WAITING TIMES REPORT

Transcription

1 Meeting of Lanarkshire Lanarkshire NHS Board NHS Board: Kirklands 25 March 2015 Fallside Road Bothwell G71 8BB Telephone: PURPOSE This paper is coming to the Board: WAITING TIMES REPORT For approval For endorsement To note The paper: provides an update for Board Members on performance in the delivery of key Scheduled and Unscheduled Care Waiting Time targets; highlights areas of pressure and challenge; and describes the actions being taken and planned, aimed at delivering sustained improvement. 2. ROUTE TO THE BOARD This paper has been: Prepared Reviewed Endorsed By the following Committee: or Is a standing item From the following Committee: The acute activity within this report is extensively discussed at the Acute Operating Management Committee/Divisional Management Team and also within the CHP/Divisional Management Teams in relation to primary care and mental health targets. 3. SUMMARY OF KEY ISSUES The Board continues to perform well in relation to planned care activity. There continues to be a significant focus on Unscheduled Care which remains challenging. Of note however, is the improved performance during the reporting period at Monklands Hospital and the overall reduction in 8 and 12 hour waits. 1

2 4. STRATEGIC CONTEXT This paper links to the following: Corporate objectives LDP Government policy Government directive Statutory requirement AHF/local policy Urgent operational issue Other 5. CONTRIBUTION TO QUALITY This paper aligns to the following elements of safety and quality improvement: Three Quality Ambitions: Safe Effective Person Centred Six Quality Outcomes: Everyone has the best start in life and is able to live longer healthier lives; (Effective) People are able to live well at home or in the community; (Person Centred) Everyone has a positive experience of healthcare; (Person Centred) Staff feel supported and engaged; (Effective) Healthcare is safe for every person, every time; (Safe) Best use is made of available resources. (Effective) 6. MEASURES FOR IMPROVEMENT Waiting time Access Guarantees set by the Scottish Government in relation to Scheduled/Unscheduled Care. 7. FINANCIAL IMPLICATIONS Financial implications are included in the Director of Finance report. As previously reported, these issues relate to the commissioning of additional waiting list activity which is currently exceeding planned expenditure at this time. 8. RISK ASSESSMENT/MANAGEMENT IMPLICATIONS Unscheduled Care features on the Corporate and Acute Division Risk Registers as a Very High Risk Work continues with regards to the Treatment Time Guarantee and the risk going forward for sustainability of this target 2

3 9. FIT WITH BEST VALUE CRITERIA This paper aligns to the following best value criteria: Vision and leadership Effective partnerships Governance and accountability Use of resources Performance Equality management Sustainability 10. EQUALITY AND DIVERSITY IMPACT ASSESSMENT An E&D Impact Assessment has not been completed because this in activity report, reflecting the Board s policy of equality of access to services. 11. CONSULTATION AND ENGAGEMENT The issues highlighted in the attached paper are discussed extensively at Divisional and Operating Management Committees. 12. ACTIONS FOR THE BOARD The Board are asked to: Approval Endorsement Identify further actions Note Accept the risk identified Ask for a further report X The Board is asked to Note the Waiting Times report, and to confirm whether it provides assurance about the delivery of Waiting Times targets to date, and about the actions being taken and planned to address areas where performance is off-target. 13. FURTHER INFORMATION For further information about any aspect of this paper, please contact Heather Knox Director of Acute Services Telephone: Heather Knox Director of Acute Services 3

4 Meeting of Lanarkshire NHS Board: 25 th March 2015 NHS Lanarkshire Headquarters, Kirklands Fallside Road, Bothwell G71 8BB WAITING TIMES REPORT 1. PURPOSE The purpose of this paper is to update the NHS Lanarkshire Board on performance against: Planned Care waiting time access guarantees and targets set by the Scottish Government as at the end of February AHP and mental health waiting time access guarantees and targets set by the Scottish Government as at the end of February The 4 hour Emergency Department standard until week ended 15 th March In addition the report will identify issues that are effecting achievement of standards and will outline the measures that have been taken to secure improvement. 2. WAITING TIME GUARANTEES - ACUTE SERVICES 2.1) Treatment Time Guarantee (TTG) The 12 Week Treatment Time Guarantee (84 days) applies to eligible patients who are receiving planned treatment on an inpatient or day-case basis and states that patients will not wait longer than 12 weeks from the date that the treatment is agreed to the start of that treatment. Delivery of the Treatment Time Guarantee has continued to be challenging and during the month of February there were a total of 100 patients who breached their TTG date. This is a reduction from the January position of 122. The breakdown is detailed below: Table 1 Number of Patients who Breached TTG DT Feb 15 Grand Total Treatment location (if known) Sub specialty Hairmyres Hospital C12 Vascular Surgery 1 1 C7B NHSL Cataract List 7 7 C8 Orthopaedics 5 5 CB Urology 7 7 Foot & Ankle Hairmyres Hospital Total Monklands District General Hospital C8 Orthopaedics 6 6 CB Urology 8 8 C5 ENT 3 3 4

