Haringey CCG MDT Integrated Contract Monitoring Report July 2015

Transcription

1 Haringey CCG MDT Integrated Contract Monitoring Report July 2015

2 Executive Summary 2

3 Executive Summary Contents Title page Executive Summary: Finance 4 Executive Summary: Performance 9 Executive Summary: Quality 20 Executive Summary: Quality and Performance Provider Specific 24 NMUH Quality and Performance 25 UCLH Quality and Performance 29 Whittington Health Quality and Performance 31 Whittington Community 34 BEH Quality and Performance 38 3

4 Executive Summary: Finance 4

5 Finance Summary: Acute Provider Year-to-Date Plan Actual Variance Plan Annual Forecast Out-turn Variance North Middlesex 18,182 18, ,500 73,216 ( 284) GREEN The Whittington Hospital 19,520 19, ,082 78,082 ( 0) GREEN Barnet, Enfield and Haringey MH Trust 7,767 7, ,767 7,767 0 GREEN University College Hospital 4,276 4,066 ( 210) 17,102 16,956 ( 147) GREEN Royal Free Hospital 2,957 3, ,827 11,827 0 GREEN Barts Health 875 1, ,500 4, RED Moorfields Eye Hospital 844 1, ,376 3, RED Barnet and Chase Farm 1,025 1, ,098 4,098 ( 0) GREEN Total 55,445 56, , , Status Where the actual figure is the same as the budget, this is due to 15/16 contracts remaining unsigned. 5

6 HCCG Financial Summary Year-to-Date Annual Service Line Forecast Plan Actual Variance Plan Out-turn Variance Status Resource Allocation ( 83,542) ( 83,542) 0 ( 338,003) ( 338,003) 0 GREEN In-Sector Acute Trust 47,655 47, , ,198 ( 223) GREEN Out of Sector Trusts 3,161 3, ,644 12,626 ( 18) GREEN Other Acute 4,112 4,012 ( 99) 16,720 16,728 8 GREEN Acute Commissioning Total 54,927 55, , ,552 ( 233) Mental Health 9,056 9, ,473 37, GREEN Continuing Care 4,797 4, ,188 19, GREEN Community Services ( 18) 3,212 3, GREEN Better Care Fund 2,109 2, ,438 8,438 ( 0) GREEN Prescribing 7,314 7, ,257 29,257 ( 0) GREEN Other Commissioning (incl Primary Care) 1,139 1, ,558 4,558 ( 0) GREEN Non-Acute Commissioning Total 25,219 25, , , Programme Corporate Cost ( 12) 2,388 2,388 0 GREEN Running Cost 1,510 1, ,274 6,274 0 GREEN Reserves and Contingency 1,289 1,039 ( 250) 5,431 5,181 ( 250) GREEN TOTAL ( 0) ( 0) Key Messages NMUH is over performing by 122k. This is mainly in Outpatients Procedures, Non Elective Admissions and High Cost Drugs. UCLH is under performing by 210k. This is mainly Non Elective Admissions Critical care. Royal Free is over performing by 459k YTD. The main areas of over performance are in Critical Care and Non Elective Admissions. A contract query notice has been issued and a breakeven position on the forecast out turn is showing until this issue has been handled. Barts is over performing by 211k. This is mainly due to Non electives and outpatients. Moorfields is over performing by 205k. This is mainly in Outpatients Procedures and A&E. Barnet & Chase Farm is over performing by 42k. A contract query notice has been issued and a breakeven position on the forecast out turn is showing until this issue has been handled. Whittington and BEH are on a block contract. 6

7 Executive Summary Key Messages Key Messages Value Based Commissioning (VBC) Haringey Clinical Commissioning Group will be leading on VBC for Older People with Frailty. As leading commissioner, HCCG will oversee the implementation of this particular VBC contract and monitor how this is rolled out across the participating providers. This programme is being launched with the aim to have contracts signed and implemented by September The expected benefits will include improved outcomes that matter to groups of patients with similar needs, with no increasing costs to deliver. Providers, including those in the Haringey region, will work together to deliver a co-ordinated pathway of care for patients. The CCGs and lead providers in North Central London are currently attending workshop sessions to identify and understand how this will impact on their contracts that have been agreed or are in place for 2015/16 and also the future, five year plan for VBC. Data Issues across key HCCG providers Whittington Health has not issued any activity data for Month 1 and Month 2. Islington CCG, in conjunction with their Commissioning Support Unit staff, have sent a notification of an Information Breach to the Trust on 30 th June This gives Whittington Health Trust three months in which to remedy the breach or 1% of the actual monthly value of the contract may be withheld. Royal Free and Barnet and Chase Farm have been issued with a Contract Performance Notice on 9 th July 2015 (by Barnet CCG) regarding the activity data submission in Month 2. They have been issued with the Month 2 data submission, where the Trust have made significant counting and coding changes, as well as changing their local prices (as per their business case for the local price convergence). Neither the coding changes or the local prices have been agreed and are being discussed as part of the 2015/16 contract negotiations. The Trust have been asked to rectify the changes to the data and resubmit in line with the 2014/15 contract agreement and Default Tariff Rollover pricing agreement. Their resubmission was received by the CSU late on 6 th July However, validation and processing of this data took a further two days to complete. Emergency Readmissions Audit An audit of Emergency Readmissions at North Middlesex University Hospital has been agreed to be conducted on 23 rd July The purpose of this audit is to quantify the percentage of patients from a sample of notes reviewed that should not be readmitted within 30 days. These breaches result in a financial penalty being levied on the Trust should these be correctly evidenced to go beyond the target of 30 days. 6

