Highland NHS Board 6 December 2011 Item 3.7. IMPROVEMENT COMMITTEE Report by Elaine Mead, Chief Executive. The Board is asked to:

Transcription

1 Highland NHS Board 6 December 2 Item 3.7 IMPROVEMENT COMMITTEE Report by Elaine Mead, Chief Executive The Board is asked to: Note that the Improvement Committee met on Monday 3 October 2 with attendance as noted below. Note the Assurance Report and agreed actions resulting from the review of the specific topics detailed below and the Balanced Scorecard (attached). Panel: Mr Garry Coutts, Chair Dr Ian Bashford, Medical Director Mr Ian Gibson, Non-Executive Director Dr Iain Kennedy, Non-Executive Director Ms Elaine Mead, Chief Executive In Attendance: Ms Margaret Brown, Head of Service Planning Mr Kenny Oliver, Performance Manager Miss Irene Robertson, Board Committee Administrator Apologies: Mrs Linda Kirkland Respondents: Mr Bill Brackenridge, Chair, Argyll & Bute CHP Mr Mike Evans, Chair, Raigmore Hospital Mrs Gillian McCreath, Chair, South East Highland CHP Mr Okain McLennan, Chair, Mid Highland CHP Mr Colin Punler, Chair, North Highland CHP Mr Derek Leslie, General Manager, Argyll & Bute CHP Mr Chris Lyons, General Manager, Raigmore Hospital Mrs Sheena MacLeod, General Manager, North Highland CHP (videoconference) Mrs Gill McVicar, General Manager, Mid Highland CHP Mr Nigel Small, General Manager, South East Highland CHP Mr David Garden, Interim Director of Finance (item a) Dr Margaret Somerville, Director of Public Health (items 2.a, 5a, 5b and 5c) Mrs Mairi Milne, Business Manager, Public Health (item 2.a) Ms Fiona Clarke, Senior Health Promotion Specialist (item 2.a) Mrs Christine McIntosh, Cancer Network Manager (item 2.b) Ms Maimie Thompson,8 Weeks RTT Programme Manager (item 2.c) Ms Morag MacLeay, CAMHS Network Manager (item 2.d) Mr Gavin Sell, Long Term Conditions Manager (item 2.e) Dr Adrian Baker, GP (item 2.e) Mrs Anne Gent, Director of Human Resources (items 2.2e and 4) Ms Christian Goskirk, Long Term Conditions Manager (item 3) Dr Paul Findlay, Consultant Physician in Stroke Medicine (item 3) Ms Linda Campbell, Stroke Coordinator for Highland (item 3)

2 TOPICS DISCUSSED. Review of Board Assurance Report Actions a. Financial Position 2. Balanced Scorecard Heat Targets a. Healthy Weight of Children b. All Cancer Treatments c. 8 Weeks Referral To Treatment d. CAMHS e. A&E Attendance Rates 2.2 Standards a. Sickness Absence Argyll & Bute CHP b. SMR Recording c. Complaints 2 day response target d. Mental Health DNA Rates e. eksf f. New Outpatient Waiting Times Maximum Wait 2 Weeks g. Inpatient/Day Case Waiting Times Maximum Wait 9 Weeks 3. Stroke 4. Service Improvement Group Update 5. AOCB a. Drug and Alcohol Waiting Times Target Data Quality b. Mainstreaming Keep Well in NHS Highland Strategic Engagement and Governance c. Breast Screening Data d. Latest Risk Assessment for NHS Highland DATE OF NEXT MEETING The next meeting will be held on Monday 9 January 22 in the Board Room, Assynt House, Inverness at.3pm. 2