5 Monklands District General Hospital Total Wishaw General Hospital C8 Orthopaedics C1 General Surgery 2 2 Wishaw General Hospital Total Glasgow Nuffield Hospital C8 Orthopaedics Glasgow Nuffield Hospital Total Ross Hall Hospital C7B NHSL Cataract List 1 1 C7Bz4 Cataract External 3 3 Ross Hall Hospital Total 4 4 Grand Total The TTG performance for the month of February has stabilised to 98.2% from 97.6% in January 2015, again a slight improvement. During the month of February that Scottish Government allocated NHS Lanarkshire a non recurring sum to treat patients who were waiting over 84 days for surgery. However, as the funding is non recurring and had to be committed by 31 st March 2015, there were very limited options to create internal capacity and so, following a tender exercise, patients have been sent to the Independent Sector for surgery. Patients were contacted directly by NHS Lanarkshire staff and given the option of having treatment in the Independent Sector and this has been well received by patients. During February and March the following patients will be treated externally: 36 Foot and Ankle patients 80 Orthopaedic patients 40 Cataract patients In February there were 27 Foot and Ankle patients who waited over 84 days in month. Regular meetings with the Foot and Ankle Team have been established and the services of a locum have been secured for the month of March to backfill the Consultant from trauma which will allow her to operate on complex cases over a 3 week period. There were 41 orthopaedic patients who breached their TTG. The numbers have been exacerbated by gaps in the Consultant workforce due to the difficulty in securing locums and the pressures in delivering services over 3 sites. The pressure in Urology (8 TTG patients who breached) is due entirely to gaps in the Consultant staffing. It is, therefore, likely that there will be further Urology patients who will breach their TTG dates in the coming months. 2.2) Improvements to TTG Performance Additional capacity has been sourced in the Independent Sector and through the Capacity Plans for 2015/16 further options will be explored to maximise capacity and efficiency. The overall performance of this standard in NHS Lanarkshire remains robust when compared to other Scottish mainland boards. (See Figure 1) 5

6 FIGURE 1: TTG Published by ISD on 25 th November for quarter ending 30 September 2.1) 18 Weeks RTT The HEAT standard is that 90% of planned/elective patients commence treatment within 18 weeks of referral. The January position is detailed below (February position is not yet available): Combined performance was Admitted performance was Non-admitted performance was 92.6%, same as December 64.8%, down from 69.5% in December 96.4%, up from 96.1% in December The specialties below 70% admitted performance were: Vascular 54.5% (51.9% in December) Oral & Max Fax 47.6% (42.3%) Anaesthetics 13.3% (7.1%) ENT 65.7% (67.0%) Ophthalmology 38.4% (53.1%) Orthopaedics 27.9% (39.7%) Urology 63.8% (62.9%) We are required to report on the number of patients waiting over 26 weeks by specialty for both admitted and non-admitted pathways. There was a sharp rise in the number of patients within the Orthopaedic admitted pathways that were waiting over 26 weeks in February. This will continue as we treat patients with long waits. Over the course of February the number of inpatients and day cases waiting over day 85 is detailed in Table 3 below: 6

