ACUTE WAITING TIMES REPORT

Transcription

1 NHS Lanarkshire Headquarters, Kirklands Fallside Road, Bothwell G71 8BB ACUTE WAITING TIMES REPORT 1. PURPOSE The purpose of the paper is to update the NHS Lanarkshire Board on: Waiting Time Access guarantees and targets set by the Scottish Government as at the end of October 2014 Progress against national waiting time guarantees as they impact on access to Mental Health Services and local Community AHP targets Update the Board on performance against the 4 hour Emergency Department standard. In addition, to identify issues that are affecting achievement of this very important standard and to outline the measures that haven t been taken in each of the acute sites the hospital across the Acute Division. 2. ACUTE SERVICES l) Treatment Time Guarantee (TTG) Delivery of the Treatment Time Guarantee has continued to be challenging and during the month of October there were a total of 18 TTG breaches. 17 of the breaches were at Hairmyres Hospital and 1 was at Wishaw General Hospital. During the month of October, Hairmyres Hospital has been extremely challenged from an unscheduled care perspective, particularly so during the last week of the month. In discussion with the Chief Executive and senior members of the Corporate Management Team it was agreed to cancel all planned care activity on the Hairmyres site from Monday 27 th October to Wednesday 29 th October. During this 3 day period only clinically urgent and cancer cases proceeded. As a result of this a total of 66 procedures were cancelled and this included inpatients, daycases (general anaesthetic and local anaesthetic) and scopes. 1

2 The impact on TTG is therefore as follows : Foot and Ankle 8 TTG breaches due to capacity issues all at Hairmyres Foot and Ankle 2 TTG breaches due to cancellation all at Hairmyres Opthalmology 5 TTG breaches (all GA cases) due to cancellation all at Hairmyres Orthopaedics 1 TTG breaches due to cancellation all at Hairmyres Orthopaedics 1 TTG breach due to capacity at Wishaw Urology 1 TTG breach due to cancellation at Hairmyres Summary total of 18 TTG Breaches as at 31 th October However in relation to overall performance for TTG, NHSL performance remains positive at 99%. As previously reported to the Board, the on-going delivery of TTG in orthopaedics is a particular challenge in the next few months due to pressures in medical staffing and the constraints in commissioning additional internal capacity such as weekend and evening lists. We have continued to experience particular pressures in relation to the Foot and Ankle service, which is provided by a single consultant and a detailed piece of work is progressing on options and solutions to these pressures. This now includes a clinical review of the waiting list. The SGHD Access Team has been kept fully appraised of the issues during this period and of the impact on TTG. The detailed analysis of all the key components of Orthopaedic Demand, Capacity, Activity and Queue (DCAQ) has been completed for individual consultants. In particular the individual conversions rates from outpatient appointment to surgery are being analysed in conjunction with benchmarking data. This will be shared with the Clinical Leads at the next meeting on 18 th November and meetings have also been set up with each of the site clinical and managerial teams. During the first 2 weeks in November there have been 15 Foot and Ankle TTG breaches and a further verbal update with be provided at the Board meeting. The outcome of the clinical review will be used to inform the agenda of a meeting with the multi disciplinary team who deliver the Foot and Ankle Service together with the senior management team in the near future 2.2) 18 Weeks RTT The unvalidated 18 week RTT position for October is 93% which is slightly down from the September position of 93.4%. However this position compares favourably with the reported performance across NHS Scotland. There are a range of service pressures which are impacting upon the admitted pathway for RTT performance (i.e. performance less than 70%) and these include Orthopaedics Pain Clinic, ENT, and Opthalmology. In addition to this the combined waits for some specialties 2

