe and responsive care. The Nursing Associate will also play a key part of the multi-disciplinary workforce that is needed to respond to the future needs of the public and patients. Once they have completed and passed their 2 year training they will be registered with the Nursing and Midwifery Council. Page 46

47 Assurance visits Where care and treatment is commissioned from the CCG, the quality team has worked closely with the local Providers on ensuring that the quality of care is of a good standard. Mechanisms are in place for regular monitoring of these providers allowing the CCG to quickly identify areas of poor performance and quality for which sanctions are issued and focussed improvement initiatives are implemented. This can be through a contract performance notice or a financial penalty. The quality team with the CCG lay members have undertaken a number of observational visits to our local providers and fed back to the provider on what was observed. If any actions are required to be taken these are monitored through the clinical quality review meetings. The observational visits are based on the key lines of enquiry that are the basis for Care Quality Commission inspections. There have been some focused visits for example on end of life care and complaints. April April Bracknell Urgent Care Centre Maidenhead Urgent Care Centre May Wexham Park Hospital Ward 17 July August September November December December January February April Berkshire Healthcare NHS Foundation Trust Campion Ward Berkshire Healthcare NHS Foundation Trust Rose Ward Bracknell Urgent Care Centre Wexham Park Hospital Parapet Healthshare Frimley Park Hospital G5 Bracknell and Ascot Extended Hours Wexham Park Hospital complaints Berkshire Healthcare NHS Foundation Trust complaints The quality team submitted a poster to the Bristol Patient Safety Conference in May 2016 on the work that they had done on clinical concerns, assurance visits and the nursing vision. The poster was entitled Patient Safety from a commissioner s perspective and was awarded the DAC Beachcroft Award for the most innovative project. Commissioners also hold serious incident panels at which all serious incident investigation reports are scrutinised and signed-off. This involves the agreement and monitoring of action plans for each case, along with thematic reviews and overarching action plans where required. Page 47

48 Never events are serious incidents that are wholly preventable as guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers. Each never event type has the potential to cause serious patient harm or death. However, serious harm or death is not required to have happened as a result of a specific incident occurrence for that incident to be categorised as a never event. Never events include incidents such as: wrong site surgery retained instrument post operation wrong route administration of chemotherapy Total Never Events by Provider Trust No. of Never Events 15/16 No. of Never Events Q1 16/17 No. of Never Events Q2 16/17 No. of Never Events Q3 16/17 No. of Never Events Q4 16/17 BHFT FPH HWPH RBFT SCAS Other As with the serious there is a robust system that ensures lessons are learnt from such incidents and the learning is shared across the whole organisations. Each provider that has a National Standard Contract has an opportunity for developing CQUINS (Commissioning for Quality and Innovation). The CQUINS are worth 2.5% of the contract value. There are both locally defined CQUINS and nationally mandated ones. The National CQUINS 2016/17 There are a number of national CQUINS with a different % value available depending on the type of organisation. Below is a list of the national CQUINS which local providers are undertaking. Type of Provider Applicable National Indicators National Acute Sepsis, NHS Staff health and wellbeing, Antimicrobial resistance CQUIN % Local CQUIN % Community PSMI, NHS Staff health and wellbeing Ambulance NHS Staff health and wellbeing Mental Health PSMI, NHS Staff health and wellbeing Independent Sector NA Care Homes NA Page 48

49 The CQUINS below are the areas for improvement agreed between the CCG and providers. There are a number of milestones throughout the year that have to be achieved before payment is agreed. Local CQUINS for Frimley Health 1. Improving AKI diagnosis and treatment in hospital and care planning to monitor kidney function after discharge 2. Improving Cancer Care Delivery 3. Unscheduled Services for Children, FH setting up a GP helpline 4. Improving Quality of Discharges (Safety and Timeliness) 5. End of Life Care Individualised Care Planning Local CQUINS for Berkshire Health Foundation Trust 1. End of Life Care 2. CMHTs to adopt an Outcomes Profile tool for patients with Dual Diagnosis (cluster 16), and to provide training to staff in each of the 6 CMHTs to improve engagement and outcomes with Dual Diagnosis patients 3. Failure to return from agreed leave Local CQUINS for South Central Ambulance Services (999) 1. Enabling electronic transfer of discharge information from epr devices to Primary care. 2. Care Homes Ambulance Access 3. To improve the Special patient notes Local CQUINS for Royal Berkshire Foundation Trust 1. Paediatric Transition 2. Advance Care Planning 3. Awareness raising and management of decreased foetal movements (DFM) 4. Patient Flow Local CQUINS for Henley Suite (BUPA Care Home) 1. Support for the family/carer prior and following the death of a fast track EoL patient 2. Hydration of patients Local CQUIN for BMI Princess Margaret Hospital 1. Dementia Initiatives Local CQUINS for SPIRE Thames Valley 1. For GP s to receive discharge documentation in real time and in an electronic format. 2. To improve the surgical care pathway for patients Local CQUINS for Bracknell Urgent Care Centre 1. Reviewing Referrals to Emergency Department for Appropriateness 2. Sepsis screening Page 49