8 Executive Summary Claims Claims and Data Submission Diagnostic Imaging Variances Diagnostic Imaging is showing significant over-performance at NMUH, particularly for Haringey and Enfield patients. There is significant over-spend for ultrasound scans that take less than 20minutes at 46k and 34k respectively. However, the CSU is querying this activity for potential double-counting of maternity activity. Diagnostic Imaging has also been identified as an area to investigate by the Claims Team at the CSU owing to the large variances between patient-level data (SUS) and Non-patient-level datasets. Where activity is not submitted to SUS, commissioners will not fund the activity charged locally in non-sus reports. High Cost Drugs - Rheumatology - NMUH Rheumatology drugs over-performance has been challenged in the month 2 Claims letter. The Trust has changed practice with regard to billing for Homecare in 2015/16. The Trust is now sending an invoice on the issue of the prescription instead of waiting for confirmation that this activity has occurred. This has resulted in a higher number of invoices than anticipated and concerns from commissioners regarding the accuracy of invoicing on a prospective basis. A meeting was held on 30 th June 2015 between the Trust and CCG Pharmacy Leads and the issue has also been challenged in a letter sent on 8 th July 2015, noting an expectation that the Trust will change back to the previous practice of billing once the activity has occurred. It is important to note that the change in practice only came to light following the meeting with Pharmacy leads despite requests for an explanation for the increase in Rheumatology drugs expenditure raised at the Contract Technical Group and through the monthly challenge process. The impact of this change equates to a significant overspend for Haringey and Enfield CCGs in Quarter One. The table above highlights the increase in actual spend at NMUH in the first two months of 2015/16 compared with the previous year. This highlights the large over-performance. 7

9 Contractual Notices/Queries Title Issued By Issued To Date of Issue Reason for CQN Progress Update 02/06/2015 A&E Performance Haringey CCG NMUH 02/06/2015 NMUH achievement for the Operating Standard E.B.5 (percentage of A&E attendances where the Service User was admitted, transferred or discharged within 4 hours of their arrival at an A&E department), was 94.45% for month 1, 2015/16. This actual performance is below the standard of 95% stipulated in the 2015/16 Contract. Awaiting final submission of RAP 05/06/2015 A&E Performance Haringey CCG NMUH 05/06/2015 NMUH achievement for the Operating Standard E.B.5 (percentage of A&E attendances where the Service User was admitted, transferred or discharged within 4 hours of their arrival at an A&E department), was 93.87% for month 2, 2015/16. This actual performance is below the standard of 95% stipulated in the 2015/16 Contract. Awaiting final submission of RAP 10/07/2015 A&E Performance Haringey CCG NMUH 10/07/2015 NMUH achievement for the Operating Standard E.B.5 (percentage of A&E attendances where the Service User was admitted, transferred or discharged within 4 hours of their arrival at an A&E department), was 94.19% for month 3, 2015/16. This actual performance is below the standard of 95% stipulated in the 2015/16 Contract. Awaiting final submission of RAP 02/06/2015 Quality of Maternity Services Barnet CCG Royal Free London 02/06/2015 Maternity quality: The Trust has been asked to identify clinicians who are available to meet during the week commencing 15th June 2015 with CCG clinical representatives and take them through the draft Remedial Action Plan and receive comments and feedback on the plan. This will enable the Trust Board to receive the plan, understand the position of clinical commissioners and ensure that there is commissioner support for the proposed way forward. Exception report to be discussed at a meeting on 10 th June M-RO-14-RFL RFL CPN Price Harmonisation Barnet CCG Royal Free London/Barnet Chase Farm 09/07/2015 The Trust have made significant counting and coding changes as well as changing their local prices (as per their business case for the local price convergence). Neither the coding changes or the local prices have been agreed and are ongoing issues as part of the 2015/16 contract negotiations. The Trust have been asked to rectify the changes to the data and resubmit in line with the 2014/15 contract agreement. Their resubmission was received by the CSU on late 6th July but took two working days to process and validate. IBN Islington CCG Whittington Health 30/06/2015 The Trust failed to submit SLA data for month 1 & 2 on the specified date. The Trust did submit the required data on the 3rd July, meeting the requirements of the Breach Notice but not leaving sufficient time to validate and process the data that day 8

10 Executive Summary: Performance 9

11 Cancer Waits 18 Weeks Referral to treatment and Diagnostics HCCG Performance Dashboard Theme KPI / Measure Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May YTD Target A&E A&E All Types Performance 96.5% 95.5% 95.1% 94.3% 97.1% 96.9% 94.1% 94.3% 91.9% 94.4% 92.5% 93.4% 95.2% 94.6% 94.9% 95% 18 Weeks RTT Adjusted Admitted 89.3% 92.7% 90.0% 90.1% 86.7% 85.4% 89.0% 89.2% 90.2% 92.0% 90.0% 90.3% 91.3% 88.2% 89.7% 90% 18 Weeks RTT Non-Admitted 95.8% 95.2% 94.9% 95.9% 95.3% 93.0% 91.9% 94.6% 96.0% 95.6% 95.7% 96.8% 95.8% 95.2% 95.5% 95% 18 Weeks RTT Incomplete Pathways 91.7% 91.9% 91.3% 88.1% 87.8% 89.8% 90.1% 93.1% 92.9% 93.8% 94.5% 93.9% 94.3% 92.9% 93.5% 92% 6 Weeks Diagnostic Waits 98.6% 97.9% 97.5% 98.4% 99.2% 99.1% 99.3% 98.4% 98.9% 98.2% 99.0% 98.8% 98.7% 97.9% 98.4% 99% 2 Week Cancer Wait 91.7% 92.7% 93.5% 90.9% 90.2% 92.1% 92.9% 94.8% 94.3% 95.1% 93.8% 92.8% 93.1% 93.1% 93% 2 Week Cancer Wait: Breast Symptoms 31 day Cancer Wait: 1st definitive treatment 31 Day Cancer Wait: Subsequent treatment (Surgery) 31 Day Cancer Wait: Subsequent treatment (Chemotherapy) 31 Day Cancer Wait: Subsequent treatment (Radiotherapy) 62 Day Cancer Wait: GP Referral 62 Day Cancer Wait: Screening service 87.1% 90.6% 88.6% 95.5% 90.4% 93.7% 96.9% 94.2% 95.6% 97.3% 97.0% 95.6% 94.7% 94.7% 93% 98.5% 97.3% 98.5% 100.0% 100.0% 98.7% 96.8% 100.0% 100.0% 98.5% 97.9% 98.2% 96.7% 96.7% 96% 100.0% 100.0% 92.9% 100.0% 100.0% 100.0% 88.9% 100.0% 100.0% 93.8% 100.0% 100.0% 83.3% 83.3% 94% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 97.4% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 0.0% 0.0% 94% 95.5% 84.0% 100.0% 90.9% 91.7% 90.6% 96.2% 87.9% 78.6% 85.7% 81.3% 94.7% 96.1% 96.1% 85% 100.0% 100.0% 100.0% 100.0% 100.0% 80.0% 50.0% 100.0% 100.0% 71.4% 50.0% 50.0% 90% 62 Day Cancer Wait: Consultant Upgrade 87.5% 93.3% 100.0% 100.0% 100.0% 85.7% 100.0% 100.0% 87.5% 83.3% 90.9% 91.7% 100.0% 100.0% No Threshold 10

