Greater Nottingham CCGs Monthly Performance Report November 2018

Transcription

1 Greater Nottingham CCGs Monthly Performance Report November 2018 Section 1 Section 2 Section 3 Section 4 Indicators below standard Other Indicators Greater Nottingham CCGs Contract Summary Glossary This report sets out the CCGs current performance for 2018/19. The table below displays a summarised view of performance against a range of key national indicators. The current position is shown by CCG as well as from a provider perspective. Further detail around the Indicators below standard is shown within the report including the key contributory factors as well as remedial actions being taken to improve performance. Where performance is below the national, or local standard, a further narrative is provided on subsequent pages listing the underlying issues; the remedial actions being taken to recover performance; any contract mechanisms being employed for improvement; and the timescales for recovery. Members are asked to note there are five areas of performance that are in formal escalation to NHS England, four of these areas are showing improvement: Cancer 62-day GP urgent referral to treatment; Children waiting less than 18- weeks for a wheelchair; Full NHS continuing healthcare assessments taking place in an acute hospital setting; and Reliance on inpatient care for people with learning disabilities or autism. The remaining area in escalation is A&E four hour wait. Details are shown on the relevant pages. Section 3 of the report provides a high level financial summary of the major contracts held by the CCGs, identifying the main areas of performance variation for all Greater Nottingham CCGs. Members are asked to note that a more detailed contract report is presented to the Finance Committee on a monthly basis. The final section provides a glossary of the acronyms used throughout the report. Key Performance Indicators where the CCGs have been escalated by NHS England Indicator CCG Provider Total Notts City NNE NW Rush NUH Circle A&E 4 Hour Standard => 95% Aug-18 Sep-18 ### ### ### ### ### 3 Cancer 62 Day GP Urgent Referral to Treatment => 85% Aug-18 Aug-18 ### ### ### ### ### ### 4 & 5 Wheelchairs Children waiting less than 18 weeks for a wheelchair => 92% Q Q ### ### ### ### ### 8 Continuing Health Care Full NHS CHC assessments taking place in acute hospital setting <= 15% Q ### ### ### ### 14 Transforming Care Partnership: Learning Disability Inpatients Reliance on Inpatient Care for People with LD or Autism Standard Latest data period Latest period data CCG Provider Page in Report CCG Commissioned <= 20 Sep-18 ### 15 & 16 NHSE Commissioned <= 26 Sep-18 ### 15 & 16 Total <= 46 Sep-18 ### 15 & 16 1

2 Performance Against Key National Indicators Indicator Standard Latest data period CCG Provider Total Notts Grt Notts Latest period data CCG City NNE NW Rush NUH Circle EMAS Notts A&E 12 Hour Trolley Waits = 0 Sep Week Wait => 93% Aug-18 Aug-18 ### ### ### ### ### ### Cancer 2 Week Wait - Breast Symptoms => 93% Aug-18 Aug-18 ### ### ### ### ### 31 Day Decision to Treat to First Treatment => 96% Aug-18 Aug-18 ### ### ### ### ### ### Incomplete % => 92% Sep-18 Sep-18 ### ### ### ### ### ### 18 Weeks RTT Incomplete number of 52 week waiters = 0 Sep-18 Sep Diagnostics Patients waiting longer than 6 weeks <= 1% Aug-18 Aug-18 ### ### ### ### ### ### 7 Cancelled Operations DToC Ambulance Activity Variance to Plan (YTD) = 0 Sep-18 ### ### = 0 Sep <= 3.5% Sep-18 ### <= 697 Sep <= 269 Sep <= 1347 Aug-18 ### <= 1046 Aug <= 2392 Aug-18 ### <= 00:07:00 Sep-18 ### ### ### ### ### 9 & 10 <= 00:18:00 Sep-18 ### ### ### ### ### 9 & 10 <= 00:15:00 Sep-18 ### ### ### ### ### <= 00:40:00 Sep-18 ### ### ### ### ### 9 & 10 <= 02:00:00 Sep-18 ### ### ### ### ### 9 & 10 <= 03:00:00 Sep-18 ### ### ### ### ### 9 & 10 <= 2% Aug-18 ### ### ### ### ### <= 2% Aug-18 ### ### ### ### ### <= 2% Aug-18 ### ### ### ### ### <= 2% Aug-18 ### ### ### ### ### <= 2% Aug-18 ### ### ### ### ### <= 2% Aug-18 ### ### ### ### ### <= 2% Aug-18 ### ### ### ### ### <= 2% Aug-18 ### ### ### ### ### <= 2% Aug-18 ### ### ### ### ### 11 Non-elective spells complete - 1+ Length of Stay <= 2% Aug-18 ### ### ### ### ### 11 Non-elective spells complete <= 2% Aug-18 ### ### ### ### ### 11 A&E Attendances excluding follow ups <= 2% Aug-18 ### ### ### ### ### 11 Number of Completed Admitted RTT Pathways <= 2% Aug-18 ### ### ### ### ### 11 Number of Completed Non-Admitted RTT Pathways <= 2% Aug-18 ### ### ### ### ### 11 Number of New RTT Pathways (Clockstarts) <= 2% Aug-18 ### ### ### ### ### 11 Entering Treatment - Month => 1.5% Aug-18 ### ### ### ### 12 Entering Treatment - Rolling Three Months => 4.4% Aug-18 ### ### ### ### 12 Improving Access to Recovery Rate => 50% Aug-18 ### ### ### ### Psychological Therapies Waiting Times - First Treatment within 6 Weeks => 75% Aug-18 ### ### ### ### 13 Waiting Times - First Treatment within 18 Weeks => 95% Aug-18 ### ### ### ### Dementia Diagnosis Rate => 67% Aug-18 ### ### ### ### EIP Treated within two weeks % - Rolling Three Months => 50% Sep-18 ### ### ### ### CYP Eating Disorders Continuing Health Care TCP: Learning Disability Inpatients Rebooked within 28 Days Urgent Operation Cancelled for a Second Time As a % of occupied beds (Greater Nottingham) Beds Occupied by Long Stay Patients (7+ days) Beds Occupied by Long Stay Patients (21+ days) Total Days Delayed (Nottinghamshire County) Total Days Delayed (Nottingham City) Total Days Delayed (Total Nottinghamshire) Category 1 Life-threatening illnesses or injuries - Average Category 2 Emergency calls - Average Category 1 Life-threatening illnesses or injuries - 90th centile Category 2 Emergency calls - 90th centile Category 3 Urgent calls - 90th centile Category 4 Less urgent calls - 90th centile GP Referrals (G&A) Other Referrals (G&A) Total Referrals (G&A) All 1st OP - Consultant led Follow-up OP - consultant led Total Elective spells - Day Cases Total Elective spells - Ordinary Total Elective spells Non-elective spells complete - 0 Length of Stay Routine Cases <4 Weeks - Complete Pathways Urgent Case <1 Week - Complete Pathways NHS CHC eligibility decisions made by CCG within 28 days Reliance on Inpatient Care for People with LD or Autism with a length of stay of 5 years and over => 95% Q ##### ### ### ### 13 => 95% Q ### ##### ##### ##### 13 => 80% Q ### ### ### ### CCG Commissioned <= 7 Sep NHSE Commissioned <= 22 Sep-18 ### Total <= 29 Sep-18 ### Out of Area Placements Inappropriate Out of Area Placement Bed Days (NHCT) <= 4600 Q ### 17 Provider Page in Report 2