50 C.difficile cases Pre-72hr cases Post 72-hr cases Monthly limits Safe staffing Providers are also monitored on their safe staffing levels and report to their Boards on a 6 monthly basis on the capacity and capability of their staff. Infection prevention and control The Infection Prevention & Control Nurse (IPCN) (seconded 10 hours a week) is working to a plan improving and developing communication networks across provider organisations, CCG settings, and practices. The Infection Prevention & Control Nurse raises awareness and profile of the role and develops relationships and networks across the whole health economy in East Berkshire. Education support and advice is given to primary care on infection control measures to ensure compliance with Care Quality Commission regulation and to reduce health care acquired infections impact in the community. The IPCN has visited a number of practices for infection prevention & control compliance visits. These have been supporting the CQC compliance of practices. Antimicrobial prescribing and resistance rates The IPCN has been working closely with the medicine optimisation and public health team on antimicrobial prescribing and resistance rates. There is a local plan to improve antibiotic prescribing in primary and secondary care. Post infection reviews There is support and attendance at provider root cause analysis & post infection review meetings including primary care to investigate local healthcare acquired infections. Local meetings are organised for C difficile and MRSA that are allocated to primary care. The review ensures working together with colleagues to identify any area for learning about cases and taking forward recommendations across the health economy, eg, awareness and compliance with antibiotic prescribing guidelines. There were 2 MRSA bacteraemia identified for the East Berkshire CCGs, but following review and arbitration these were designated third party. Infection prevention and control summary report The numbers of Clostridium difficile cases 2016/17-to-date for each East Berkshire CCG are shown in the tables below. Table 2a: Clostridium difficile cases in NHS Bracknell and Ascot CCG 2016/17 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar No pts n/a YTD cases YTD limits n/a N.B.: 1 patient in Bracknell/Ascot CCG accounts for 2 CDI cases; the patient had a CDI episode in October and a repeat case in December. Page 50

51 C.difficile cases Pre-72hr cases Post 72-hr cases Monthly limits Table 2b: Clostridium difficile cases in NHS Slough CCG 2016/17 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar No pts n/a YTD cases YTD limits n/a N.B.: 1 patient in Slough CCG accounts for 2 CDI cases; the patient had a CDI episode in August and a repeat case in October. C.difficile cases Pre-72hr cases Post 72- hr cases Monthly limits Table 2c: Clostridium difficile cases in NHS Windsor, Ascot and Maidenhead CCG 2016/17 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar No pts n/a YTD cases YTD limits n/a 2 (WAM CCG) patients have each had 2 reportable CDI episode in this year (1 in June and a repeat in July; the other in November with a repeat in January). 1 lapse for Windsor/Ascot/Maidenhead case in October at WPH as antibiotics were not in line with policy 1 lapse for WAM (Runnymede) case in November as inappropriate antibiotics were given to a patient known MRSA (which preceded her CDI). Page 51