3 (for outpatients and inpatients/day cases) is in excess of 18 weeks and this reflects on the RTT performance. Over the course of October the number of inpatients and day cases waiting in weeks 10 to 12 has increased to 554. This is an increase of 113 from the September position and reflects the continuing pressures in orthopaedics and emerging pressures in ophthalmology and urology with increasing numbers of patients being booked at week 10 and over. This is demonstrable within the RTT performance. The profile of waits and the associated costs in the Capacity Plan is monitored and managed weekly across NHS Lanarkshire by the Director of Access through the weekly Medical and Surgical Waiting Time meetings. 2.3) Stage of Treatment Guarantees As indicated above there were 18 TTG breaches in October and 12 of these were in Orthopaedics and this is set in the context of 230 patients that are waiting over 9 weeks. This figure has remained relatively static over the year as has the total number of in patients and day cases over 9 weeks. However clearly this is an area of concern. Urology and Opthalmology both have increasing patient numbers waiting over 9 weeks. There are currently 2 Consultant vacancies in Urology which are impacting on elements of planned care activity and in Opthalmology there is an increasing trend of patients required general anaesthetic procedures rather than local anaesthetic procedures which are impacting. In regard to out patients it was reported there are 783 waiting over 12 weeks at the end of October, this is slight improvement of 28 from August (811 in September). However it must be noted that there are 174 patients waiting over 18 weeks and he main areas are Respiratory (47), Rheumatology (49), Pain Clinic (32) and Orthopaedic Foot and Ankle (40). In relation to Respiratory medicine this specialty remains under strain, with the outpatient waits ranging from 18 weeks to 26 weeks. There are particular pressures at Hairmyres at the longest waits are at this site. The Access Team have established fortnightly meetings with the clinical and managerial team and it s been agreed to progress a clinical review of the patients waiting to be seen. To date NHS Lanarkshire has not been successful in recruiting to the locum posts. Discussion has also taken place with the clinicians on all 3 sites in relation to establishing different clinical pathways for common conditions for example cough. With regard to Rheumatology there is planned and unplanned leave in the service and despite additional clinics being arranged and the appointment of a (retired) part time locum consultant, the numbers of patients waiting over 12 weeks has increased. The multidisciplinary clinical review of all patients waiting over 8 weeks is continuing and there is the possibility of securing an additional locum early in the new year. Again regular meetings with the clinical team have been established. 3

4 The electronic reminder system (Reminder Plus) is now in 57 different specialties / subspecialties and specific management action has been targeted at certain specialties to optimise productivity. However the Did Not Attend Rate (DNA) for new patients in the month of October remains at 11.3% against standard of 9.5%. DNA rates for specialties (by site and by consultant) are discussed at the weekly Waiting Times meetings and the Planned Care Improvement Board has oversight of this. With regard to the diagnostic waits, there are a small number of patients waiting over 6 weeks and this is due to equipment failure and capacity issues. The Endoscopy Governance Group has commissioned a piece of work looking at alternatives to colonoscopy and 2 clinical leads are in the process of writing up a proposal for consideration at the next meeting of the Governance Group on 18 th December The detail of the number of patients waiting over stage of treatment targets, by specialty, is attached as Appendix 1. The Capacity Plan is now showing an overspend of 245,000 and 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 scopes (increase in demand). 2.4) Audit Scotland Reporting The unavailability report that is accessed from national data has not been updated since June (Qtr /15). The next publication is at the end of November which will give us the end of September (Qtr 2) comparison. The trend graph shows that NHS Lanarkshire has mirrored the NHS Scotland figures. However, at all times this has been below the national averages. A review of other elements of the dashboard of nationally available is now being shared at the weekly Waiting Times meetings through the NHS Lanarkshire Information Repository to facilitate local monitoring at individual specialty/consultant level. As a requirement arising from the Audit Scotland report a monthly independent review of a sample of 30 records is undertaken. This review looks at a range of requirements and identifies compliance with such or otherwise. This work has been undertaken monthly since December 2013 and the main area for improvement has been our ability to evidence the generation of patient letters. However NHS Lanarkshire has successfully introduced automatic generation of Treatment Time Guarantee (TTG) letters on 3rd November 2014 for the majority of letters. However any improvement in compliance will not be realised until February 2015 as there will be a 12 week lag time. 2.5) Cancer Services Two cancer waiting time standards are in place on which NHS Boards are asked to deliver; the 62 day standard includes A & E patients, screened positive patients and all 4