3 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Section 1 - Indicators Below Standard Indicator A&E - 4 Hour Standard Standard 95% Caroline Nolan A&E 4 Hour Wait Period Performance Nottingham City Aug % Nottingham North & East Aug % Nottingham West Aug % Rushcliffe Aug % Nottingham University Hospitals Sep % 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% NUH A&E Performance High bed occupancy at QMC in the medical bed base has resulted in a lack of flow from admissions areas and subsequently out of ED. As a result bed waits in ED triggered NUH internal escalation to OPEL 4 status on 1 occasion during September ED staffing gaps, particularly overnight and at weekends have compounded difficulties in coping with the surges in demand Surges in hourly attends for ambulances reported which has impacted on the ability of the ED to deal with patients in a timely manner resulting in increased waits to be seen and decision to admit times triggering internal escalation. A&E board have requested a deep dive to understand the reasons behind the surges and any mitigating actions that can be taken The number of beds occupied by long stay patients (LOS 21 days) had reduced to 235 from a high of 285 in March The A&E board are overseeing a robust action plan including daily executive leadership and oversight to support the delivery of the nationally set ambition for NUH, which is 200 by December 2018 Medically safe patients waiting over 24 hours for supported discharge increased in the final week of August. This was the result of a surge in referrals to community services for patients requiring supported discharge. At the end of September referral levels reduced with the majority of the waits for pathway 1 (home support) DTOC continues to achieve the standard with September reported at 3.0% of occupied beds National Standard RAP Trajectory 2017/18 RAP Trajectory Achieved RAP Trajectory Not Achieved NUH RAP Actual Trajectory Performance Apr % 83.0% May % 84.8% Jun % 86.5% Jul % 81.3% Aug % 83.2% Sep % 83.1% Oct % Nov % Dec % Jan % Feb % Mar % ED expansion Work underway on emergency pathway front door redesign at QMC, this includes: Expand majors by 10 cubicles - from 20 to 30 Create integrated urgent treatment centre combining NEMS and minors in single location Ambulatory pathway unit adjacent to ED Create a new front door for ambulatory attends requiring urgent care at NUH New surgical pathways reducing reliance on diagnostics within ED Status: Estate Work has started and project work streams designing the new processes are in place with system partners attending where appropriate St Francis A business case is being developed through the A&E board, if approved this would deliver - 48 bedded community facility at Nottingham City Hospital to support winter demand Detailed design and service model to be agreed with community providers Issues and Challenges System resources (staff, space, money) to put in place required capacity Stability in homecare market and no firm plans in place to increase home care/reablement capacity to support the winter plan. Plan for October A&E board to reach agreement on mitigation of the identified capacity gap Affordability of the overall system winter capacity plan 3