52 Table 3: MRSA bacteraemias for the Berkshire East and Frimley Health NHS Foundation Trust 2016/17 Month Bracknell & Ascot CCG Slough CCG WAM CCG Frimley Health (FPH/Wex) April 0 0 (case attributed to third party) 0 0 May June July August September October November December January February TOTAL An analysis of 2016 quarter 3 E.coli bacteraemia has been undertaken to help inform the work that will be required for the 2017/18 quality premium related to gram-negative bacteraemia reductions. The CCG is represented at key public health protection meetings, to support increasing immunisation uptake rates, reducing vaccine or cold chain incidents and to support the reduction in infections across the CCGs. The CCG also has a quarterly East Berkshire Joint Infection Control Group, which brings together health organisations for a joined-up approach to infection prevention and control. The CCG facilitates a flu working group that brings together NHS England, public health, providers and primary care to support the flu campaign across East Berkshire. This group also meets in the summer to plan for the following year s campaign. The uptake of the flu vaccine this year was an improvement on the previous year. Nationally, a large proportion of TB disease occurs in people born outside of the UK. Slough and South Reading are areas with ethnically diverse populations and highly mobile populations (Table 1). Since 1999, Slough and Reading local authority areas have consistently had the highest TB rates in the Thames Valley area. Rates of TB in Slough have stayed stable over this period, at between 40 and 60 per 100,000 (55.2 per 100,000 in 2013). Increases in the resident populations over the last decade means that absolute numbers of TB cases have increased. Page 52

53 TB patients have been more often adult male. In Slough men aged were the most common group. Most patients were born abroad; In Slough, Indian and Pakistani were the most common ethnic groups among people with TB; the majority of these individuals were born in India or Pakistan. Slough CCG was awarded money from NHS/PH England in order to improve uptake of Latent TB Infection (LTBI) screening in the target population there the key focus of the project this year has been to: strengthen referral routes into the existing LTBI screening services in order to increase referral from primary care, social care and community groups raise awareness of latent and active TB among target populations locally raise awareness of local new-entrant LTBI screening services and how to access them among target populations raise awareness of the impact of active disease on families and preventing spread of disease (contact screening and cost of this) The results are showing an increase in the number of people being screened for LTBI following a process in place with Primary care to identify at risk individuals. There was a raising awareness event for World TB day and a number of health professional awareness sessions. There has been close working with the local Public Health Team, Primary care and Frimley Health. The CCG has a representative on the South of England TB Board. Non Acute Trusts Berkshire Healthcare NHS Foundation Trust (BHFT) Seven Day Working in Mental Health Inpatient Wards Background As part of the negotiation for 2016/17 a quality schedule indicator was agreed with a target of 95% of mental health inpatient admissions were to be discussed with a Consultant over the phone during admissions out of hours. Assurance 97% cases where the duty doctor had completed the assessment of the admitted patient before 12 midnight had evidence of discussion with the on-call consultant. This is an improvement from Q2 results (94%). There were cases where the patient had arrived in hospital before midnight during weekdays and weekends but the duty doctor was only able to complete assessment after midnight. These cases were not routinely discussed with the consultant, as per agreed protocol, unless there was a clinical indication or clinical query. Appropriate action plan in place. Page 53

54 Percentage of assessments completed before 12 midnight for all patients 100% 80% 60% 40% 20% 0% Q1 Q2 Q3 2016/17 Timeliness of Inpatient Discharge Summaries Background For the 2016/17 contract a requirement was agreed for 95% of discharge summary letters from community inpatient wards to be received by GPs within 1 working day. Assurance Target achieved in M09 but fell below the threshold in M10 to just under 90%. Action plan from Wokingham Hospital was noted at CQRM. Discussions have taken place at team meetings and posters have been produced to ensure threshold is met. 100% Timeliness of CHS Inpatient Discharge Summaries 2016/17 95% 90% Threshold 95% 85% 80% 75% 70% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Page 54

55 CRHTT response to 4-Hour urgent GP referrals (Local 48) Berkshire Healthcare NHS Foundation Trust (BHFT) Seven Day Working in Mental Health Inpatient Wards Background As part of the negotiation for 2016/17 a quality schedule indicator was agreed with a target of 95% of mental health inpatient admissions were to be discussed with a Consultant over the phone during admissions out of hours. Assurance 97% cases where the duty doctor had completed the assessment of the admitted patient before 12 midnight had evidence of discussion with the on-call consultant. This is an improvement from Q2 results (94%). There were cases where the patient had arrived in hospital before midnight during weekdays and weekends but the duty doctor was only able to complete assessment after midnight. These cases were not routinely discussed with the consultant, as per agreed protocol, unless there was a clinical indication or clinical query. Appropriate action plan in place. 100% Percentage of assessments completed before 12 midnight for all patients 80% 60% 40% 20% 0% Q1 Q2 Q3 2016/17 Timeliness of Inpatient Discharge Summaries Background For the 2016/17 contract a requirement was agreed for 95% of discharge summary letters from community inpatient wards to be received by GPs within 1 working day. Assurance Target achieved in M09 but fell below the threshold in M10 to just under 90%. Action plan from Wokingham Hospital was noted at CQRM. Page 55