5 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. NHSL has consistently delivered on both standards. Published Validated performance; Q % 95.9% Q % 97.6% Q % 98.6% Overall performance remains very positive. However urology performance has dropped during the last quarter and this is reflected in the number of patients waiting up to 12 weeks for surgery. The 62 days performance is 88.6% and there were 4 breach patients with a maximum of 100 days. The 31 days performance was 93.4% and there were 6 breach patients with a maximum wait of 70 days. In both standards the Scottish Government have asked us to justify the performance and we have articulated the pressures in theatre time. 3) AHP WAITING TIMES For the majority of Allied Health Professions (AHPs), there is no national time to treatment guarantees (NTTG). However, NHS Lanarkshire has a local time to treatment target/guarantee (LTTG) of 12 weeks for those services not included within a NTTG. However, a similar approach to the rules pertaining to the NTTGs is applied to the LTTGs in that it is expected that 90% of patient will receive their appointment within 12 weeks. In Audiology, CAHMS and Psychological Services, their waiting times do form part of a NTTG target. As such, these targets carry significant importance in relation to national reporting. Services where the patient is waiting beyond the 12-week local waiting time standard are detailed below. 3.1) Allied Health Professions, Paediatric and Community Services All patients who attend NHS Lanarkshire AHP services are triaged by the relevant clinicians. Triage is the process of determining the clinical priority of patients' treatments based on the severity of their condition. Patients with conditions that are deemed urgent or have red flags are usually seen within 24 or 48 hours. 3.2) Musculoskeletal (MSK) Physiotherapy 5

6 At present, there are three main areas within the MSK Physiotherapy service under waiting time pressures. These areas include the Biggar, North Locality and CamGlen. In total there 234 patients for are waiting beyond the LTTG of these patients, 9 are waiting beyond 126 days (18 weeks). In the Biggar area the physiotherapist located at the Biggar Health Centre has returned to work following a protracted period of sick leave. At present, there are 14 patients who are waiting in excess of the LTTG, but below 18 weeks. Patients have been offered alternative appointments at either Carluke or Lanark Health Centres, but unfortunately this offer has been rejected as patients have stated they wish to be treated locally. The service has introduced additional hours in an effort to alleviate this backlog, and the service is projecting that the service will return to the LTTG by the end of October The impact of the recruitment process associated with issues in filling acute rotational vacancies is still having an adverse effect on primary care, particularly in the North Locality where two patients have been waiting 113 days (16 weeks). Patients have been offered appointments an alternative clinic, but all offers of alternative arrangements have been rejected. Within the CamGlen area, the physiotherapy provision has reduced due to two members of staff having taken up posts elsewhere within NHS Lanarkshire. This issue has also been compounded due to maternity and sick leave. There are currently 158 patients waiting in excess of the LTTG. However, the vacant posts have been recruited into, and it is anticipated that the service will return to the LTTG in the near future. A staff member from the Bellshill Locality has also been re-located to the CamGlen area to support service provision and to reduce the waiting times. Patients from this area have also been offered the opportunity for treatment at Douglas Street Hamilton and Blantyre Health Centre. Unfortunately, patients have been unwilling to accept an appointment at either of these two locations. However, it should be noted that 95% of all MSK Physiotherapy patients are being seen within the 84 days (12 weeks) target. 3.3) Podiatry In the podiatry service, the longest waiting time is 111 days (15 weeks). The waits are located in the North CHP within the Airdrie Locality. This represents a reduction of 5 weeks from the October report. The total number of patients now waiting beyond the LTTG has reduced to a total of 2 patients who have been waiting 15 weeks. The reason for these 2 patient waits of 15 weeks is being investigated. However, it should be noted that the waiting times in Podiatry have improved significantly. There are no patients waiting above the local waiting time standard across the South CHP. 6