12 Executive Summary for HCCG. A&E Performance Issues & Priorities Accident & Emergency (A&E) HCCG did not meet the 95% four hour wait standard in May The performance was 94.6%. Attendances were lower than the previous month, numbering 9,987 and there were 534 breaches. The CCG s two main A&E providers, NMUH and WH, who comprise approximately 70% of HCCG A&E activity, also individually failed the standard, with achievement of 93.8% and 93.2% respectively. WH has now failed the A&E standard for three consecutive quarters. The Trust report that their poor performance is a consequence of significant bed pressures and short-term sickness in middle grade doctors and some nursing staff. 50% of the Trust s available bed capacity is taken up by longer staying patients i.e. stays exceeding nine days. The Trust are developing a new bed modelling plan which will be presented at the next Systems Resilience Group (SRG) which is intended to resolve the bed pressure issues. In addition, a Senior Practitioner from Haringey Social Services has been involved in discharge planning and a Matron from Haringey reviewed the patient list and agreed a set of actions. HCCG have issued three Contract Performance Notices to NMUH as a result of their poor A&E performance and are now working with the Trust to finalise their Remedial Action Plan. Further work is being carried out to relieve pressure on the emergency department by developing the Urgent Care Centre and an Ambulatory Emergency Care model Haringey CCG split of A&E activity by trust % 4.5% 2.7% 31.6% 38.9% 3.5% BCF NMH RFH WHIT UCLH Others 11

13 Executive Summary for HCCG. 18 weeks Referral to treatment (RTT) Performance Issues & Priorities 18 weeks Referral to Treatment standard (RTT) HCCG have achieved all three of the RTT pathway standards since November In May 2015 HCCG failed the admitted adjusted standard for the first time since November 2014 with a performance of 88.44% against the 90% standard. Although HCCG have been regularly achieving the monthly standard, some individual providers have failed Haringey patients within the month. University College London Hospital have failed HCCG s patients regularly (each of the last 8 months) as have Whittington Health and Royal Free London on occasion. When RFL have failed Haringey in the past, their proportion of HCCG total waiting list activity has been around 12-13%. In May 2015 however, because RFL have now resumed reporting at Barnet & Chase Farm, RFL s proportion of HCCG total waiting list activity has more than doubled and is now around 31%. If UCLH continue to fail to achieve the standard for HCCG patients and RFL continue to hold a larger percentage of HCCG total waiting list activity then HCCG are likely to continue to fail this standard for an unpredictable length of time. As from, 24 th June 2015, the admitted and non-admitted operational standards are being abolished and the incomplete measure will become the sole measure of patients constitutional right to start treatment within 18 weeks. To maintain transparency and safeguard against these changes having unintended consequences, there will be some minor amendments to the monthly RTT collections. This will add clarity and a greater understanding around the current waiting list. Notification will be given as to when these changes will occur. Supporting sustained delivery of the 18 week elective care standards NMUH Monitor, NHS England and the Trust Development Authority have jointly developed a tool whose aim is to support further sustainable delivery of the 18 week elective care standards. The tool raised a number of questions on operational grip and the accuracy of the Trust s waiting list (PTL). The Trust has been working to provide responses to these queries to ensure necessary assurance to the CCG. At the Contract Review Group meeting, held on 2 nd July 2015, it was noted that NMUH had submitted a partial response to the RTT query. Operation grip was demonstrated by the Trust. Further information is required in relation to the data submissions. This response is outstanding and further requests have been issued to the Trust. 12

14 Executive Summary for HCCG. 18 weeks Referral to treatment (RTT) ctd. Performance Issues & Priorities RTT 52 weeks Royal Free London There are currently 15 Haringey patients who have been waiting for more than 52 weeks for treatment at RFL. The lead commissioner, Barnet CCG, is ensuring that those patients breaching 52 weeks for treatment have: A priority clinical review and treatment if appropriate Been offered alternative Provider(s) to expedite treatment A date for a next event e.g. Outpatient Appointment (OPA) or To Come In (TCI) date. Following treatment there is an expectation that: The Clinical Quality Review Group (CQRG) will review the patient pathway and treatment outcome to determine if harm has occurred due to the extended wait A Serious Incident Review will be initiated in the case of a finding of harm due to extended waiting. A root cause analysis of the breach will be completed, reviewed and acted on where necessary. At a meeting at Barnet CCG on 14 th July 2015, commissioners will decide whether to issue RFL with a contract performance notice in relation to their RTT performance. 13