4 Indicator Cancer 62 Day RTT Standard 85% Simon Castle Cancer 62 Day GP Urgent Performance Referral to Treatment Aug-18 Q Nottingham City 81.08% 87.94% Nottingham North & East 78.95% 88.98% Nottingham West 90.00% 92.94% Rushcliffe 90.00% 82.35% Nottingham University Hospitals 79.56% 83.38% Circle 93.33% 92.00% NUH + Circle 82.63% 85.23% In August 2018, NUH reported performance was 79.56%. Technical development work is taking place on the national cancer reporting system to enable automatic adjustment for late tertiary referrals. Until the additional functionality is implemented the standard will continue to be formally monitored using the unadjusted performance position. Gynaecology Performance against the 62 day standard for gynaecology at NUH was 70.6% in August Reduction in surgical capacity in previous months is still having an impact on performance alongside an increase in complex tertiary referrals from surrounding hospitals. Urology Performance against the 62 day standard for urology at NUH was 76.3% in August A significant increase in referrals (+30%) has been seen recently but this has now returned to the baseline. However, there is a backlog of patients now requiring treatment although this has begun to reduce. Historic Performance Nottingham University Hospitals Aug % 93.33% 82.63% Jul % 85.39% 80.09% Jun % 94.51% 84.24% May % 89.66% 86.21% Apr % 92.54% 85.05% Mar % 86.05% 86.57% Feb % 86.25% 82.31% Jan % 85.86% 82.55% Dec % 91.57% 84.53% Nov % 82.61% 81.33% Oct % 82.14% 86.55% Sep % 86.73% 81.61% Cancer 62 Days GP Urgent RTT Performance by Main Tumour Individual tumour site RAPs are in place. Progress against these are reviewed on a fortnightly rolling basis East Midlands Cancer Alliance transformation funding is being released to CCGs and Providers in order to redesign pathways in Urology, Lung, and Colorectal cancer. This will reduce diagnosis and treatment waiting times and improve 62 day performance Gynaecology Waiting list initiative sessions continued to be implemented during October. Meanwhile, a case of need is currently being formulated for an additional consultant surgeon. Plans have also been submitted to extend theatre working sessions which will increase the number of procedures undertaken. This is currently awaiting approval by the Trust Executive team. Urology The first phase of the Prostate Pathway Transformation plan has been implemented in. This will reduce the number of patients requiring diagnostic biopsy and surgery. The directorate is also undertaking waiting list initiatives at weekends to reduce surgery waiting times. Timeline for recovery It is forecast that performance in October and November will improve but remain below 85% as NUH continue to reduce backlog numbers. Circle NUH + Circle Aug-18 Sites - NUH Patients % Breast % Gynaecological % Haematological (Exc AcuteLeukaemia) % Head & Neck % Lower Gastrointestinal % Lung % Other % Skin % Upper Gastrointestinal % Urological (Excluding Testicular) % 4

5 Indicator Cancer 62 Day RTT Day Waiters Standard 85% Simon Castle The JCC is reminded that the CCG writes to NUH s Chief Executive on a monthly basis to inform them of the number of patients still waiting 104 days or more for their first definitive treatment. As at the end of September 2018 NUH had 25 patients waiting 104 days or more. This compares to 26 at the end of August Harm reviews are undertaken on all 104 day patients. Below is a table listing the number of 104+ day waiters at NUH by CCG. Please note that this indicator measures patients still waiting at the end of the month, whereas the 62 Day RTT indicator measures patients treated during the month. CCG Sep-18 NHS Nottingham City CCG 11 NHS Nottingham North and East CCG 4 NHS Rushcliffe CCG 3 NHS Newark & Sherwood CCG 2 NHS West Leicestershire CCG 2 NHS Lincolnshire West CCG 1 NHS Nottingham West CCG 1 NHS Mansfield and Ashfield CCG Cancer Days Incomplete Waiters at NUH 10 0 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 NUH has weekly phone calls between tertiary units to enable timely escalation and resolution of issues. This is to ensure any delays in the transfer are minimised for the patient. NUH benchmark well against peer trusts with levels of 104 days waiters similar to Sheffield Teaching Hospitals, United Lincolnshire Hospitals and University Hospitals of Leicester; and significantly lower than Leeds Teaching Hospitals and The Newcastle Upon Tyne Hospitals. 5

6 Indicator RTT Incomplete - 52 Week Waiters Standard 0 Nina Ennis RTT Incomplete 52 Week Waiters Period Performance Nottingham City Sep-18 7 Nottingham North & East Sep-18 2 Nottingham West Sep-18 0 Rushcliffe Sep-18 2 Nottingham University Hospitals Sep Circle Sep-18 0 RTT Incomplete 52 Week Waiters - Sep-18 NUH Trauma & Orthopaedics 5 ENT 4 Other 5 Total 14 The 5 breaches in Other are broken down as follows - 4 x Colorectal 1 x Upper Gastrointestinal Week Waiters NUH Circle There has been an increase in the number of patients in ENT who have waited over 52 weeks. This is due to pathway recording errors made much earlier in the pathway by one member of staff who was stopping pathways incorrectly. The CCGs have been assured that NUH have: reviewed all of the stops made by this person confirmed that the incorrect working practice was isolated to this one person arranged additional training with the rest of the team anyway reviewed oversight processes to understand whether this error could have been identified earlier NUH are in the process of offering TCI dates to all long waiting patients who do not currently have a confirmed TCI ensure that they are treated as quickly as possible. A weekly forecast for improvements in the 52 week position has been agreed with NUH. The Trust is working hard to reduce the number of patients waiting over 52 weeks and forecast to have zero by the end of March This position assumes that the profile of activity which takes into account historic seasonal trends is maintained but does not assume a significant reduction in electives over winter. To support the delivery of the improvement plan: CCGs receive and analyse a full PTL every week from NUH. The CCG process includes challenging the Trust where 40-week+ patients do not have a TCI; this analysis is discussed at the NUH Quality and Performance meeting which escalates issues to the NUH Contract Executive Board CCGs work with NUH to monitor all patients approaching 52 weeks, offering a range of dates and implementing waiting list initiatives where possible. Any patients who have chosen to wait are still contacted with offers of dates sooner in case circumstances have changed NUH have sub-contracted additional spinal surgery capacity within the local Independent Sector for clinically appropriate patients. Patients will be offered the choice to move providers 6