56 Discussions have taken place at team meetings and posters have been produced to ensure threshold is met. 100% Timeliness of CHS Inpatient Discharge Summaries 2016/17 95% 90% Threshold 95% 85% 80% 75% 70% Apr May Jun Jul Aug Sep Oct Nov Dec Jan CRHTT response to 4-Hour urgent GP referrals (Local 48) Background The CCGs asked BHFT to audit Crisis Resolution Home Treatment Team performance in responding to 4-hour urgent GP referrals. Assurance Fifty-eight urgent referrals were received in Q3, of which 10 (17%) were not seen within 4 hours which is a slight improvement on Q2 when 19% of the patients were not seen within 4 hours. In 3 cases it is clear patients made a choice not to be seen within 4 hrs. 3 patients did not want any input from the CRHTT service. 2 patients were not able to be contacted, street triage and police were involved with 1 of these cases. The final case was appropriately downgraded. Four of these cases were deemed to be an inappropriate referral. In a majority of the cases, there was no evidence that the risk was discussed with the shift coordinator although this does not necessarily mean that it was not done. Further information around clinical risk assessments for postponed visits to be included in future reports. Page 56

57 CHRTT Response to 4 hour Urgent GP Referrals 2016/17 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Q2 Q3 Seen within 4 hours Not seen within 4 hours South Central Ambulance Service NHS Foundation Trust (SCAS) 999 Service SCAS was issued a contract performance notice (CPN) in October 2015, which transferred into an SDIP (service development improvement plan) in the 2016/17 contract relating to response times for Red 1, Red 2 and Red 19 calls. Red 1, Red 2 and Red 19 Response Times 100% 80% 60% 40% 20% 0% Red 1 Response Times Red 1 Red 1 Trajectory Red 1 Threshold (75%) Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar % 80% 60% 40% 20% 0% Red 2 Response Times Red 2 Red 2 Trajectory Red 2 Threshold (75%) Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Page 57

58 100% Red 19 Response Times 80% 60% 40% 20% 0% Red 19 Red 19 Trajectory Red 19 Threshold (95%) Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Red 1 and Red 2 calls require an emergency response within 8 minutes; Red 19 calls require an emergency response within 19 minutes. Red 1 shows an improving trend since October 2016, with the planned trajectory being met in December and January. Red 2 performance has not achieved the planned trajectory set by SCAS and is significantly below the threshold; the action plan is being formally monitored by the SCAS contract review meeting. Actions relating to long wait audits are being reviewed at the CQRM to ensure patient safety is maintained until SCAS are achieving these indicators. Identified reasons for long waits usually include: demand on the service, staffing, calls being re-graded to a higher priority and where policy states that a crew is not able to be assigned to a job. Care bundles 100% Care Bundles: STEMI 80% 60% 40% 20% 0% STEMI STEMI Threshold (85%) Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar % 80% 60% 40% 20% 0% Care Bundles: Asthma Asthma Asthma Threshold (95%) Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Page 58

59 100% 80% 60% 40% 20% 0% Care Bundles: Febrile Convulsions in Children Febrile Convulsions in children Febrile Convulsion Threshold (95%) Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar % 80% 60% 40% 20% 0% Care Bundles: Single Limb Fractures Single limb fractures Single Limb Fractures Threshold 75%) Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 SCAS achieved the threshold in relation to care bundles for Acute ST-elevation Myocardial Infarction (STEMI) for the first time in October October figures are the latest available for STEMI at time of writing. Performance for Asthma, Febrile Convulsions and Single Limb Fractures all remains below the set thresholds. SCAS are progressing with design modifications for the Electronic Patient Record (EPR) in order to ensure that crews record details of all assessments and interventions to meet the requirements of the care bundles. This was initially rolled out for STEMI, which correlates with an improvement in the performance for this care bundle (the main issue had been that staff were not recording the second pain score). It is hoped that the current roll out across the other care bundles will have a positive effect on performance data. Falls SCAS 999 service has an indicator in the Quality Schedule where the provider will support prevention and recovery for patients who fall by ensuring appropriate assessments and referrals are made to falls services. This has continually been below the target so at the January CQRM a Contract Performance Notice was issued and an action plan from SCAS will be monitored for evidence of improvement. A slight improvement was seen in the January 2017 figures (the latest available) with performance just over 50% for the first time; however, this is still well short of the 95% threshold. Page 59