3 IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 3 October 2 The Committee s role and remit is to scrutinise NHS Highland s performance and ensure remedial action is taken, as required. REVIEW OF BOARD ASSURANCE REPORT ACTIONS Issues/Risks Assurance Actions Financial Position Month 6 September 2: Raigmore: Extremely challenging position. Increasing cost pressures. Impact of efficiency savings - potential risk to patient care. Issue around clinical buy in. A range of measures already taken and other options being considered, however these will not achieve the necessary savings. Raigmore to prepare a report for the December Board detailing all the options being explored to achieve the required savings, both recurring and non-recurrent, and their potential impact. Consideration to be given to the contribution that colleagues, particularly in South East and Mid Highland CHPs, can make to dealing with delayed discharges and thereby facilitating other changes to be made to realise savings. Action: C Lyons North CHP: Deteriorating position, break-even will not be achieved in the current financial year. Significant prescribing costs. Impact of increased costs of Laboratory Managed Service Contract (MSC). Contribution to Highland wide review of mental health services need joined up working with other CHPs. Mid CHP: Impact of Laboratory MSC. Cost pressures. Some slippage in relation to OOH and other schemes. Argyll & Bute CHP: Locum costs Breakeven plan has been developed which has been agreed by both management and staff, however not all of the savings are deliverable in the current financial year. Break-even position had been anticipated, however costs associated with Laboratory MSC may impact on ability to deliver breakeven. Confident of achieving break-even. Discussions ongoing with Argyll & Copy of the plan to be forwarded to the Board Chair and submitted to the December Board with the relevant CHP Committee minute. Action: S MacLeod Whole systems approach needs to be taken to service delivery in order to identify and share out savings across the area, focussing on recurrent savings and reducing dependency on non-recurring savings. Action: GMs 3

4 IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 3 October 2 Relationship with NHS Greater Glasgow & Clyde. Bute Council regarding their contribution to mental health services redesign. South East CHP: Risks around prescribing and OOH. Costs associated with joint SLAs (Highland Council, Police) Savings plan being reviewed; expect to see improving position. Alcohol Brief Interventions: Improving position, particularly in South East CHP. More people have been trained to deliver interventions, and recording has improved. 2. BALANCED SCORECARD 2 22 HEAT TARGETS Issues/Risks Assurance Actions Healthy Weight of Children: Behind target. Changes in national guidance have impacted on delivery rates. Challenges in engaging hard to reach families and recruiting to the full X programme. There is a need for cultural and behavioural change. Capacity issue for Public Health Nurses in delivering interventions. A suite of interventions has been developed, in addition to the X programmes, and resources to support :, group and school based interventions are available. The : interventions delivered by Public Health Nurses are proving particularly effective. The schools based intervention has been piloted in P and will be evaluated with a proposal to roll it out from May 22. Existing community based activities are being enhanced. National campaign planned for early in the new year to raise awareness of the issues. Agreed to set a target for this year to assist towards the overall target due for delivery by 24. Propose to hold a Board development session around the Healthy Weight Strategy, looking at the whole population adults as well as children, and working with the Highland Council and other partner agencies to address environmental issues Action: F Clarke / L Power 4

5 IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 3 October 2 All Cancer Treatments: 62 and 3 day targets not achieved in Quarter 2 (April June 2). The two main areas of concern were Breast Cancer (one stop breast clinic) and Colorectal Cancer Breaches occurred in Quarter 3 (July September 2) in Endoscopy, Radiotherapy and Surgery. Breaches have already occurred in Quarter 4 (October December 2). Potential impact on Quarter position. Some delays occurring around head and neck cancer issue relating to sub-specialisation in ENT. 8 Weeks RTT: Percentage of linked pathways needs to be increased. Some capacity management issues to be resolved. Series of actions taken/planned, both within specialities and pan-highland, to address delays in Endoscopy and Radiotherapy, however a higher uptake of endoscopy appointments at the Belford Hospital is needed in order to maximise this resource. The position in relation to Breast Cancer has been recovered. It is anticipated that, as a result of actions taken, Endoscopy and Radiotherapy will return to trajectory by end of Quarter 4. Work continuing to further increase level of linkage. Position improving in relation to admitted pathways 96% linkage / 86% performance. A number of milestones have been developed against which to monitor progress. Pro-active KPI reports based on real time data. Ongoing training and management. Further systems upgrade. Noted that Argyll & Bute have achieved %. Position to continue to be monitored. To follow up issues identified in relation to head and neck cancer. Action: C Lyons/C McIntosh Approach to be made to GP practices about referring patients to Belford Hospital for endoscopy, where this is clinically appropriate. Action: C Lyons/C McIntosh Report to be prepared for the next meeting of the Improvement Committee on 9 January 22, detailing progress with the workstreams and proposals for sustainability in the future. Action: M Thompson 5