7 Indicator Diagnostic - 6 Week Waiters Standard Not greater than 1% Nina Ennis Diagnostic - 6 Week Waiters Period Performance Nottingham City Aug % Nottingham North & East Aug % Nottingham West Aug % Rushcliffe Aug % Nottingham University Hospitals Aug % Circle Aug % Previous 12 Months Nottingham City Nottingham Nottingham North & East West Rushcliffe NUH Circle Aug % 2.8% 3.0% 2.9% 2.7% 0.0% Jul % 0.3% 0.4% 0.4% 0.4% 0.0% Jun % 0.5% 0.6% 0.2% 0.5% 0.5% May % 0.3% 0.6% 0.5% 0.7% 0.5% Apr % 0.6% 0.5% 0.7% 1.2% 0.8% Mar % 0.4% 0.4% 0.6% 0.6% 0.5% Feb % 0.2% 0.3% 0.4% 0.4% 0.3% Jan % 1.1% 0.5% 0.5% 0.6% 0.6% Dec % 0.7% 0.7% 0.2% 0.4% 0.7% Nov % 0.5% 0.4% 0.2% 0.7% 0.5% Oct % 0.5% 0.2% 0.2% 0.4% 0.3% Sep % 0.3% 0.2% 0.1% 0.1% 0.3% Following a recent enquiry with NUH regarding the length of wait for two individual patients NUH has discovered a recording issue for some patients referred for DEXA scans. Investigations revealed patients referred by GPs for DEXA were not being correctly recorded as RTT clock starts and, therefore, were not featuring on the reported monthly returns, but more importantly, the patients diagnostic test was not being scheduled according to their RTT length of wait. This led to a backlog of patients waiting longer than their 6-week guarantee date. The investigation was concluded in September 2018 and the Trust corrected the recording issue immediately, which included the publication of the correct position for the national diagnostic report for August. The corrected August position for the Trust reported 176 patients waiting 6-weeks or more for DEXA scan, which added to the 55 patients waiting 6-weeks or more for other modalities (231 in total). The outcome of this is that NUH failed the 6-week diagnostics standard (1% permissible tolerance) with 2.7% of patients waiting more than the 6-week threshold. To achieve the 6-week threshold the Trust must typically have no more than around patients waiting more than 6-weeks. The Trust has reacted positively to the investigation and its findings and has developed a recovery plan to demonstrate the actions being taken to provide patents with DEXA scans within 6-weeks and recover the backlog of patients who have already waited longer than the national standard. Actions include: The commissioning of additional DEXA capacity at Loughborough An additional member of clinical staff to utilise the Loughborough capacity and increase throughput of patients The appointment of 3 additional HCAs to assist individual patients thorough the diagnostic test Additional admin support to schedule patients Further capacity is in the process of being sourced with neighbouring providers and once confirmed will be offered to patients should they choose to transfer provider to expedite their diagnostic test. On request the Trust has investigated all other diagnostic services and has confirmed similar issues of misrecording do not exist in other areas. A recovery trajectory for reducing the DEXA backlog to below 1% has been agreed and will be delivered no later than 30 November Progress against the plan and corresponding residual backlog numbers will be monitored on a weekly basis. Formal tracking of recovery under the NHS Standard Contract will be monitored through the Commissioners monthly Quality & Performance Meeting with NUH. 7

8 Indicator Wheelchairs - Children waiting less than 18 weeks for a wheelchair Standard 92% Mark Sheppard Wheelchairs - Children waiting less than 18 weeks for a wheelchair Period Children waiting 18 weeks or less Children waiting over 18 weeks Performance Nottingham City Q % Nottingham North & East Q % Nottingham West Q % Rushcliffe Q % Nottingham University Hospitals Q % CCGs continue to work with NUH to sustain the 92% standard for this service and are aiming to achieve 100% during Quarter 3. 5 children waited over 18 weeks in Quarter 2; of the 5 children all had a wheelchair and were waiting for a new wheelchair or an adaptation. Breach reasons include complexity of need, delays in assessment appointments being booked and lack of capacity. All of which have been addressed through the RAP. The actions outlined in the RAP have been progressed and met the required timescale for completion. The key themes identified within the RAP are: Outpatient capacity Outpatient administration Pathway administration Approved contractor administration The CCGs are continuing to receive an anonymised patient tracking list (PTL) on a weekly basis enabling the progress of individual patients to be tracked and the Trust can provide assurance of improvements to the overall position The PTL enables CCGs to differentiate between patients who are waiting for their first wheelchair and patients who already have a wheelchair and are waiting for a new wheelchair or modifications to an existing chair Review of the PTL is highlighting that there are occasions when children are not brought for appointments, a review of this and specific actions to address it are being proposed and will be presented to the NUH Quality and Performance Committee during Quarter 3 8

9 Indicator Standard Ambulance Indicators See table below Julie Theaker and Helen Jones Please note: Notts performance includes Mid Notts CCGs and Bassetlaw East Midlands Ambulance Service Performance Measure Standard September 2018 Only Notts City NNE NW Rush Category 1 Life-threatening illnesses or injuries Average 00:07:00 00:07:01 00:05:42 00:07:47 00:07:37 00:08:09 Category 2 Emergency calls Average 00:18:00 00:29:08 00:24:54 00:26:50 00:26:19 00:30:06 Category 1 Life-threatening illnesses or injuries 90th Centile 00:15:00 00:12:15 00:08:48 00:12:31 00:12:29 00:13:00 Category 2 Emergency calls 90th Centile 00:40:00 01:00:20 00:51:27 00:50:10 00:54:33 00:58:19 Category 3 Urgent calls 90th Centile 02:00:00 02:58:43 03:01:10 03:14:58 03:18:04 03:02:33 Category 4 Less urgent calls 90th Centile 03:00:00 02:23:58 01:50:22 00:20:45 03:06:23 00:16:55 00:14:00 00:10:30 00:07:00 00:03:30 Category 1 - Average City NNE NW Rush Standard 00:00:00 00:50:00 00:40:00 00:30:00 00:20:00 00:10:00 00:00:00 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Category 2 - Average City NNE NW Rush Standard Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 The provision of emergency ambulance services for patients in Greater Nottingham is commissioned across the East Midlands by Hardwick CCG. As associate commissioners to the contract Greater Nottingham CCGs have a Memorandum of Understanding with Hardwick as part of the collaborative commissioning agreement to ensure the management of the contract takes place including performance management of standards. Achievement of the national standards has not been maintained at Division (county) or CCG level for a number of years. Key influencing factors include issues around capacity, delays in patient handover and workforce. The core EMAS contract will continue to operate as a block; however, two key elements relating to performance were agreed in the contract for 2018/19; Performance related payment In 2018/19, performance will be monitored against the quarterly trajectories developed by ORH, and delivered at a county level, with national performance standards being delivered quarterly from April 2019 onwards. The additional financial value will be apportioned to each CCG based on their share of the 2018/19 contract value. It was agreed that there will be monthly trajectories to support the monitoring of performance, but achievement will be measured on a quarterly basis. EMAS are aware of commissioner s expectation that there will be no deterioration in performance at a CCG level. Full payment will be made each quarter by each CCG if EMAS achieve all six of the quarterly performance trajectories for the County within which each CCG resides. If any of the six performance trajectories are not achieved at a County level, then the payment made by each CCG within that County will be reduced by an equal share (i.e. one sixth) for each trajectory missed in the quarter. No payment will be made where there is underachievement against one of the trajectories, but overachievement on the same standard in a subsequent quarter. Once a trajectory has not been achieved, the payment attributable to that standard, for the relevant county, is no longer payable. Continued on Page 10 9