15 Executive Summary for HCCG. Diagnostics Performance Issues & Priorities Six weeks Diagnostic waits HCCG did not achieve the 99% standard in May 2015, with a performance of 97.9%. This standard has not been met in ten out of the preceding fourteen months. The main breaches by modality were Audiology Assessments and Urodynamics. Urodynamics does not present a huge risk to commissioners as there are very low numbers of patients for this service - for HCCG there were three patients waiting over six weeks at NMUH. There were twenty one Haringey patients waiting more than six weeks for an audiology assessment at the RFL. NEL CSU in conjunction with Barnet CCG are managing the RFL s diagnostic underperformance. The trajectory for compliance is expected by December Much of the focus so far has been on endoscopy and cystoscopy recovery plans, but a closer look is now being taken at the audiology assessment numbers. The main breaches by modality were Audiology Assessments and Gastroscopy, the latter modality having failed every month last year: Gastroscopy therefore is the biggest risk to the CCG in terms of not meeting the standard. KPI / Measure Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May YTD Target 6 Weeks Diagnostic Waits 98.6% 97.9% 97.5% 98.4% 99.2% 99.1% 99.3% 98.4% 98.9% 98.2% 99.0% 98.8% 98.7% 97.9% 98.4% 99% The table above demonstrates, aside from compliance with the standard in February 2015, that HCCG has failed to meet the target in six of the past seven reported months. 14

16 Executive Summary for HCCG. Cancer Performance Issues & Priorities Cancer waiting standards HCCG failed three of the eight standards in March day subsequent treatment surgery HCCG s achievement of this standard was 83.3%, compared to a target of 94%. The percentage achievement figure can vary substantially because of the low numbers of patients receiving this service. HCCG s performance for this standard has been at 100% for eight out of the last twelve months. There were only ten patients treated in the reporting month and two of those breached the target. One of the patients breached because of a capacity issue and the other because of administration reasons. These breaches in all likelihood occurred at UCLH for urology. The data does not tell us this, but the NCL CCG breaches correspond to the only provider breaches in this standard at ULCH. From discussion with the trust and close monitoring of their action plan we know that they have problems with urology surgical capacity. The issues are: Increasing volumes of prostate patients being sent to UCLH Insufficient surgical capacity for robotic prostatectomy both in terms of equipment and trained consultant staff. This has formed part of UCLH s recovery action plan since December The trust initiated a one-stop prostate clinic in March 2015 for direct referrals. They have a capital bid in progress for an additional robot. The trust has outsourced two additional lists to the Princess Grace hospital since October They lost a urology consultant earlier this year but have since appointed another. We believe that these two additional lists are insufficient due to the continued standard failure. In addition, if the trust passes through the reconfiguration gateways they will receive increased volumes of prostate patients from Barking, Havering and Redbridge University Hospitals and we have therefore asked for a urology business continuity plan. NHSE specialised commissioning have asked UCLH to meet the London average performance for urology to pass through the gateway and then to meet the standard following this. 31 day subsequent treatment radiotherapy HCCG s achievement of this standard was 0% vs a target of 94%. Radiotherapy on the 31 day standard is a target that is usually met for all providers. The treated population, however, is small for each CCG and one breach when there was only one patient on the pathway means that the achievement (0%) looks alarming compared to the standard. The breach was because of a capacity issue at NMUH; however, this was the single breach in the past twelve months. 15

17 Executive Summary for HCCG. Cancer ctd. Performance Issues & Priorities 62 day screening service HCCG s achievement of this standard was 50%, compared to a target of 90%. This standard has not been met for two consecutive months and achievement is declining (71.4% last month). HCCG failed to meet the standard on four occasions in the past twelve months having achieved it every month of the year prior to that. In common with the other two standards above, patient numbers on this pathway are low. There were two patients treated in the reporting month and one of them breached the target. The reason given was patient choice. More than any other standard, for 62 day screening service it must be stressed that screening uptake is a challenge to meet in London as the small numbers divided into CCG treated populations make it difficult for CCG s to consistently meet the standard. In April 2015, standard failure in the breast screening service across NCL was by two patients. There were 13 breast patients on this standard and three breached (the threshold was one). It is not possible to tell where patients were screened. However, given the low numbers in the dataset, it is likely that the two patient choice breaches in NCL took place at UCLH. The operational threshold takes account of patient choice. Yet, in this case, two patient choice breaches out of seven patients meant that UCLH failed the standard. Due to the small volumes this has not been raised as an issue with UCLH but it is monitored. Recent performance, including the issue of patient choice, has been highlighted by the CSU to the lead commissioner and will be followed up. 16

18 Executive Summary for HCCG. LAS Summary LAS Performance Dashboard Target Monthly Trajectory April 2015 Performance Year to Date Trajectory Year to Date Performance Red 1 Performance (8 minutes) 75% % % Amber Red 2 Performance (8 minutes) 75% % % Red Cat A Performance (19 minutes) 95% % % Amber Green 1 Performance (20 minutes) 90% 78.4% 44.6% 78.4% 44.6% Red Green 1 Performance (45 minutes) 99% 93.6% 75.6% 93.6% 75.6% Red Green2 Performance (30 minutes) 90% 71.2% 56.3% 71.2% 56.3% Red Green 2 Performance (60 minutes) 99% 89.7% 76.9% 89.7% 76.9% Red Green 3 Performance (60 minutes) 90% 86.3% 72.1% 86.3% 72.1% Red Green 3 Performance (90 minutes) 99% 94.1% 84.6% 94.1% 84.6% Red Green 4 Performance (60 minutes) 90% 76.3% 51.3% 76.3% 51.3% Red Green 4 Performance (120 minutes) 99% 94.3% 74.4% 94.3% 74.4% Red Local CCG Cat A Performance (08:45 minutes) 75% 62.5% 62.5% Cat A Performance - LAS Total Cat A Performance - Haringey CCG Red Key Messages 2015/16 sees performance across London as a whole and Haringey CCG individually starting at a lower point than last year. There were 1,678 conveyances to an Emergency Department in April ,110 conveyances within Haringey went to NMUH and 443 to the Whittington. This equates to 92% of all ambulance conveyances from Haringey to an Emergency Department Care Pathway location. The graph opposite shows performance against LQR category A (8 minutes and 45 seconds) including last year s performance and the London average. 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2014/ /16 Target 100% 90% 80% 70% 60% 50% 40% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2014/ /16 Target 17