6 IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 3 October 2 CAMHS: Currently not on trajectory. Meeting the 26 week target for 22/3 will be challenging. Demand for services is exceeding capacity. Limited scope for further efficiencies given the extent of service redesign undertaken to date. Argyll & Bute CHP: Staffing capacity issues impacting on support for Tier 3 referrals. Mid CHP: Challenging position A&E Attendance Rate: Previously Raigmore ED was the only department with an IT system. Plans have therefore been developed on the basis of Raigmore data. Caithness and Belford have been using the IT system since February this year and their data is now beginning to be analysed. Some data quality issues at Belford. Lorn & Isles have had significant technical problems. Considerable ongoing activity to review service delivery and address waiting lists. The allocation of central funding to support the development of the service should lead to a significant improvement over time. Interviews arranged in early November for two clinical psychology posts. Recruitment to these posts should impact on waiting lists and improve the range of therapeutic services which can be provided. Arrangements with NHS Greater Glasgow & Clyde are being reviewed. Position to continue to be monitored. Further report to come to the Improvement Committee only if any issues arise. Action: S Amor A report to be prepared for the Improvement Committee meeting on 3 April 22, looking at making the most effective use of A&E staff, and including feedback on patients experiences. Action: G Sell/A Baker 6

7 IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 3 October 2 Significant numbers of minor self referrals Frequent Attenders a small number of people are very high users of A&E. Orthopaedic patients are sent to A&E first prior to admission for an x-ray. Work ongoing to develop a protocol for the safe re-direction of people to the appropriate service before they are registered on the A&E system (EDIS). Working with multi-agency group to develop case conference type approach for this group, to try and pre-empt their attendance at A&E. Work ongoing with the Orthopaedic Department to look at alternative booking in arrangements for this group of patients. Discussions ongoing in relation to radiography provision in peripheral units. Need for consistent messages both publicly (press, media) and during direct patient contacts about appropriate use of A&E services Know who to turn to campaign launched; NHS Highland website updated with Know who to turn to information; work ongoing with Education Department to develop materials and events aimed at 4 8 year olds to help address issues of higher use of A&E by this age group. Looking at smart phone applications as a means of assisting young people to access advice and services. Consideration may be given to having a GP surgery in A&E/utilising OOH resource. 7

8 IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 3 October BALANCED SCORECARD 2 22 STANDARDS Issues/Risks Assurance Actions Sickness Absence Argyll & Bute CHP: High level of sickness absence As a result of actions taken and changes implemented, there has been a significant improvement in performance. The CHP has now met the 4% target. Continued support and input from all levels of management within the CHP will be required to maintain this position. Report required only if percentage rate rises. Action: D Leslie SMR Recording: Mid CHP: Capacity issue in relation to staff trained to undertake coding. Argyll & Bute CHP: Backlog of uncoded records due to lack of capacity. Issue relating to procedures identified in Islay. Raigmore: Staff capacity issues recruitment of trained coders Action plan developed. Overall there has been an improvement in the completeness of reporting. There is continued performance monitoring across all the hospitals within the CHP to ensure the agreed standard is met. Redesign work ongoing around medical records. Continuity plans being explored to ensure availability of key coding staff, including opportunities for cross cover from other CHPs. Return to trajectory is anticipated by end of March 22 provided the vacant posts are filled. The position to be kept under review. Action: GMs 8

9 IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 3 October 2 Complaints 2 day response target: Mid CHP: Not meeting the target. Staff capacity, complexity of investigations. Argyll & Bute CHP: Variable position marked deterioration in August. Raigmore: Not meeting target. Clinical complexity of a number of complaints Mental Health DNA Rates (Psychiatry), Argyll & Bute CHP: Not meeting trajectory South East CHP has only failed to meet the target once in the current year, and expects to return to performance with immediate effect. Measures implemented with a view to achieving the target without compromising the quality and robustness of investigations. Managers are being encouraged to attend SPSO training. Reasons for delays in responding to complaints are being reviewed. There have been some complex complaints requiring more time to complete the necessary investigations. Centralised monitoring in respect of timeliness and quality of responses will assist in return to trajectory. Training in the use of the DATIXWeb complaints module is being rolled out at Raigmore. Actions being taken to improve the position. These include sending text message reminders to patients who have requested this, and issuing reminder letters for all psychiatry clinics. A pilot will be undertaken in Bute whereby all patients scheduled to attend psychiatry clinics will be telephoned the day before their To consider revising the 2 day target to take account of increasing complexity of complaints. Compare NHS Highland s performance in relation to the 2 day target and the number of complaints referred to the SPSO, with the position in other boards. Action: GMs/M Morrison Work undertaken in South East CHP to reduce DNA rate to be shared with Argyll & Bute. Action: N Small/D Leslie 9