7 3.4) Occupational Therapy (OT) The waiting times in paediatric occupational therapy, continue to be within the local waiting time standard of 12 weeks. The longest waiting time is 70 days 10 weeks). The waiting times for Rheumatology OT services are showing a slight improvement, but are still in excess of the LTTG. The longest waiting time is currently 28 weeks, which represent an improvement of 6 weeks from the last report only 63% of patients are being seen within the LTGG. The deputy director of finance for primary care has provided funding for 12 weeks in an effort to reduce the waiting times. A business case has been prepared for submission to the board finance seminar being held in December The paediatric OT service transferred to NHS Lanarkshire in October It has been identified that there are 20 patients from this area who are waiting in excess of between 30 to 40 weeks. Additional paediatric OT hours have been deployed to reduce this waiting time. 3.5) Dietetic Services The dietetic service is meeting the local target of 84 days (12 weeks). However, the recurring funding of the dietetic Bariatric service remains an area on concern. 3.6) Audiology The audiology service continues to meet the requirements of the NTTG targets associated with the service. 4) MENTAL HEALTH SERVICES 4.1) Adult Mental Services In the adult mental health service, the longest waiting time is currently 161 days (23 weeks) within the North Locality. There are 10 patients who are recorded as waiting beyond the LTTG. However, the September 2014 waiting times indicate that 98% of all patients who are attending the service are seen within the LTTG. The 23 week waiting times in the North West unit is being attributed to staffing issues within the Unit. The General Manager is in the process of addressing these issues. 4.2) Old Age Psychiatry The longest waiting time in old age psychiatry is currently 89 days, which is 3 days beyond in the LTTG of 86 days (12 weeks). In total there are 3 patients who are waiting beyond the LTTG. 7

8 4.3) Psychological Therapies In the psychological therapy service, the service continues to meet and maintain the current 26-week NTTG. The longest waiting time for the service has decreased from 26 weeks in the August data to 21 weeks in the September data. The service does not predict any issues in meeting 90% of patients being seen within the 18 weeks NTTG which comes into force at the end of December It is reported in the Scottish Government return in August 2014 that 88.26% of patients within NHS Lanarkshire started treatment within 18 weeks. 8

9 4.4) Child and Adolescent Mental Health Services (CAMHS) The CAMHS services have 56 patients waiting over 26 weeks. There are 433 Patients waiting with the longest wait being 35 weeks. However, 97.2%, of patients are seen within the current 26 Weeks, and 71.5% of patients are being seen within 18 Weeks NTTG which comes into force at the end of December A waiting times initiative commenced at the beginning of October This initiative is beginning to have an impact on the performance against the 18 week NTTG target which comes into effect at the end of December In addition, since the end of September 2014, a number of Clinical Associate & Applied Psychologist (CAPPs) posts have been appointed to cover the maternity leaves within the service. There is a degree of confidence within the service that this waiting list initiative in CAMHS Tier 3 and the use of the CAPPs will get the service closer to the 90% target by the end of December However, a business case to assist the service in maintaining a consistent level of performance against 90% of patients being treated within 18 weeks by the end of December 2014 is in the process of being prepared for the forthcoming Board finance seminar. 4.5) Addiction Services The waiting times for addiction services continue to remain at three weeks and Lanarkshire is continues to be recognised as one of the best performing Boards in Scotland for this clinical speciality. 5. UNSCHEDULED CARE 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 on going 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 regular fortnightly 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. At the Acute Operating Management Committee on Monday 24 th November Hospital Site Directors will go through, in detail, the key performance issues for their sites and the improvement actions that are in place and those that are being ramped up. 9

10 Performance Performance for October 2014 was 86.76% (HM 81.69%, MK 90.41%, WG 87.56%) for NHS Lanarkshire. To date, performance in November is 82.95% (HM 82.55%, MK 88.73%, WG 77.26%). The table below gives the weekly performance by site for the past six weeks and compares to same time period last year. HM MK WG NHSL Week Ended 19 th Oct % 92.03% 92.47% 89.92% Week Ended 20 th Oct % 92.82% 90.81% 91.50% Week Ended 26 th Oct % 92.12% 85.66% 87.15% Week Ended 27 th Oct % 82.55% 84.47% 84.72% Week Ended 2 nd Nov % 89.40% 79.45% 82.20% Week Ended 3 rd Nov % 93.27% 96.68% 94.34% Week Ended 9 th Nov % 90.59% 77.63% 84.11% Week Ended 10 th Nov % 94.82% 95.54% 94.94% Week Ended 16 th Nov % 86.51% 79.75% 82.87% Week Ended 17 th Nov % 89.41% 91.90% 90.83% During the reporting period, performance has ranged between 82% and 87% this compares to performance of between 84% and 94% in the same period last year. 8 and 12 Hour Waits Scotland NHSL 8 hours 12 Hours 8 Hours 12 Hours Week Ended 19 th Oct Week Ended 26 th Oct Week Ended 2 nd Nov