60 SCAS have also been issued a Contract Performance Notice for the timeliness of response to complaints and clinical concerns. Performance on both of these indicators remains significantly below the set thresholds. Patient Transport Service (PTS) Health care professional feedback (HCPF) PTS 24 There has been a continual reduction in the number of incidents reported by HCPF since October 16. This was discussed at the CQRM which includes providers and the general consensus was that some of the initial problems were improving with delays with the transport particularly with the renal patients. Current HCPF status New - received within this reporting period Jul- 16 Aug- 16 Sept- 16 Oct- 16 Nov- 16 Dec- 16 Jan- 17 Total Open Closed HCPF - by Category Jul- 16 Aug- 16 Sept- 16 Oct- 16 Nov- 16 Dec- 16 Jan- 17 Staff Attitude Communication Delay / Non Attendance Total Driving Patient Care / Handling Total There remains an issue on the number of booking still being requested on the day from FHFT and the 30% target is not being achieved. This is being picked up through the contract review meeting and discussions by the CCG with FHFT. Page 60

61 Acute Trusts Frimley Health NHS Foundation Trust (FHFT) Issues Relating to All Sites (Heatherwood, Wexham Park and Frimley Park Hospitals): E-Referrals Further to the update provided in the last report, discussions have continued regarding patients without appointment slots on the electronic referral system (ESR). These cases are termed appointment slot issues (ASI). An interim arrangement has been agreed for the Trust to request copies of referral letters from GPs for ASI patients because the ESR system does not allow the Trust to see the letters until an appointment slot is secured. The Trust has an address for GPs to use instead of faxing letters. News of a delay in a national solution for this problem (until October 2017) is a concern and FHFT have raised this with the national lead; a response is awaited. Discussions have also been had about how far ahead slots are made available by the Trust on ESR. The standard at the moment is 6 weeks, so clinics with waiting lists longer than 6 weeks will have ASIs. The problem with extending beyond 6 weeks is that appointment slots for manual referrals will get squeezed out; currently only 38% (HWPH) and 14% (FPH) of referrals come in via ERS. Until all referrals come in on ERS the Trust states that it cannot move beyond 6 weeks slot availability on the system. The plan now is to agree a definite date for all GP referrals to be on ERS and for FHFT and the CCGs to work to a plan for 100% implementation no later than July The investigation into the cohort of ASI patients who dropped off ESR after 180 days has been completed and no harm has been identified. All patients requiring clinical follow-up have been seen. Discharge letters from FHFT to GPs Recent clinical concerns indicate that there are problems with discharge letters not being sent to GPs via Docman (the electronic document interface with primary care). The matter was explored at CQRM. The Trust reported that at HWPH there is no systemic problem, but several issues have been identified: GPs not being able to find the letter on Docman, cited as potentially a misfiling issue in practices. The Trust states that it has concrete evidence in these cases to show that the letters had been successfully sent and received. Documents being created in ICE but not completed (so not released to Docman) this is not a technical issue but a process error by the ward. The Trust has a dashboard on ICE where are monitoring this for compliance and improvement. The Trust s patient management system (ipm) showing the patient as registered with a GP who has retired or moved, which results in documents not being sent from ICE to Docman; as the ICE GP information is up to date, it does not recognise the GP. This issue applied to a small number of cases and is being explored for fixes. Page 61