19 Executive Summary for HCCG. London Ambulance Service Key Issues As at 28 th June 2015 the Trust remains at Resourcing Escalation Action Plan level 4 (Severe). Category A activity was above forecast by 2.0% with category A performance finishing at 65.7%, which is above the agreed weekly trajectory of 64.0%. Red 1 performance returned 67.0%, taking the year to date to 67.9%. Red 2 performance finished at 65.7%, with the year to date now sitting at 65.6%, which remains below the national key standard of 75% or more. Quarter 1 trajectory is 63.07% with the Trust sitting 2.57% above the trajectory. The Trust achieved the A19 trajectory of 92.0% returning 93.7%, taking the year to date position to 94.1%. The Emergency Operations Centre (EOC) achieved 95.9% call answering within five seconds against the national key standard of 95.0%, taking their year to date position to 97.5%, remaining above the national standard. The clinical hub achieved 3,228 dispositions in the week. The Trust had seven operational leavers of which six were paramedics. Planned recruitment activity to cover operational vacancies National Paramedics Recruitment The LAS graduate pipeline is currently standing at 122. This breaks down to 110 booked on courses and a further 12 with interviews planned. There are also a further 19 graduates who do not require attendance at a course joining LAS through September In addition the Trust have received ten-plus new applications from registered paramedics who have been invited for interviews. Trainee Emergency Ambulance Crew (TEAC) The current TEAC pipeline is standing at 668 WTEs. This is subject to candidates failure to progress at stages in the journey (e.g. assessment, interview and references). 33 are currently in training due to complete in Q1 41 TEACs are currently in supervision The remainder of the pipeline breaks down to; candidates booked on to courses candidates have accepted offers and we are negotiating their start dates subject to C1 driving and references - 99 candidates are awaiting interview - 91 candidates are awaiting assessment - 90 applications are being screened. International Paramedics Recruitment LAS have now completed their 2015/16 international recruitment drive and have made a total of 225 offers of employment. Of these 214 candidates have accepted offers. Please note that for newly qualified paramedics it will be a maximum of 17 weeks from start date to operational deployment. 18

20 Executive Summary for HCCG. London Ambulance Service Key Issues 2015/16 Operational Staff Trajectory work in progress Finance, Performance and Recruitment are currently finalising the graph below. However, changes to the overall trajectory are anticipated to be minimal. This has been updated to reflect changes in course numbers. The graph illustrates new frontline starters, staff in training and staff starting operationally against an establishment target of 3004 wte. LAS are forecasting to hit establishment in November, however, we will not reach fully operational levels until June The shortfall is currently anticipated to be approximately 139 FTEs and we are exploring options to address this. 19

21 Executive Summary: Quality 20

22 Quality HCCG Quality Dashboard Haringey CCG Quality Summary Theme Quality Overview KPI / Measure NMUH Whittington UCLH RFH Month Target Month YTD Month YTD Month YTD Month YTD MRSA reported infections Apr C. Difficile reported infections Apr (HCCG) Mixed Sex Accommodation (MSA) (Number of breaches) May VTE (% admitted patients assessed for VTE risk) Mar-15 95% 96.5% N/A 95.2% N/A 95.1% N/A 97.0% N/A Friends and Family Test Inpatients - Score Apr-15 N/A 92% N/A 90% N/A 97% N/A 88% N/A Friends and Family Test Inpatients - Response Rate Apr-15 N/A 27% N/A 14% N/A 24% N/A 40% N/A Friends and Family Test A&E - Score Apr-15 N/A 81% N/A 92% N/A 94% N/A 87% N/A Friends and Family Test A&E - Response Rate Apr-15 N/A 12% N/A 9% N/A 19% N/A 47% N/A Complaints number received in latest reported quarter May-15 N/A Qrt4: Complaints - % responded to within 25 working days SHIMI rate Oct13-Sep14 N/A 91 N/A 60 N/A 80 N/A 90 N/A Number of acquired pressure ulcers grade 3&4 New May-15 N/A 2 N/A 1 N/A 1 N/A 1 N/A Pressure ulcers All (2,3,4) May-15 N/A 27 N/A 20 N/A 12 N/A 61 N/A Serious incidents May-15 N/A The number of patient falls with severe harm May-15 N/A 0 N/A 0 N/A 0 N/A 0 N/A Safer Staffing Qualified Day Apr-15 N/A 91% N/A 104% N/A 95% N/A 97% N/A Safer Staffing Non Qualified Day Apr-15 N/A 82% N/A 116% N/A 127% N/A 115% N/A Safer Staffing Qualified Night Apr-15 N/A 93% N/A 101% N/A 97% N/A 104% N/A Safer Staffing Non Qualified Night Apr-15 N/A 93% N/A 138% N/A 135% N/A 125% N/A Reporting Haringey Whittington North Middlesex UCLH Royal Free BEH Month CCG Total Target Actual Trend Target Actual Trend Target Actual Trend Target Actual Trend Target Actual Trend Overdue SIs May Patient Falls (Safety Thermometer) May New CAUTIs (Safety Thermometer) May-15 1/32 1/46 1/21 4/121 0/36 Pressure Ulcers (Safety Thermometer) May-15 1/5 7/27 1/4 8/61 5/29 VTEs (Safety Thermometer) May-15 90% 89% 84% 96% 0% FFT Score - A&E Apr N/A FFT Score - Inpatients Apr N/A C.Diff Apr N/A MRSA Apr N/A VTE Assessments Mar-15 95% 95% 95% 97% 95% 95% 95% 95% N/A Mixed Sex Accommodation May N/A 21