11 Week Ended 9 th Nov As noted above, the level of 8 and 12 hour waits within Lanarkshire is disproportionally high, compared to other Boards. As previously reported, these issues continue to fall into three distinct blocks ; a) Ensuring the sufficiency of Senior Decision Makers within the Emergency Departments and Receiving Unit b) Delivering on the internal process to maximise flow on a daily basis c) Reduce the level of patients delayed on site who are past their clinical readiness date The following summaries the key improvement activities at site level: Hairmyres a) Redesign of Medical Assessment Unit/Clinical Decision Unit (Wards 2 and 3) - whilst the increase of inpatient beds in Ward 3 in 2012/13 has helped increase the overall capacity at Hairmyres, it has not yet been able to provide the fully comprehensive and integrated range of inpatient and ambulatory care services required. A formal redesign initiative is now being led by Dr John Keaney, Clinical Director for Medicine. This will bring about radical changes to the whole organisation of wards 2 and 3. b) Estimated Date of Discharge Initiative - various pilots have been held, the most recent in Ward 12, but real, dynamic change has remained elusive. A renewed initiative including delegated discharge/criteria led discharge, Ward Advocacy Board Rounds, a review of Consultant Ward Rounds, use of multidisciplinary team meetings, enhanced bed management and pharmacy provision will support this. c) The whole surgical flow will be formally reviewed with the new CD for Surgery (Mr Alistair Brown). This will include Vascular and Orthopaedics, and both the emergency and elective flow of patients into and out of theatre (particularly the additional CEPOD theatre capacity recently agreed). d) Management Reviews and Escalation Processes - a new high level Emergency Care Programme Manager will be appointed to support the delivery of the whole Action Plan, and the newly focussed escalation protocol will ensure that the daily review of the demand/supply balance is undertaken to allow informed decision making throughout the day, but particularly at the 4.30 safety/flow meeting in the ED. 11

12 e) Delayed Discharges - these will continue to be high level discussions between NHS Lanarkshire and South Lanarkshire Council to agree a sustainable way forward for both Home Care and Care Home placements. This will be supported by a range of initiatives in Older Peoples Services and the redesign of robust patient pathways. f) Emergency Care Capacity Plan - a detailed capacity plan will be developed for Hairmyres Hospital, examining all of the appropriate key performance indicators including Senior Staff from Hairmyres, NHS Lanarkshire and Scottish Government. A Flowopoly exercise (trialled in Lothian) is being held on 29 th January 2015 which will identify key capacity logistics and flow issues / solutions. This will be critical in order to accurately assess the potential impact of the Victoria closure in May 2015 and the additional capacity required at Hairmyres (and potentially Monklands and Wishaw) in order to address this. Monklands To enable Monklands Hospital to improve patients care and improve the 4 hour target performance it is proposed to implement 4 recently piloted service improvements on the 24 th November a) AEC (Ambulatory Emergency Care) - A small medicine only AEC unit will be operated over the winter period from 24/11/14 to 31/3/15 out of a 4 bedded and single bedded room in ERU. This will assist in the winter plan and provide actual data to inform a case for either a larger Medical AEC unit or a combined Surgical/Medical AEC. b) REACT Team (Rapid Emergency Assessment and Care Team) - The previous RAT will become the REACT team and this will provide early assessment, pain relief, diagnostic requests, IV antibiotics and streaming to the appropriate department. c) Pharmacy Early Assessment - Pharmacy will deliver medications reconciliation on appropriate patients and sorting out of Medications issues in A&E (right first time) d) Minors Flow - The minors flow will be relocated and the nursing rota separated from the main A&E rota. Both measures are to protect the minors flow and ensure the staff and space are protected to allow it to focus on rapidly treating patients which will avoid slowing down the minors flow and avoiding congestion and breaches. e) Criteria Led Discharge - This is being progressively implemented in all medical wards and currently being implemented in wards 17 and 14 and ward 2. 12