62 At the FPH site, an investigation into the issues has found that some discharge letters could not be found anywhere in the system, which is more of a concern. This is being explored further by the Trust and an update is due at the next CQRM. NEWS/deteriorating patients Several serious incidents have pointed towards lapses and failures in the timely identification and escalation of deteriorating patients, for which FHFT uses the national early warning score (NEWS) alongside an escalation protocol. The Trust is looking at the aggregate findings of the several investigations and will report into the next serious incident panel. In the meantime, staff education is being reinforced and supported by the outreach and resus teams, with monitoring of areas with high numbers of NEWS calls and patients with multiple NEWS calls. Safeguarding training There are continuing issues with training compliance, as reflected in the statistics below: Requirement from CCG Target Interim Target HWPH Position FPH Position at Jan 2017 at Jan 2017 Safeguarding Children Level 1 85% n/a 66% 58% Safeguarding Children Level 2 85% n/a 44% 52% Safeguarding Children Level 3 80% 75% 48% 76% Safeguarding Adults Level 1 85% n/a 66% 72% Safeguarding Adults Level 2 80% 75% 42% 66% Safeguarding Adults Level 3 85% n/a 46% 70% The CCGs Associate Director of Safeguarding met with the Trust this month to discuss these issues and the following is a summary of the current position: 96% of staff are verbally reported to have received Level 1 training which includes raising awareness, how to make a referral and who to contact. The Trust asserts that the official training figures do not accurately reflect the actual amount of training that has been done but accept that CCGs can only deal with the data being reported. Training gaps have been broken down to ward areas; each have been informed which staff require training and all training must be undertaken by 17th March The new Band 6 Adult Safeguarding Nurse started in February 2017 and is able to provide additional training along with the Band 8a to specific areas that are high risk as a priority. Every member of staff will be receiving a safeguarding adults/children information sheet attached to their payslip. This provides key information for level 1 compliance regarding adult and child safeguarding, how to report, who to report to and details of the Trust leads across Frimley Health. Page 62

63 From January 2017, Level 2 Safeguarding Adults and Child training is being provided as combined training to ensure compliance is improved over quarter 4. This means that instead of staff having 6 hours of training, this will be reduced to 3.5 hours as some of the content and principles are identical. It is planned to hold these sessions as part of the clinical staff Trust Induction Programme and some additional monthly sessions. The Trust is also introducing more Level 2 e-learning to help progress. There has been a Level 3 Safeguarding Children study day held at WPH on 25th January There were 20 attendees including various grades of doctors, nurses and allied health professionals. There is a further three study days planned throughout the year which will increase Level 3 Safeguarding Children compliance. A plan is in place for targeted training for Radiology, Critical Care, Elderly Care and Medicine for the Frimley Park site in Quarter 4. A plan is in place for targeted training for ED, Paediatrics, Elderly Care, Medicine and Surgery for the Wexham Park site in Quarter 4. The Safeguarding Team is reviewing training data weekly and meeting with all heads of services every 2 weeks. The Trust believes that the end of year figures will show an improvement, but the leads are not certain that full compliance across all levels will be achieved by then. The CCGs will scrutinise the end of year data to assess the impact of the above measures and decide on any further / necessary steps at that stage. Frimley Health Foundation Trust Heatherwood & Wexham Park Hospitals Maternity BCG vaccination supplies Background A national shortage of the BCG vaccine was identified in Q4 2014/15 and despite some relief in late 2015 / early 2016 re-emerged as an issue during This led to the Trust significantly breaching the 90% target, as the vaccine was unable to be sourced. The vaccination cannot be administered by GPs or health visitors, therefore, babies must be vaccinated on the maternity ward or at the chest clinic. Changes in eligibility for administering the vaccine by Public Health England mean that the acute trust has responsibility up to three months (as opposed to 28 days) for at-risk babies. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% HWPH % of at risk babies to receive BCG vaccination prior to discharge Threshold 90% Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Page 63

64 Assurance The shortage of supplies has been a national problem. New supplies of unlicensed vaccinations have been made available early in 2017 which should improve the numbers being vaccinated prior to discharge. As of February 2017, the backlog of 1,001 babies has been reduced to 441 and is continuing to decrease. Babies are now being vaccinated before discharge unless parents do not consent. Actions The Trust has been keeping track of children not vaccinated so that follow-up can happen on re-supply. Extra clinics have been made available for this. Maternity caesarean section rates Background It was agreed in the 2016/17 contract to set a gradually reducing target across the year, with an ambition to achieve 23% going into 2017/18. The indicator is, however, sensitive to patient choice and clinical necessity. Performance had been good until June 2016, but has remained above the interim threshold since. The Thames Valley Strategic Clinical Network has debated the use of fixed targets for C-Section and has opted instead for a benchmarking approach which will be facilitated by the launch of a new network-wide clinical dashboard. This is expected to be operational in 2017/18 Q2. The dashboard will allow comparison of provider performance and consideration of C-Section in the context of a wider set of indicators including neo-natal morbidity and readmissions within 28 days. It is hoped that this will give a more meaningful picture of quality and performance than has been possible through scrutiny of this indicator in isolation. Assurance 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% HWPH C-Section Rate Green dotted line = interim targets Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Page 64