7 Table 3 SPECIALTY DAY DAY DAY Orthopaedics Urology Opthalmology 1 Total This reflects the continuing pressures in Orthopaedics and Urology which were previously highlighted to the Board and have increased in the month of February. The issues relating to loss of additional capacity in Ophthalmology relate to staffing issues. Priority is being given to secure theatre dates for the patients who are waiting the longest in the absence of any clinical prioritisation. The overall performance of the Board remains robust against the standard as illustrated in Figure 2 below: FIGURE 2: NHS Lanarkshire 18 Weeks Referral to Treatment Combined Performance 2.2) Stage of Treatment Guarantees As indicated above in Section 2.1 there were 101 TTG patients who breached in February. Table 4 shows the increasing number of outpatients waiting over 84 days for first routine outpatient consultation by specialty. There are currently 1818 patients waiting over 84 days, an increase from 1580 the previous month. NHSL is seeing 92.6% of patients within 84 days. 7

8 Table 4 Parent Specialty Description >126 Grand Total A1 General Medicine A2 Cardiology A6 Infectious Diseases A7 Dermatology A8 Endocrinology A9 Gastroenterology AB Geriatric Medicine AD Medical Oncology AF Medical Paediatrics AG Nephrology AH Neurology AQ Respiratory Med AR Rheumatology C1 General Surgery C12 Vascular Surgery C13 Oral and Maxillofacial Surgery C3 Anaesthetics C41 Cardiac Surgery C5 ENT Surgery C7 Ophthalmology C7B NHSL Cataract List C8 Orthopaedics C9 Plastic Surgery CA Surgical Paediatrics CB Urology D1 Public Dental Service D5 Orthodontics F2 Gynaecology J4 Haematology Grand Total In relation to Respiratory Medicine this specialty remains under strain, with the outpatient waits ranging from 18 weeks to 30 weeks. Options to improve this position are currently under discussion and efforts have been made to secure a locum to concentrate on planned care. In Rheumatology there continues to be planned and unplanned leave in the service and despite additional clinics being arranged and the appointment of a (retired) part time locum Consultant, the number of patients waiting over 12 weeks have increased. The multidisciplinary clinical review of all patients waiting over 18 weeks is continuing and adverts have been placed for additional medical staff. Again regular meetings with the clinical team have been established. 8

9 In several of the medicine specialties planned care capacity is being reduced due to the impact of Physician receiving arrangements, maternity leave and vacancies. It is also worth noting that by the end of 2015 there will be 3 consultant vacancies in Dermatology and this is a nationally hard to recruit to specialty, so options are being explored to consider different models of care. Guidance has been received from the Access Support Unit which states that during 2015/16 Boards need to improve the 12 weeks outpatient performance to achieve a minimum 95% standard with a stretch aim to 100%. It is also essential that waits of over 16 weeks are eradicated. Each Board is being asked to submit a recovery/trajectory plan to deliver this. 2.3) Capacity Plan The Capacity Plan showed an overspend of 165,000 at end of February which is a significant reduction from the 265,000 overspend reported at the end of January. The main areas of spend relate to Orthopaedics (increase in conversion rate of outpatients to surgery at GJNH), General Surgery (additional Colorectal activity due to consultant absence) and Urology. 2.4) Audit Scotland Reporting /Internal Audit The monthly audit of 30 records continues and the internal audit team continue to work on their report. 2.5) Cancer Services NHSL has consistently delivered on both standards. Overall performance remains very positive. National Standard: 95% of all patients referred urgently with a suspicion of cancer will begin treatment within 62 days of receipt of referral. National Standard: 95% of all patients diagnosed with cancer will begin treatment within 31 days of decision to treat. The January (unvalidated by ISD) position is: 62 DAYS = 98.6% 31 DAYS = 98.1% The 62 day cancer standard including A&E patients, screened positive patients and all patients referred by GP/GDP urgently with a suspicion of cancer. The 31 day standard includes all patients diagnosed with cancer (whatever their route of referral) from decision to treat to 1 st treatment. The current standard is that 95% of all eligible patients should wait no longer than 62 or 31 days. 3. ACTIVITY AND THEATRE ANALYSES The Acute total activity for the month of February can be summarised in Table 5 below: 9