13 f) Mayo Audit Tool - With this tool validated discussions can be initiated with social work to propose to change the rules for complex discharges i.e. instead of waiting till the patient is medically fit for discharge before starting assessment. Initiate assessment in parallel while the patient s treatment is ongoing. g) Discharge to Assess - Dr Talbot operating a pilot with the GP Dr Brankin on discharging stable patients with ongoing care needs to have assessments competed in their own environment. Wishaw a) An Ambulatory Emergency Care (AEC) Unit is being opened as a pilot on Monday 17 th November 2014 and will run to the end of March This will commence as an assessment area for Medical GP referrals. Medical and Nursing staffing resources have been allocated and an Implementation plan has been put in place to facilitate this project. A pilot for Surgical GP direct referrals is also commencing in November as part of this Unit. The unit is starting to implement the pull model from ED. b) Work is ongoing within our Emergency Departments in relation to the high numbers of category 6 patients that are seen by MINTS staff. This continues to be over 90% and has a positive impact on the redirection of patients appropriately as well as streaming patients within this minors flow category to nurse led assessment and treatment, thus freeing up medical staff to see other patients. The nurse advisor role redirects approximately patients per week from the ED department. c) On Monday 17 th November 2014 we realigned the Bed Management team, Discharge Hub and Clinical Co-ordinators this is to facilitate daily board rounds, enhance earlier time of day discharge and identify clinically appropriate patients for decanting, if required every effort is made to reduce decant numbers on the site. d) Earlier time of day decanting, when required, to ensure use of all available hospital beds need to avoid this taking place late at night e) Escalation process is being put in place in relation to declaring of available beds to reduce time of transfer from receiving ward to downstream beds if bed not used within an hour escalated to management. f) Agreed protection of the minors flow within the ED unless clinically appropriate for staff to be moved. This is to try and enhance overall performance g) Audit in relation to Bed request at Triage for specific conditions has commenced within the ED and will run for approx 4 weeks 13

14 h) Increase accurate utilisation of EDD s across all inpatient clinical areas. The draft policy for the use of EDD has been updated and is to be circulated. In summary, it has been agreed that in order to take these proposals forward in a systematic fashion, it is now necessary to put in place a Board wide Unscheduled Care Performance Board. This will be chaired by the interim Director of Acute Services with clinical and inclusion of senior officers from North and South Lanarkshire councils. In tandem with this, a review of Programme/Improvement management at site level is underway. It is critical that this is in place to support this complex work going forward. Delayed Discharges The table below shows the monthly information pan Lanarkshire for Delayed Discharges. This shows the trend since April 2014 across Lanarkshire. North Number Breaches North Bed Days South Number Breaches South Bed Days Total Number Total Bed Days APRIL MAY JUNE JULY AUGUST SEPT OCT Multi-agency meetings are planned, involving Chief Officers from Health and North and South Lanarkshire partners on the 20 th November and 9 th December. The opportunity will be taken at these meetings to look at solutions going forward. 6. RECOMMENDATION The NHS Lanarkshire Board is asked to note The emerging pressures in delivering the Treatment Time Guarantee The very positive performance on the Referral to Treatment target The very positive performance in Cancer Waiting Time 14

15 Positive compliance with the monthly audit of records and progress against the overall Audit Scotland recommendations The robust monitoring process implemented to support the 2014/15 Capacity Plan The improvements in AHP waiting times 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 levels of delayed discharges 7. FURTHER INFORMATION For further information about any aspect of this paper, please contact Rosemary Lyness - Telephone: ROSEMARY LYNESS INTERIM DIRECTOR OF ACUTE SERVICES 18 th November