23 Executive Summary for HCCG Quality Highlights Quality Issues & Priorities Summary For quality indicators, there has been a mixed picture for Haringey CCG in May Notable highlights include a further improvement in the reduction in number of Mixed Sex Accommodation (MSA) breaches of HCCG patients. However, the patient experience indicators at NMUH, as measured by the Friends and Family Test A&E score and the deterioration of performance on the CQC Inpatient Patient Experience Survey, have deteriorated from the previous year. Whittington Health is also experiencing an increase in the prevalence of pressure ulcers and Haringey patients are waiting longer for orthodontic procedures. Mixed Sex Accommodation (MSA) HCCG had no MSA breaches reported in May 2015 which is the first month that there have been zero breaches since August In the previous three months, the MSA breaches for HCCG have been predominantly at UCLH. The Trust has undertaken a review of their reporting threshold and after identifying that they may have over reported breaches, this figure has started to reduce. Pressure ulcers and orthodontic waits at Whittington Health The prevalence of community pressure ulcers has increased at Whittington Health and an analysis of the underlying causes has led to changes in process which will be closely monitored by the CQRG. Following a Quality Alert, increased waits for Haringey patients were found for orthodontic procedures. The Trust has put in place a Remedial Action Plan and has given assurance that improvements will be demonstrated from July 2015 onwards. Friends and Family Test (FFT) NMUH has ranked well below most London acute trusts on the A&E FFT score since December 2014, with only Imperial College receiving a worse score in April The FFT response rate has also dropped from 18% in April 2015 to 8% in May The Trust reports that additional equipment to collect responses has been put in place and the CQRG will be monitoring for sustained improvements. Patient experience continues to be a concern for NMUH as the results from the Care and Quality Commission Inpatient Survey shows that NMUH is performing worse in 2015 than it did in the previous year on ten out of eleven patient experience domains. A Remedial Action Plan is in place to address poor inpatient and A&E patient experience survey results. This will be reviewed by the CQRG on a monthly basis. 22

24 Executive Summary for HCCG Quality Highlights Quality Issues & Priorities Cancer 2 week wait HCCG have written to NMUH expressing their concerns regarding a recent request to retrospectively down-grade five respiratory patients on the 2 week Cancer wait pathway. The patients were seen after the 2 week deadline had passed and the cases should have been reported as breaches of the 2 week cancer pathway. The Trust will ensure that their data submissions will now includes these breaches. A response has been received from the Trust. Haringey CCG, as the lead commissioner, is to undertake an audit of the five breach cases to gain further assurance. Intelligent Monitoring NMUH has been assigned 14 risks and nine elevated risks which broadly focus on the areas of patient experience survey results, stroke reporting and cardiovascular accident (CVA), urinary tract infection and sepsis mortality reporting. The Trust is implementing Remedial Action Plans for A&E, inpatient experience, and it will be discussing stroke and mortality reporting with the CQC at their monthly meeting. The CSU/HCCG is undertaking a stroke data triangulation exercise. These will be reported at the Trust s CQRG meeting. 23

25 Executive Summary: Quality and Performance Provider Specific 24

26 North Middlesex University Hospital Quality Highlights NMUH Key Quality Issues & Priorities 2 week cancer wait breaches not reported NMUH Trust has down-grade four Enfield and one Haringey patients on a suspected respiratory cancer pathway. These patients are required to be seen by the Trust within two weeks. Haringey CCG sent a letter expressing their concerns to the Trust. The Trust response to the letter was received on 25 th June This gave assurance that the patients have not experienced harm as a result of the breach and confirmed that the Trust is addressing the issues raised in this letter. A clinical process review is to be undertaken to seek further assurance on compliance with tracking and monitoring guidance of 2 week wait cancer referred patients. Intelligent monitoring The CQC intelligent monitoring has identified fourteen risks and nine elevated risks at NMUH. This is set against the background that the Trust has completed the action plan following their CQC inspection. A rating has not been given at this stage as the Trust was recently inspected. It was noted that most areas of risk or elevated risks relate to patient experience surveys, three risks/elevated risks to inpatient mortality reporting and two to stroke reporting. In response to the high number of risks and elevated risks HCCG have asked the Trust for a Remedial Action Plan to address risks and elevated risks. NMUH has presented their Remedial Action Plan at the June 2015 CQRG. The Trust is to discuss risks with the Care and Quality Commission in July 2015 at their monthly meeting including reporting issues for stroke. The CSU/CCG are undertaking a stroke data triangulation exercise to validate whether this data is being reported accurately. NMUH have agreed to report back on the discussion with the CQC to the CQRG taking place on 24 th July Delayed diagnosis and direct access radiology GP quality alerts have highlighted a number of incidents of delays with diagnoses at the Trust. Serious Incidents concerning delayed diagnosis have also emerged as a theme, including recurrent problems with radiology turnaround times. The HCCG Assistant Director - Acute Contracts & QIPP has informed the Trust that radiology turnaround times will be raised and this was discussed at the performance meeting on 2 nd July This issue is being monitored and discussed at the CQRG meeting at the Trust. 25

27 North Middlesex University Hospital Quality Highlights NMUH Key Quality Issues & Priorities Clostridium Difficile (C.Diff) For 2014/15, NMUH has reported 46 cases of C.Diff. This vastly exceeded the target of 21 cases for the year. The threshold target for 2015/16, in response to the high number of cases in the previous year, is set at 34. In April 2015, the Trust has reported 2 cases of C.Diff. The Trust has agreed and implemented a number of actions to bring down the number of C.Diff cases in 2015/16. These include regular audits of cleanliness of all clinical areas, weekly audits of hand hygiene in all clinical areas and improved compliance with protocol for antimicrobial prescribing. The Trust has undertaken significant analysis of the C.Diff cases and has found that a substantial proportion of cases identified were Enfield residents. Enfield CCG has identified possible contributing factors of an increased elderly population and issues with antimicrobial prescribing. Prescribing in this area will be monitored and should decrease the number of C.Diff cases for NMUH. Serious Incidents Three SIs were reported by NMUH for May 2015 and include an admission to Neo-natal Intensive Care Unit, an unexpected death and an information governance breach. This forms a marked decrease of numbers reported in April 2015 when eleven SIs were reported. There are currently thirteen overdue SI reports with a delay of up to two months. This is a marked increase in the number of overdue reports. One Never Event is still being investigated. With the implementation of the new Serious Incidents Framework, the Trust is seeking to have all pressure ulcers classified as incidents rather than SIs. HCCG is working with the Trust Safety Team on a process that ensures policies and protocols are in place to allow safe transition in the reporting. 26