10 Indicator Ambulance Indicators Issues and insight (continued from page 9): Handover delay risk share It was agreed that if the trajectories are not achieved and pre hospital handover delays within that county exceed the modelled baseline for that quarter, EMAS will ask ORH to re-model the trajectories for that quarter, for the relevant county. This remodelling will take into account 50% of any pre hospital handover delay over and above the baseline figure. This could then result in payment being made for that quarter by the respective county. Further work needs to take place to develop and agree the mechanism to manage handover delays. There will be an expectation from commissioners that EMAS develop the handover protocol for implementation across all acute trusts to reduce the numbers of prolonged handover delays. This will need to be actively managed through local Delivery Boards. EMAS has developed a strategic plan, which includes the outputs from the demand and capacity review in order to deliver national performance. New performance trajectories for the Nottinghamshire Division have been agreed as part of the 2018/19 contract negotiations facilitated by NHS England/NHS Improvement. An improvement in performance has been noted with Nottinghamshire division achieving the required standard in Category 1 calls for all three months that the trajectories have been in place, see table below. Nottinghamshire Division Category 1 Month Mean 90th centile Actual Trajectory Actual Trajectory Jul-18 00:07:10 00:08:21 00:12:19 00:15:00 Aug-18 00:06:57 00:07:08 00:11:59 00:15:00 Sep-18 00:07:01 00:07:30 00:12:15 00:15:00 Following publication of the agreed divisional trajectories and agreement of the contract, a performance monitoring process is being implemented across the region. The agreed approach is to replace four of the current divisional (local) contract monitoring meetings with regional commissioner meetings. These will be aligned to the quarterly performance reporting schedule of the divisional trajectories agreed in the contract. There is a financial incentive for the delivery of the performance trajectories and EMAS will be implementing the outputs of the recent strategic review to improve performance including; Recruitment of additional staff to staff double crewed ambulances to support sending the correct resource to the patient Management of current staff abstraction rate from 31% - 28% (nationally recognised standard) Improving the CAT (clinical assessment team) to increase the calls receiving hear and treat and reduce ambulance dispatch Increasing resource to EOC (emergency operations centre) to improve the processes for call handling and reduce initial dispatch 10

11 Indicator Standard Activity Variance to Plan (YTD) Less than +2% variance Mark Sheppard Activity Variance to Plan (YTD) Period Greater Nottingham Nottingham Nottingham Notts City North & East West Rushcliffe GP Referrals (G&A) Aug % % -1.59% 0.89% -0.98% Other Referrals (G&A) Aug % -7.22% -3.18% 5.02% 0.12% Total Referrals (G&A) Aug % % -2.10% 2.23% -0.63% All 1st OP - Consultant led Aug % % -5.86% -3.48% -4.69% Follow-up OP - consultant led Aug % -4.66% -3.80% -0.96% -2.89% Total Elective spells - Day Cases Aug % -4.94% -4.01% 1.98% -2.37% Total Elective spells - Ordinary Aug % -9.45% -3.39% 0.68% 3.67% Total Elective spells Aug % -5.57% -3.93% 1.80% -1.53% Non-elective spells complete - 0 Length of Stay Aug % 22.54% 13.00% 14.55% 19.12% Non-elective spells complete - 1+ Length of Stay Aug % 1.31% 0.91% 5.12% 2.75% Non-elective spells complete Aug % 6.85% 3.90% 7.46% 6.85% A&E Attendances excluding follow ups Aug % -0.48% 1.27% 3.08% 10.93% Number of Completed Admitted RTT Pathways Aug % % -9.69% -5.77% 2.04% Number of Completed Non-Admitted RTT Pathways Aug % % 6.60% -3.45% -3.55% Number of New RTT Pathways (Clockstarts) Aug % % 11.35% 2.52% 0.31% Non-elective and A&E There has been a growth in zero day Non-Electives at NUH, commissioners are working with the Trust to investigate the cause of this and whether there has been any pathway changes. Work is ongoing to understand how any pathway changes that may have been made would benefit patients Comparative analysis has shown that the growth is primarily influenced by patients aged 0-4 and a step change in admission volumes can clearly be seen This issue accounts for 50.2% of the variation seen within 2018/19 The remainder is a genuine increase in demand indicating year on year growth in activity and is expected to remain for the remainder of the financial year Non-Elective Pathway changes are being discussed with the Trust and the impact of these will be agreed prior to the changes being implemented CCGs continue to work with GP Practices to mitigate any further increases for patients who do not require hospital admissions, particularly in those patients with long-term conditions Care Coordinator teams are being re-focused and tasked to increase the prevention of non-elective admissions. This includes a team specific target which increases their current run-rate to that which was in the original plan and to further increase this to recover the non-elective spells over-performance in the second half of the financial year. These targets are the focus of discussions between commissioners and community providers, including the recruitment to vacant Care Coordinator posts agreed in the plan System-wide meetings are taking place weekly with primary care and community care to ensure progress is maintained The A&E Delivery Board continues to discuss the recovery of ED performance which includes how patients are managed in the department and the clinical conditions which warrant admission The scale of recorded admissions growth is likely to remain high compared to planned levels for the remainder of the year Year-on-year growth will reduce once a full year impact has been seen in the stepped change which may have occurred as part of any pathway changes CCGs and Providers will agree the impact of any pathway changes on coding, counting and classifications in all future changes. This will apply to forthcoming pathways changes for ENT and Spinal Surgery at NUH The project to standardise and refocus the care coordination function across Greater Notts is progressing to plan with all vacancies recruited to across Greater Notts. A relaunch event is planned for the beginning of November. This will bring providers together to ensure all care coordinators are spending at least 50% of their time on admission avoidance workflows; the other 50% of the time on areas that are a particular issue to their locality. The outcomes from the workflows can now be monitored to allow commissioners to assess the impact of care coordination function Analysis of the most recent data has shown that ASC NELs continue to be driven by Flu and pneumonia, COPD, Cellulitis and ENT. In addition to making the care coordination function more effective projects have been put into place around flu, increasing access to pulmonary rehab for those most at risk and updating cellulitis guidelines. Monitoring will take place to show impact of these projects 11