10 Table 5 April to Feb Elective Inpatient Emergency Inpatient Total Inpatient Daycas e New Outpatients Medicine -7% +3% +2% +4% +6% 12.9% Surgical -3% -2% -2% +2% 0% 10.7% Women s +3% +13% +8% -13% +3% 10.9% Clinical Haematology +6% +2% -6% +2% +33% 10.2% Care of the Elderly -46% +6% +8% +67% +2% 8.8% TOTAL -3% +2% +1% +2% +3% 11.4% New DNA Rates Discussion is on-going with colleagues in IM&T regarding the production of routine OPERA theatre activity reports. 4. NATIONAL AND LOCAL AHP WAITING TIME STANDARDS For the majority of Allied Health Professions (AHPs) there are no national time to treatment guarantees (NTTG). However, NHS Lanarkshire has a local time to treatment guarantee (LTTG) of 12 weeks for those services not included in national targets. A similar approach to the rules pertaining to the national targets is applied to the local targets; in that 90% of patients will receive their first appointment within 12 weeks of referral. In Audiology, CAMHS and Psychological Services, waiting times do form part of a NTTG target. As such, these targets carry significant importance in relation to national reporting arrangements. Revised national targets of 18 Weeks TTG for CAMHS and Psychological Services were introduced at the end of December 2014, prior to this both TTG targets were 26 weeks. 4.1) Allied Health Professions and Paediatric Services All patients who attend NHS Lanarkshire AHP services are triaged by each service. Triage is the process of determining the clinical priority of patient treatments based on the severity of their condition. Patients with conditions that are deemed urgent or have red flags are generally seen within 24 or 48 hours. The services under the remit of the CHPs who are fully meeting their current waiting times targets are: Audiology Dietetics MSK Podiatry Speech and Language Therapy Paediatric Occupational Therapy Medical Paediatrics CAMHS Psychological Therapies Addiction Services The services that are experiencing some challenges with their waiting times are: 10

11 4.2) Musculoskeletal (MSK) Physiotherapy In MSK physiotherapy 90% of patients attending the service were treated within the 84 days (12 week) target. Although the service is meeting 90% of the patients being treated within the LTTT there are nonetheless 483 patients in total who are waiting beyond the 84 days target time for treatment. These 483 patients can be broken down by both CHPs and their localities. In the South CHP there are 267 patients in total waiting. Cam glen locality has the longest reported wait which is 25 weeks. The situation within Cam glen has arisen due to 2 members of staff taking up posts elsewhere. In addition, a member of the staff commenced maternity leave. Although one of the vacancies has been filled, strenuous efforts are being made to recruit to the remaining vacancy. A number of actions have been taken by the service to try and alleviate the protracted waiting times. These actions have included physiotherapy staff members being redeployed to Gam glen to assist in sustaining the service. Alternative treatment locations have also been offered with very limited success as patients have indicated they would prefer to be treated locally and are prepared to wait. The numbers of staff that can be redeployed into the Cam glen locality is also a limiting factor as the number of treatment bays available can only accommodate 3 staff members at any one time. The waiting times in Clydesdale highlighted in previous reports have dramatically improved and is almost resolved. In the North CHP a total of 155 patients are waiting beyond the 84 days target. The longest waiting time is within the Bellshill Locality and is 16 weeks. Patients are being offered appointments within the surrounding localities to assist the situation, but again patients are reluctant to travel. It is anticipated that the waiting time issues in Bellshill will be resolved in the near future as a new MSK rotation is being instigated between Wilshaw General Hospital and the Bellshill locality. 4.3) Occupational Therapy (OT) The waiting times for Rheumatology OT services are showing an improvement and the waiting times at all sites are within 6 weeks. This level of performance has been achieved due to additional short-term funding being made available by the Deputy Director for Finance in Primary Care. Unfortunately, this funding came to an end in mid-january However, the Director of Access, Acute Division, has intimated that short-term funding for 4 months has been obtained to support the service. However, a more sustainable funding stream is still being sought to support the service in the long term. Although the Rheumatology service has been under significant waiting time pressures it should be noted that from Oct 2014, the Rheumatology occupational therapy service have received a total of 9 positive responses about the patient centred approach of this service. 11