28 North Middlesex University Hospital Performance Highlights NMUH Key Performance Issues & Priorities A&E NMUH failed to meet the standard in May 2015 with a performance of 93.87%. This is the eighth consecutive month that the Trust has failed the standard. Attendances decreased again to 13,482 in May 2015 and were consequently at their lowest level since September The key issues regularly being reported by the Trust for failing the standard are: Failing to recover for a number of days following a surge in activity Low numbers of patient discharges and delayed transfers of care Increased admission rates and a lack of bed availability Shortages of staff due to short notice sickness which was not covered by agency locums HCCG have issued three Contract Performance Notices to NMUH following their poor performance to date in The issues were discussed with the Trust at a meeting which followed the issuing of the notices and a Remedial Action Plan was then produced to address HCCG s main concerns. Key themes addressed by the Remedial Action Plan, include attendance avoidance; front door redirection, recruitment, management and discharge planning. In addition to the Remedial Action Plan, work is underway to divert more patients through the Urgent Care Centre and develop the Ambulatory Emergency Care model. NMUH have also been incentivised via Commissioning for Quality and Innovation payments to increase weekend discharge rates and increase discharges before 12 noon to alleviate bed management pressures. 27

29 North Middlesex University Hospital Performance Highlights ctd. NMUH Key Performance Issues & Priorities RTT - Changes in reporting NHSE wrote to NMUH on 24 th June 2015 to confirm that the admitted and non-admitted operational standards are being abolished. The incomplete standard (i.e. those patients who are yet to receive treatment) will be the sole measure of performance. A patient s legal right to start non-emergency Consultant-led treatment within 18 weeks of referral is unchanged. The CSU, in conjunction with the lead commissioner, will continue to monitor the Trust s RTT performance and raise any concerns as appropriate. Cancer NMUH met all the national cancer access standards in April 2015 with the exception of the 31 day wait target for subsequent chemotherapy treatment. The Trust s achievement was 96.15% against a target of 98%. This standard has been met every month for the past two years with a performance of 100% except in the reporting month. There were 26 patients receiving this treatment in April 2015 and one of the patients breached. The Trust has confirmed to the lead commissioner that five patients have not been reported as failing the 2 week wait standard when in fact they should have been. The Trust will amend their breach data submissions. It may be that when this error is corrected, the Trust will fail that standard in the reporting month because of these additional breaches. Following the failure in the reporting of the 2 week wait data the Trust has agreed to review their data processes which will be carried out in conjunction with the Senior Cancer Commissioning Manager from the CSU. Cancer breaches in May 2015 The Trust was issued with an Exception Report for May data, which demonstrated a breach in 62 day screening. Standard North Middlesex 62 Day - Screening 66.7 This exception was caused by a single patient choice breast screening breach from three patients. There was no early warning of this scenario. The screening standard is particularly challenging to meet given the small numbers involved in this service. 28

30 University College London Hospital Quality Highlights UCLH Key Quality Issues & Priorities RTT Clinical Harm Review The Trust provided an update at the June 2015 CQRG of all reported 40+ week wait patients who were clinically reviewed at month end. As at March 2015, there were 478 cases requiring a clinical review. Out of these, 58 were found not to be patients genuinely waiting for longer than 40 weeks. This has highlighted the Trust not having accurate data quality systems in place. The Trust will continue to report progress on the Clinical Harm Review through the monthly CQRG meetings and clinical harm remains a substantive item for assurance on each CQRG agenda week waits: 306 clinical reviews have been completed and the Trust has not detected to date any evidence of deterioration or significant new morbidity related to delays in treatment for the patients. Maternity The Trust presented their Quarterly maternity assurance report and the Trust NCL maternity dashboard. The Trust have had a number of term admissions to the neonatal unit, as the indicators have shown red for three months. The Trust are using alternative guidelines rather than NICE guidelines which may have implications for robust Contract Technical Group (CTG) result interpretation. Concerns have been highlighted in relation to a high number of women presenting at UCLH receiving a caesarean section or instrumental delivery. The Trust will review the current guidelines used for CTG interpretation and provide a response back on findings and progress. The reasons for the high number of women receiving a caesarean section or instrumental delivery is due to patients having long term pre-existing medical conditions, women having received assisted conception treatment, as well as an older patient group. The Trust has reviewed the admissions to the neonatal unit and have identified some learning areas, in particular to CTG interpretation and appropriate escalation. Safer Staffing The Safer Staffing measures show the overall average percentage of planned/actual day and night hours for registered nurses/midwifes and non-registered care staff in hospitals which are filled. UCLH data shows the average fill rate for registered nurses/midwifes during the day in March 2015 was 92.34% and 97.75% at night. The average fill rate data for care staff during the day is % and % at night. The CCG will continue to seek assurances through the CQRG and twice yearly board reports on staffing received. 29