12 Indicator Standard IAPT - Entering Treatment See table below Maxine Bunn IAPT - The number of people who receive psychological therapies Period Month Standard Rolling Quarter Latest Month Performance Performance Most Recent Three Months Patients Entering Treatment Additional Patients Required to Meet Standard Nottingham City Aug % 4.43% 1.29% 4.11% Nottingham North & East Aug % 4.43% 1.54% 4.43% 689 N/A Nottingham West Aug % 4.43% 1.48% 4.87% 489 N/A Rushcliffe Aug % 4.43% 1.58% 5.53% 567 N/A Nottingham City Nottingham North & East Nottingham West Rushcliffe Rolling 3 Standard Performa Entering Performanc Entering Performanc Entering Performanc Entering Months nce Treatment e Treatment e Treatment e Treatment Aug % 4.11% % % % 567 Jul % 4.36% % % % 585 Jun % 4.58% % % % 565 May % 4.67% % % % 565 Apr % 4.44% % % % 560 Mar % 4.39% % % % 560 Feb % 4.09% % % % 505 Jan % 4.45% % % % 510 Dec % 4.43% % % % 480 Nov % 4.60% % % % 490 Oct % 4.29% % % % 480 Sep % 3.81% % % % 445 The percentage of patients entering treatment in August has been calculated against the revised prevalence values that have been agreed with NHS England. These provide a lower and more accurate estimate of the prevalence of IAPT within the CCGs and enable a more appropriate comparison of performance against the national standard. Providers continue to review their delivery models and have reviewed skill mix across teams; for example upskilling staff to become Psychological Wellbeing Practitioners, recruiting counsellors to treat depression, utilising group counselling sessions and implementing digital solutions such as text therapy due to a shortage of Cognitive Behavioural Therapists. For the three months to August 2018 Nottingham City CCG failed to achieve the 4.43% standard with performance at 4.11%. There has been a decline in the number of referrals in to IAPT services across the CCG over the summer months, this has resulted in less patients entering the service. The CCG are investigating why this has impacted Nottingham City CCG more than the other Greater Nottingham CCGs. As the service is open to self- referral a communication plan to promote the service to GPs and the public will be implemented during Quarter 3 Funding has been agreed for 9 trainees to start the 18 month training programme which will add capacity to the system A bi-monthly steering group is in place which includes representatives from all IAPT providers. This enables discussion on plans to improve capacity across the system including increasing group therapy and digital therapy 12