65 See actions section we cannot infer a definite quality issue from the indicator in isolation. The November and December high percentages were due to more emergency C-sections being carried out; electives have remained fairly constant between 14% and 15%. This was explored at the February CQRM; the Trust reported that the challenge here is that normal births are going down while the Birth Centre is out of action during the building works, with more women electing to go to FPH. Elective summary hospital mortality indicator (SHMI) Rates Background Elective summary hospital mortality indicator (SHMI) rates have been higher than expected at HWPH since March This has been explored through reviews of case notes, overseen by the Trust s Mortality Review Group. Assurance This was discussed at the February CQRM and the Trust gave the following briefing: The higher than expected elective SHMI rates for HWP over the past six months are related to the badging of emergency admissions as elective in certain circumstances, i.e. ill patients arriving from clinic, repatriations from tertiary referral centres and transfers of emergency admissions to the private sector. A review of case notes has not, so far, revealed a clinical problem but this surveillance will continue. COPELAND S RISK ADJUSTED BAROMETER medical practice triggers shock / cardiac arrest Background Shock or cardiac arrest is hypotension or cardiac arrest on the wards. A rising trend is evident in Q3 with numbers above the Upper UK Norm. 8 General Care / Shock or Cardiac Arrest, UK Norm: Shock or Cardiac Arrest % Admissions with Triggers Lower UK Norm Upper UK Norm Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Page 65

66 Actions The Trust believes that this may be related to increased emergency activity but is carrying out an urgent investigation to establish the factors behind these numbers. Other quality issues HWPH Site Diagnostic group SHMI Following identification of relatively high SHMI rates for patients with sepsis at HWPH in 2015, a review of cases was carried out in April 2016, the results of which were reported to the recent CQRM. The review found that in 13 out of 22 deaths there was a delay in antibiotic administration. This was found to be principally due to failure to recognise potential sepsis and delays in escalation to medical staff. A new sepsis screening tool was launched on 16 January 2017; usage is being audited and it is hoped this will aid in improving rapid identification and escalation to treatment. Timeliness of treatment is being monitored by commissioners via the quarterly CQUIN data and we expect to see an improved picture in the Q4 results. SHMI rates are within the expected for other diagnostic groups. Stillbirths (WAM and Slough) The integrated assurance framework identified relatively high stillbirth rates for WAM and Slough. The CCGs and FHFT have been working together on looking at the data for the Wexham Park maternity unit. The higher numbers mainly involve the SL1 and SL3 postcodes, with UK, Pakistani and Romanian ethnicity featuring. It is thought that lack of antenatal engagement by some within these groups could be contributing the higher numbers, and further work is being done to enhance outreach, information and support in these areas. This work is being steered by a joint CCG / FHFT maternity group. FHFT Frimley Park Hospital (FPH) Background In mid-2015 NHS England introduced a 104-day backstop (threshold = zero) for cancer patients waiting for treatment. Trusts are now required to report on these figures and to provide root cause / harm analyses for any cases exceeding the backstop. Page 66

67 FPH Number of Cancer Patients Waiting 104+ Days (Zero Target) Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan % 1.4% 1.2% 1.0% 0.8% 0.6% 0.4% 0.2% 0.0% FPH % of Cancer Patients Waiting 104+ Days (Zero Target) Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Assurance The relatively (compared to HWPH) high numbers being reported by FPH was explored at CQRM where the Trust cancer lead presented on improved tracking / review processes and MDTs reviewing breach cases for learning. Q1 data showed an improving trend. Q2 and Q3 have seen some increase but figures remain lower than in 2014/15. The Trust has produced and shared improvement plans for those tumour groups not meeting their 62-day targets, and provided summaries of root cause / harm analyses for individual cases exceeding 104-days. RCA summaries submitted in Q3 CQUIN evidence concluded that there had been no harm caused by the length of waits in any of the cases. Reasons identified were a mixture of patient choice, complex diagnostic pathways, and late referrals from third party providers. Actions Improvement plans in place for tumour groups failing the 62-day targets. Review and analysis process with learning in place within Trust. RCA summaries shared with commissioners. Page 67