12 5. MENTAL HEALTH SERVICES 5.1) Adult Mental Health Outpatient Clinics In the adult mental health service, the longest waiting time is currently 130 days (18 weeks). In total, there are 4 patients who are waiting beyond the LTTT which is a reduction of 6 patients since the last report. However, the January 2015, waiting time data indicates that 99% of all patients who are attending the service are seen within the LTTT. The 18 week wait is in the Hamilton locality and is being attributed to staffing issues within the locality the Unit Management Team are in the process of addressing the situation. 5.2) Old Age Psychiatry Outpatient Clinics The longest waiting time in old age psychiatry indicates 1 patient who is waiting 107 days (15 weeks), in total there are 8 patients who are waiting beyond the 12 weeks LTTT. The current waiting times indicate that 97% of all patients who are attending the service are seen within the LTTT. The management team is addressing these small numbers of patients who are breaching the waiting time target. 5.3) Psychological Therapies The latest ISD published information at the end of February 2015, sees the Psychological Therapy service of NHS Lanarkshire ranked third across NHS Scotland. There are only three Boards meeting the new 90% target introduced in December These Boards are NHS Tayside (98.5%), NHS Greater Glasgow and Clyde (95.1%) and NHS Lanarkshire (93.3%) Ayrshire (89.87%) 5.4) Child and Adolescent Mental Health Services (CAMHS) The CAMHS service is meeting the new waiting time target of 18 weeks, which was introduced at the end of December The ISD performance data published at the end of February 2015, reports that NHS Lanarkshire CHAMS Services achieved 95.1% of completed waits against a 90 % target of 18 weeks. This service is also in the top three across NHS Scotland. 5.5) Addiction Service The waiting times for addiction services, which are available quarterly, continue to remain at 21 days (3 weeks). NHS Lanarkshire is recognised as one of the best performing Boards in Scotland for this clinical speciality. 6. UNSCHEDULED CARE NATIONAL STANDARD: 95% of patients attending Accident & Emergency to be admitted, discharged or transferred within 4 hours of arrival. 12

13 The delivery of a sustained improvement in the performance against the 4 hour Emergency Department standard remains a key priority area for NHSL. There has been an ongoing substantial clinical and managerial focus on this issue which has at its heart patient safety and quality. The Board has received monthly updates over the course of the past two years on performance, including updates on the action plans held at site level. Support from a number of colleagues at Scottish Government has been in place since November There are monthly performance reviews with the Scottish Government team to check on planned actions, to provide constructive challenge to performance, guidance on metrics to be used and further potential solutions. Hospital Site Directors presented updates on performance and improvement plans in detail at the Acute OMC on Tuesday 17 th March During the reporting period, there has been significant focus on the development of Safety & Flow Huddles at each of the Acute sites. These are now in place, using slightly different formats and have been reviewed by the Director of Acute Services. To support this, site management teams have been released from formal meetings for the first two hours of the day. This has allowed the teams locally to focus on any emerging the operational challenges over the next 24 hour period. Performance Performance for January 2015 was 86.79% (HM 78.61%, MK 96.00%, WG 84.42%) for NHS Lanarkshire. Performance in February 2015 was 85.38% (HM 81.69%, MK 93.27%, WG 80.30%). The table below gives the weekly performance by site for the past five weeks and compares to same time period last year. HM MK WG NHSL Week Ended 15 th February % 93.7% 81.64% 88.2% Week Ended 16 th February % 85.69% 89.91% 85.7% Week Ended 22 nd February % 91.39% 82.73% 85.60% Week Ended 23 rd February % 87.73% 82.16% 82.6% Week Ended 1 st March % 95.81% 79.88% 85.30% Week Ended 2 nd March % 89.73% 92.87% 89.0% Week Ended 8 th March % 97% 89.04% 93% Week Ended 9 th March % 90.93% 91.47% 91.8% Week Ended 15 th March % 94.74% 85.54% 90.7% Week Ended 16 th March % 90.92% 93.87% 92.8% As noted above, performance during this period has ranged from 83% to 91%, this compares to the national averages of between 77% and 94% during the reporting period. Significant discussion took place during the Acute Operating Management Committee. A pan-lanarkshire Unscheduled Improvement Board has been established and the inaugural meeting was held on 23 rd January This group was chaired by the Director of Acute Services. There was agreement to develop a Performance Matrix for use on the Site/Sector Improvement Groups and the overarching Programme Board. In addition, there will be closer links between the Hospital Site Directors and Directors of the Health and Social Care Partnerships to reduce the number of delays. 13