13 Indicator IAPT - First Treatment within 6 weeks Standard 75% Maxine Bunn IAPT Waiting Times - First Treatment within 6 weeks Period Performance Nottingham City Aug % Nottingham North & East Aug % Nottingham West Aug % Rushcliffe Aug % Historical Nottingham Nottingham Nottingham Performance City North & East West Rushcliffe Aug % 78.77% 78.51% 72.96% Jul % 84.85% 82.14% 86.67% Jun % 78.57% 80.00% 83.33% May % 83.75% 75.32% 75.32% Apr % 77.78% 82.61% 78.46% Mar % 84.85% 81.48% 84.62% Feb % 92.31% 84.62% 83.33% Jan % 76.00% 82.61% 78.26% Dec % 83.87% 84.21% 77.78% Nov % 84.85% 83.87% 77.27% Oct % 88.24% 84.62% 91.30% Sep % 85.71% 88.89% 86.96% There are 3 IAPT providers who deliver IAPT services across Greater Nottingham. An issue was identified with one of the providers, Trent PTS, who were not achieving the 6 week treatment target; this was negatively affecting overall performance. The provider analysed their data and identified a recording issue that had affected their wait time recording. An action plan to address the issue was submitted by the provider in July 2018, it is anticipated that the standard will be achieved from September Indicator Children and Young People Eating Disorders Standard 95% by April 2020 Routine - Seen within 4 weeks Urgent - Seen within 1 week Charlotte Reading Children and Young People Routine Urgent Period Eating Disorders Complete Complete Nottingham City Q No Patients 0.00% Nottingham North & East Q % No Patients Nottingham West Q % No Patients Rushcliffe Q % No Patients Historical Performance Nottingham City Nottingham North & East Nottingham West Routine Complete Urgent Complete Routine Complete Urgent Complete Please note: Values are suppressed due to small numbers policy Routine Complete Urgent Complete Routine Complete Rushcliffe Urgent Complete Q No Patients 0.00% 66.67% No Patients 50.00% No Patients % No Patients Q % % No Patients % % No Patients 66.67% 0.00% Q % % % No Patients 0.00% 33.33% % 0.00% Q % No Patients % No Patients No Patients No Patients % % Q % 50.00% No Patients 0.00% No Patients No Patients 0.00% 0.00% Q % No Patients 0.00% No Patients 0.00% 0.00% 50.00% No Patients Q % No Patients 0.00% No Patients % No Patients No Patients No Patients Q % 0.00% No Patients 0.00% % No Patients 66.67% No Patients The target is to make further progress towards delivering the 2020/21 waiting time standards whereby 95% of patients receive their first definitive treatment within four weeks for routine cases and within one week for urgent cases. Across Nottinghamshire CCGs the service (NHT CAMHS Eating Disorder Service) has not met the standard consistently. It was identified that the service had insufficient workforce capacity to deliver the target. A business case was submitted by NHT to increase staffing to move to a same day assess and treat model. This was signed off by all CCGs at the end of July Recruitment will take place after the additional funding has been transacted into the contract (due at the end of September 2018). It is envisaged that this will take 3 months in order to recruit and the service will then be remodelled to a same day assess and treat offer. NHT will provide monthly updates around recruitment and this has been added to the Service Development and Improvement Plan which will be monitored via CRM. Commissioners are confident this will enable the service to meet the access and waiting time standard. A review will take place once the additional staff are recruited and the new same day assess and treat model has been implemented. Analysis of data submitted to SDCS has highlighted that the volume of patients entering the service is lower than in neighbouring CCGs. Therefore work is taking place to examine the data submitted to the national system and ensure that it accurately reflects all activity undertaken for Greater Nottingham patients. 13

14 Indicator Continuing Health Care - Full NHS CHC assessments taking place in acute hospital setting Standard Less than 15% Jane Godden Full NHS CHC assessments taking place in acute hospital Period Performance setting Nottingham City Q % Nottingham North & East Q % Nottingham West Q % Rushcliffe Q % Historical Performance Nottingham City Nottingham North & East Nottingham West Q % 11% 7% 11% Q % 8% 29% 15% Q % 27% 10% 21% Q % 40% 30% 47% Q % 58% 63% 56% Q % 64.00% 52.00% 65.00% In calculating the percentage of CHC assessments that take place in an acute setting, this quality premium standard measures how system partners work together to ensure that individuals are safely discharged from hospital to a care setting that can meet their rehabilitation needs in a timely manner and that CHC does not contribute to Delayed Transfers of Care (DToC) rates. The integrated discharge pathway has been implemented, however accommodating the complex needs of some patients remains a challenge. Rushcliffe Performance across the quarter has varied by CCG and improved in Quarter 2 with all four CCGs achieving the 15% target over the quarter. Performance against this standard is being monitored and reviewed at the Greater Nottingham A&E Delivery Group. CHC Nurse Assessors are alerting CCG CHC team in real time to requests for assessment in the hospital setting where there are concerns about appropriateness. Weekly monitoring of the numbers and reasons for assessments being carried out in hospital is undertaken by CHC SRO and CHC teams with issues or concerns in relation to requests being escalated to locality and urgent care colleagues. Routine sharing of weekly monitoring data with colleagues in locality, analyst and urgent care teams for information, usage and inclusion at the relevant meetings. Weekly reporting to DCO team of performance and fortnightly calls to provide assurance. A checklist for use by CHC Nurse Assessors prior to agreeing to undertake an assessment was in place during May and has contributed towards a reduction in assessments being undertaken. Regular audit of all assessments carried out in a hospital setting which will show if there has been progress in terms of patients being unsuitable for any of the pathways in place via Discharge to Assess and whether the quality of requests for assessment within a hospital setting is improving. 14

15 Indicator Transforming Care Partnership - Reliance on Inpatient Care for People with LD or Autism Standard See individual months Theodore Phillips LD IP Rate per Million GP Transforming Care Partnership - Reliance on Period Registered Population Inpatient Care for People with LD or Autism Plan Performance Variance CCG Commissioned Sep NHSE Commissioned Sep Total Sep This standard measures those services commissioned by CCGs and the equivalent services commissioned by NHS England Specialised Commissioning Team. Members are asked to note that the CCG are meeting the trajectories set, however the NHS England secure beds trajectory is not being met, this has resulted in the total trajectory being missed for September The escalation of this standard to the Regional office of NHS England remains due to the under-performance of the NHS England Specialised component. Following local reviews by the TCP (in conjunction with the NHS England DCO team) of all patients to ensure that robust discharge plans were in place, the TCP has requested that there is a regional / national review of the specialised patients to get external challenge and support to ensure that there are no additional people who can be expedited for discharge. This request has now been agreed and two whole day reviews were scheduled for 13th and 20th July 2018 There is a continued focus on ensuring that discharge plans are robust and timely and close monitoring of these at individual patient level. Concerns in relation to discharge plans are escalated to the SRO and TCP Programme Manager to address at service / provider level There were four admissions in June A review of these was undertaken by the SRO in order to understand the reasons for admission. The review included a focus on the community services that had been commissioned to prevent unnecessary admissions and also explored whether reopening of the Orion Unit had been a contributory factor. The TCP held a learn and share event on 25th July The event focussed on the journey and progress that has been made to support successful discharge, retention in the community and to prevent a hospital admission. Case studies were used to analyse what is working, what is not working, what are the gaps and creative ideas for improvement. Discussions were based around four key topics areas, the legal framework for discharge, advocacy, workforce strategy and innovative practice happening elsewhere in the region (as shared by NHS England colleagues) The TCP have been successful in obtaining the additional funding requested from NHS England in our doing things differently bid as well as a small amount of investment which has been allocated to a number of TCPs. This means that there is an extra 685,000 of funding available and will be used to support community infrastructure. Continued on Page 16 15