31 University College London Hospital Performance Highlights ctd. UCLH Key Performance Issues & Priorities A&E For Q1, UCLH is ranked within the top five London Trusts (second to Moorfields NHS Trust). The Front Door Model has been implemented with success. This model superficially categorises patients entering the department and determines how urgent their care is, if necessary at all. However, issues can arise when there is a lack of Emergency Nurse Practitioners or medical cover, thus the streaming model is not as effective. With the new front door model, majors is quieter and calmer, even with the recent high level of attendances. UCLH is looking into providing more support to the reception staff to help the registering of patients to ensure the steady fruition of patients continues.. The Flow Management system at the Trust is now using an IPAD app which is the front end of the bed management system, which gives a real time state for beds. Diagnostics The Trust is showing improvement of diagnostics against the expected trajectory. This is mainly driven by improvement in MRI and endoscopies. Demand and Capacity modelling is showing that clearance of backlog in MRI and endoscopy will take longer than expected and June compliance will not be achieved. The Contract Query Notice is being monitored via the RTT bi-weekly meeting and exceptions are brought to the Contract Review Group meeting on a monthly basis. MRI is using portable scanner as well as outsourcing. MRI has also seen an increase in demand over one year. The demand and capacity planning shows that MRI will be compliant in July Endoscopies UCLH has also discovered that echocardiology patients were not accurately recorded by the Heart hospital administration team and the current backlog has increased by fifty patients. The Trust has revised the original trajectory as June 2015 compliance will not be achieved due to demand and capacity work in MRI and endoscopies. Endoscopies, at this time, are predicted to be compliant by August Cancer Waits UCLH failed five standards this month, 2 week wait, 31 day (first and second surgery treatment) and 62 day (urgent GP referral and screening) standards. 2 week wait - Failure of this standard is by 0.6%, or 5 breaches. The Trust is likely to refresh this data for the quarter. Skin and lower Gastrointestinal accounted for the most breaches. There were 58 patient choice breaches, three due to administration and three due to capacity. 31 day first and subsequent treatments: The cause of these exceptions is due to a large number of breaches in the urology tumour group. The Trust reports capacity issues with the urology tumour site and has been outsourcing two robotic surgery lists since October. The breach reasons are exclusively reported as due to capacity. 32 day (urgent GP referral): As with previous months, this is caused by persistent issues with capacity, administrative issues and inter-trust transfer delays across a number of complex treatment pathways and tumour sites. There are capacity issues and risks to the Trust performance in this standard: 62 day screening: This exception is due to a single breach against a small number of patients for both the breast and lower GI screening services. Both of these breaches were recorded as patient choice. 30

32 Whittington Health Quality Highlights Whittington Key Quality Issues & Priorities Medical Staffing Recruitment to middle grade medical staff remains a significant challenge in the Emergency Department. The vacancy rate is approximately 30-40%. In contrast, nursing recruitment across the department has been very successful with no vacancies currently. The Trust are developing a number of proposals to address middle vacancies, including converting middle grade posts to other roles such as consultants and advanced nurse practitioners. The Trust is also looking towards the development of clinical simulation fellows working in the Emergency Department. The Trust have reported that by the end of July 2015 this position will decrease to 3.5 whole time equivalent. With the increasing demand on the Emergency Department, the Trust has to achieve the 95% 4 hourly target. The CQRG will monitor this area of recruitment very closely. Pressure Ulcers The division of Integrated Care and Acute Medicine have stated that in April 2015 the pressure ulcer prevalence for the division is reporting as 7.48%. The Trust have acknowledged that this is too high with the majority of incidences occurring in the community. A report has been produced by the division that highlights where the specific problems are and if there are any themes running through the incident investigations. This report has been presented to the Trust s Quality Committee and also identifies what improvements have been put in place which includes increased education for patients and families. The Trust will be closely monitoring the action plan to reduce pressure ulcer prevalence which will be regularly monitored at the CQRG Meeting. Orthotics The Trust has experienced some increased waiting times for Haringey patients (6-8 weeks), Islington patients are currently only waiting 1-2 weeks. A Quality Alert was raised as a result of the increased waiting times from three to six months for cast orthotics. Issues were primarily due to workforce as staff members working for Haringey had transferred and this had caused a backlog in processing orders. As a consequence, staff have been relocated to help with the backlog and to bring the waiting times back into acceptable limits. The Trust is also reviewing the appropriateness of the some of the orders which will also help bring down the backlog. Appraisal The overall Trust rate has decreased, in April, by 3%. The Trust reported in May 2015 that the new system for undertaking an appraisal is very time consuming and onerous. The Trust has now agreed new paper work for the Appraisal process. There are many areas of good practice across the hospital and community and any areas of poor practice will be liaising with these departments to share how they have achieved this compliance. 31

33 Whittington Health Performance Highlights Whittington Key Performance Issues & Priorities A&E The Trust has failed the standard for five weeks out of ten in 2015/16 and will not meet the target for quarter 1. The issues in the early part of the month were a result of bed capacity due to a significant increase in the number of patients with a length of stay above nine days, which peaked at 110. More recently the issues have been around staffing levels with short term and long term sickness as well as high levels of vacancies in the nursing and medical teams. This has caused pressure during periods of peak demand. There appears to be no particular pattern to the peaks in attendance, whereas previously these had been in the evenings. The Trust has submitted plans through the System Resilience Group for an alternative bed model to increase the number of medical beds, following demand and capacity modelling. An action plan has been implemented to reduce the number of patients with long lengths of stay, which has been shared with the CSU/CCG. Haringey Social Care Team have a representative based in the operations room at the Trust for one day a week to support the discharge process for Haringey patients. Islington Social Care team recently relocated and now provide an In-reach service, having previously been colocated in the hospital. The Trust have an ongoing recruitment campaign focussed on nursing staff but also medical vacancies. The Trust are also liaising closely with the Deanery in respect of middle grade doctors, of which there will be fewer on the next rotation. Following implementation of the action plan the number of patients with a length of stay above nine days has reduced to seventy-five and the Trust are confident that this will continue on a downward trend. Diagnostics The Trust remains compliant against the 6 week wait standard in the reported months (i.e. to April 2015). Lately the Trust has reported a particular pressure with endoscopies, where demand has increased quite significantly. Therefore, the published data for May 2015 will indicate a drop in performance. The Trust created an additional twenty clinics to manage the demand on the service and to meet the target in June The Trust published data shows compliance to date across all diagnostics. The Trust identified the capacity issues in endoscopy at an early stage and have managed this demand by increasing capacity in the short term to clear the backlog and expect to reach a compliant position again in June

34 Whittington Health Performance Highlights Whittington Key Performance Issues & Priorities Cancer breaches in May 2015 Whittington Health was issued with an Exception Report, for May 2015 data, as the Trust exceeded the tolerance level of the cancer access standard for 2 weeks waits. The below table shows that this exception was caused by five breaches over the operational standard. 34 of these were recorded as patient choice, three capacity and one administrative breaches. There was no early warning of this scenario. The Trust may retroactively improve their monthly performance and in addition adjusted quarterly performance may result in an overall improvement. This will be seen when June 2015 data is submitted. 33