14 8 and 12 Hour Waits Scotland NHSL 8 hours 12 Hours 8 Hours 12 Hours Week Ended 15/02/ Week Ended 22/02/ Week Ended 01/03/ Week Ended 08/03/ Week Ended 15/03/15 TBC TBC 29 0 As noted above, the table above sets out the level of 8 and 12 hour waits within Lanarkshire is compared to the rest of Scotland. As previously reported, the issues in Unscheduled Care continue to fall into three distinct blocks; a) Ensuring the availability of Senior Decision Makers within the Emergency Departments and Receiving Unit. b) Delivering on the internal processes to maximise flow on a daily basis. c) Reducing the level of patients delayed on site who are past their clinical readiness date. The following summarises the key improvement activities at site level: Hairmyres A comprehensive improvement plan is now in place for this site with an agreed trajectory to deliver improved performance. A revised escalation decision tree has now been drafted and is currently being discussed for agreement with the clinical teams. In addition, the new Duty Manager of the Day initiative commenced on Monday 2 March and has already made a positive difference. The revised 8.15am Capacity Planning Meeting is also having a positive impact bringing robust data, including predictions with clear prioritisation of actions which are taken forward by the Duty Manager of the day. The Scottish Ambulance Service are now on site on a daily basis which will assist in patient discharge and transfer. However, delayed discharges remain a major concern with 31 Home Care delays (18>5 days) and 58 CCA s within the Sector. A trajectory for delivery of the new 72 hour (Home Care) and the 14 days (CCA) target from 1 April 2015 has been requested from SLC. Monklands Although the site continues to performance above 90%, there continue to be gaps in the junior rota in Emergency Department at weekends and this is going to be an issue for coming months. Work is on-going to reconfigure the current Emergency Receiving Unit to an Assessment Area encompassing Ambulatory Emergency Care, Surgical Assessment Area, Medical Assessment Area and Frailty Assessment Area. 14

15 Wishaw There are gaps in the ED medical staff rota and some issues with locum cover. IN response, an external review of ED will commence Monday 10 th of March which will look at a number of issues in the department e.g. leadership, processes and the allocation in relation to workforce demand. The medical flow is the main challenge; performance in the medical flow was 56.18% in January and 41.64% in February. Pre-noon discharge rates for this flow group are at 19.4% with discharges peaking at 4pm this is as a result of job plans ward rounds do not happen until late in afternoons and juniors not making decisions during the day until consultant arrive. A morning safety huddle has been established to ensure patient safety and test barometer of hospital. In addition, there has been a change to the bed management model being developed to cover longer into the evening. Delayed Discharges The table below shows the monthly information pan Lanarkshire for patients in delay based on the Delayed Discharge census. A breach is defined as any non-complex patient who has waited over 28 days from their clinical readiness date. Patients who are involved in the Adults with Incapacity (AWI) are excluded from this target, as are any patient whose needs are defined as complex. Typically, activity associated with patient awaiting homecare services is omitted from this report unless they are still an inpatient on the 15 th of each month when the snapshot for the census is taken. This shows the trend since April 2014 across Lanarkshire. North Number Patient Breaches North Bed Days South Number Patient Breaches South Bed Days Total Number Total Bed Days APRIL MAY JUNE JULY AUGUST SEPT OCT NOV DEC JAN FEB Delayed Discharge Groups are now in place in both North and South Lanarkshire, and will report progress as part of the Unscheduled Care Improvement Board. Work is underway focussing on all bed days associated with delayed discharge to provide a more complete figure regarding the utilisation of beds associated with this patient group. 15

16 7. RECOMMENDATIONS The NHS Lanarkshire Board is asked to note: The significant pressures in delivering the Treatment Time Guarantee. The emerging pressures on the Referral to Treatment Target. The very positive performance in Cancer Waiting Time. The Local delivery Planning Guidance 2015/16 on waiting time for first outpatient consultation standard. The on-going challenges and focussed actions being taken in relation to Unscheduled Care and the prioritised actions in the three distinct areas being implemented to address the performance gap, with clear improvement to be made towards the 95% target and the detailed work that is taking place in each of the three acute hospitals. The on-going work in relation to delayed discharges. 8. FURTHER INFORMATION For further information about any aspect of this paper, please contact Heather Knox, Telephone: HEATHER KNOX DIRECTOR OF ACUTE SERVICES 17 th MARCH