16 Indicator Transforming Care Partnership - Reliance on Inpatient Care for People with LD or Autism Actions being taken to improve performance (continued from page 17): The NHS England Associate Director of Nursing & Quality, Nottinghamshire Health and Care Sustainability and Transformation Partnership continues to work with the Nottinghamshire TCP to ensure links with the Nottinghamshire Integrated Care System and NHS England DCO/Regional TCP teams. A Nottinghamshire Transforming Care Virtual Support Team is being established. This is being set up by the Local Government Association in conjunction with the Nottinghamshire Integrated Care System. This team aims to identify the priority areas for Nottinghamshire and will work together to co-produce a bespoke support package and plan which addresses local needs and strategic development as well as coordinating the deployment of resources to support its delivery. Nottinghamshire TCP remains on level 3 support, due to the TCP wide trajectory for inpatients not being met, predominantly within secure beds commissioned by NHS England Timeline for performance recovery: Recovery trajectories for CCG / Specialised Commissioning and the TCP overall for 2018/19 have been modelled, reviewed and approved regionally and nationally. These can be seen below for the entirety of the 2018 / 2019 year Monthly In Patient Trajectories 2018/19 Q1 2018/19 Q2 2018/19 Q3 2018/19 Q4 2018/19 Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Non Secure Trajectory Secure Trajectory TCP Totals

17 Indicator Standard Inappropriate Out of Area Placement Bed Days See individual quarters Lucy Anderson Out of Area Occupied Bed Days Performance Period Performance Trajectory Nottinghamshire Healthcare Foundation Trust Q Trajectory NHT Q Q Q Q Inappropriate Out of Area Occupied Bed Days - Nottinghamshire Healthcare Foundation Trust OOA Occupied Bed Days Trajectory Q Q Q Q Q Q Q Q Q Q Q Q This standard measures mental health patients inappropriately occupying beds out of the area. There is a national performance target to reduce all inappropriate adult inpatient placements by 2020/21. The Quarter 2 trajectory for Nottinghamshire was to not exceed 4,600 occupied bed days. This was not achieved with performance at 4,994 occupied bed days (+8.6% above trajectory). There are a number of actions that Nottinghamshire Healthcare NHS Foundation Trust (NHT) are required to take, for example reviewing the length of stay and discharge plans for all inpatients. System partners are also required to undertake various actions including ensuring a social care package is implemented to enable timely discharge from inpatient services. For the actions required by NHT, the following assurance process is in place: Submission of a monthly out of area placements reduction plan which details current performance and progress against agreed actions. The reduction plan is reviewed at the monthly Contract Review Meeting and includes details of mitigating actions if not on track. Performance is reported to the monthly Contract Executive Board. NHT has established a Programme Management Office (PMO) to coordinate work streams to support the reduction of out of area placements; the CCG is a member of the PMO. Actions that are required to be taken by NHT are monitored via the monthly Contract Review Meeting and Contract Executive Board. Ongoing actions to improve the position are detailed below: An Out of Area Case Manager came into post in Quarter 1 and reviews all out of area patients to ensure discharge plans are in place and on track. This has started to make an impact on reducing lengths of stay An STP-wide Steering Group has been established which met on 06/09/2018 to review all reasons for delayed discharge from inpatient wards and identifying actions for system partners to complete 17

18 Section 2 - Other Indicators Indicator A&E - 12 Hour Trolley Waits 0 NUH Sep-18 0 City Aug % NNE Aug % Cancer - 2 Week Wait NW Aug % 93.0% Rush Aug % NUH Aug % Circle Aug % City Aug % NNE Aug % Cancer - 2 Week Wait - Breast Symptoms 93.0% NW Aug % Rush Aug % NUH Aug % City Aug % NNE Aug % Cancer - 31 Day Decision to Treat to First Treatment NW Aug % 96.0% Rush Aug % NUH Aug % Circle Aug % City Sep % NNE Sep % 18 Weeks RTT - Incomplete % NW Sep % 92.0% Rush Sep % NUH Sep % Circle Sep % Cancelled Operations - Rebooked within 28 Days NUH Sep Circle Sep-18 0 Cancelled Operations - Urgent Operation Cancelled for a NUH Sep Second Time Circle Sep-18 0 Delayed Transfers of Care - As a % of occupied beds 3.5% Gr Notts Sep % City Aug % IAPT Recovery Rate IAPT Waiting Times - First Treatment within 18 Weeks Dementia - Diagnosis Rate EIP - Treated within two weeks % - Rolling Three Months CHC - % of NHS CHC eligibility decisions made by CCG within 28 days TCP - Reliance on Inpatient Care for People with LD or Autism LOS 5 years and over - CCG Commissioned TCP - Reliance on Inpatient Care for People with LD or Autism LOS 5 years and over - NHSE Commissioned TCP - Reliance on Inpatient Care for People with LD or Autism LOS 5 years and over - Total Standard Organisation Latest Data Period NNE Aug % 50.0% NW Aug % Rush Aug % City Aug % NNE Aug % 95.0% NW Aug % Rush Aug % City Aug % NNE Aug % 67.0% NW Aug % Rush Aug % City Sep % NNE Sep % 50.0% NW Sep % Rush Sep % City Q % NNE Q % 80.0% NW Q % Rush Q % 7 Gr Notts Sep Gr Notts Sep Gr Notts Sep Previous 12 Months/Quarters Performance Performance < Oldest Latest > 18