68 Other quality issues FPH Site Copeland's risk adjusted barometer medical triggers/surgical complications There has been a rise in urinary complications of all surgical patients at FPH. This is currently under review by the Trust. Readmission numbers are relatively high in surgical patients at FPH. COPELAND S RISK ADJUSTED BAROMETER does not distinguish between emergency and elective readmission and therefore may be an overestimate but this is under review currently. Royal Berkshire NHS Foundation Trust (RBFT) Caesarean section rates As per other acute providers, the C-Section rate at RBFT is routinely monitored. There is no contractual threshold or target set for RBFT; for other Trusts we have looked for an improving trajectory with an aim of achieving 23%. A rise in cases since October 2016 has seen the numbers reach the same levels as those at WPH; but while the WPH increase is in emergency numbers, RBFT s numbers are fairly evenly split between elective and emergency. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% RBFT C-Section Rate (%) 2016/17 Apr-16 May-16 Jun-16 Jul-16 Aig 16 Sep-16 Oct-16 Nov-16 Dec-16 Actions The Thames Valley Strategic Clinical Network has debated the use of fixed targets for C-Section and has opted instead for a benchmarking approach which will be facilitated by the launch of a new network-wide clinical dashboard. This is expected to be operational in Q4. The dashboard will allow comparison of provider performance and consideration of C-Section in the context of a wider set of indicators including neo-natal morbidity and readmissions within 28 days. It is hoped that this will give a more meaningful picture of quality and performance than has been possible through scrutiny of this indicator in isolation. Page 68

69 Ashford and St Peter s Hospitals NHS Foundation Trust (ASPHFT) A&E - % of Patients admitted/transferred/discharged within 4 hours of arrival UCL CL LCL Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 A&E within 4 hours of arrival either admitted/transferred/discharged The Trust missed the 4 hour A&E target in December with performance recorded at 87.5%. This was 1.2% below last month s performance score and 7.7% below the agreed recovery trajectory of 95.2%. In January the Trust recorded performance at 87.2%. This was a 0.3% decline on last month and 8% below the agreed recovery trajectory of 95.2%. The graph above highlights with the trend line a minimal improvement in the percentage of patients that were admitted/transferred/discharged within 4 hours of arrival over the course of 21 months. Attendances & admissions were higher than January 2016, coupled with deficient social and community care capacity, in part created slow flow from the Emergency Department to the wards and the requirement for elective cancellations. Part of January also had non-urgent elective procedures stopped as directed by NHSI to support non-elective bed capacity. Stroke proportion of patients admitted directly to an acute stroke unit within 4 hours of hospital arrival The stroke performance standard for December is recorded at 43%. In January this score de creased by 4% to 39% however this is still below the 90% threshold. It is clear by reviewing the Trusts most recent data that the Trust continues to experience difficulty in meeting this KPI due to disruption in stroke pathway, no acute bed being immediately available due to non-elective bed pressures, medical need and different presenting complaint. Page 69

70 A number of initiatives are underway to support improvement in the Trust s stroke performance including: 2 additional stroke consultants have been recruited, The stroke unit will be potentially expanded as the new Surrey wide model is implemented (public consultation pending), Weekly stroke team review with ED colleagues to review breaches & action improvement, New escalation process in place to provide better protection for ring-fenced stroke beds, All medical specialist registrar briefed regarding providing out of hours stroke support, & Revised escalation process to eradicate delays waiting specialist neurological opinion from SGH. Reducing new grade 2 pressure ulcers The Trust has a target for a further 15% reduction in hospital acquired grade 2 pressure ulcers for 2016/2017 which equates to 18.2 per month (there is a threshold target of zero tolerance for both grade 3 and grade 4 pressure ulcers). Grade 2 pressure damage The Trust had 22 hospital acquired stage 2 pressure ulcers affecting 18 patients in December 2016 and the target has not been achieved. The Trust had 26 hospital acquired stage 2 pressure ulcers affecting 22 patients in January Grade 3 pressure damage - The Trust has a target of zero tolerance for hospital acquired unavoidable stage 3 pressure ulcers for 2016/2017 this has not been achieved with 3 hospital acquired stage 3 pressure ulcers reported. Grade 4 pressure damage -The Trust has a target of zero hospital acquired stage 4 pressure ulcers for 2016/2017 this has been achieved with no hospital acquired stage 4 pressure ulcers reported. Number of handovers between ambulance and A&E taking place after 30 mins & Number of handovers between ambulance and A&E taking place after 60 mins Page 70