10 IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 3 October 2 appointment to confirm their attendance. If found to be effective this will be rolled out across the CHP area. eksf: Below trajectory. Overall activity currently at 24%. Variable position across the Operational Units. Capacity issues for managers undertaking reviews. New Outpatient Waiting Times maximum wait 2 weeks and Inpatient / Day Case Waiting Times maximum wait 9 weeks: North CHP: The chronic pain service breached the target during September due to the absence on sick leave of the specialist who provides the service. Operational Units confident that the plans they have developed will enable them to meet the target. North CHP is achieving the target in most specialties with the exception of the chronic pain service. A locum consultant was recruited to support the service and get it back on trajectory. To develop a trajectory to move the PDP work forward in the year, for existing NHS Highland staff, for the next 2 3 years against which to measure progress. Agreed that staff transferring to Highland under the Planning for Integration project would not be included in the trajectory. Action: A Gent/General Managers To review the impact of eksf and PDP in relation to staff development. Action: A Gent/Staff Governance Committee Acknowledging the vulnerability of services provided by single handed practitioners, the Committee requested that a report be prepared for the next meeting setting out proposals for a more sustainable service. Action: S Macleod Mid CHP: One breach at Belford Hospital. Apart from one breach, all the targets were met.

11 IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 3 October 2 Argyll & Bute: Two breaches in Ophthalmology, due to an administrative error. The main waiting time pressures are in Orthopaedics, Ophthalmology, ENT, Dermatology and Anaesthetics (pain clinic) Raigmore: Breaches in Restorative Dentistry for first outpatient appointments. With regard to admissions, two patients breached the 9 week wait in September The specialties identified are undergoing redesign to improve patient pathways and capacity. During September no patient waited over 2 weeks for their first outpatient appointment with the exception of Restorative Dentistry. Apart from the two breaches in Ophthalmology all other patients were treated within the 9 week period. With the exception of Restorative Dentistry there are no breaches anticipated in October for either the 2 weeks or 9 weeks waiting time. 3 TOPIC: STROKE Issues/Risks Assurance Actions NHS Highland position as at June 2 was 34% against the trajectory of 5%. Some challenges around the collection of SSCA (Scottish Stroke Care Audit) data. Issue relating to reporting of data which will be followed up with ISD. The data to end September 2 which has just been received indicates an improving position. Action plans have been developed, based on the LEAN methodology. Work is ongoing to improve bed management. A review of medical staffing in the Stroke Unit, with two additional posts now established, will Follow up report to be prepared for the Improvement Committee meeting on 3 April 22 detailing progress with LEAN activity and its impact. Action: C Goskirk/P Findlay

12 IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 3 October 2 Capacity within the Stroke Unit. Delays in moving patients from the Stroke Unit, when clinically indicated, back into the community, due to, for example, lack of the necessary rehabilitation facilities, availability of community hospital/care home beds. enable further improvements to be made. Work is ongoing with the CHPs to enable patients to be transferred more timeously from the Stroke Unit to community hospitals/facilities. Belford Hospital will shortly become an accredited stroke unit, thereby creating further capacity 4 TOPIC: SERVICE IMPROVEMENT GROUP UPDATE The Committee received and noted the minutes of meetings held on 9 September and 24 October 2. The Chair sought assurance that the various projects and redesign work currently underway would ensure NHS Highland meets its aims and objectives. It was agreed that a summary report would be prepared, with details of the projects, their anticipated impact and contribution to the Board objectives. Action: A Gent 5 ANY OTHER COMPETENT BUSINESS a. HEAT A Drug and Alcohol Waiting Times Target Data Quality and Compliance Issues Margaret Somerville drew the Committee s attention to an issue raised by the Scottish Government Drugs and Alcohol National Support Programme regarding Highland ADP s data quality and compliance in relation to the Drug and Alcohol Treatment Waiting Times Database. Dr Somerville was able to assure the Committee that our new Substance Misuse Manager, Suzy Calder, had resolved the issues identified. b. Mainstreaming Keep Well in NHS Highland Strategic Engagement and Governance Margaret Somerville reported that with effect from April 22 NHSScotland will mainstream the Keep Well programme. National guidance has been produced to inform NHS Boards local planning for the mainstreaming process. GP involvement is a key element in the delivery of the programme. Pending the development of a national specification Boards were requested to commence negotiations with their local GP practices to agree the arrangements. 2

13 IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 3 October 2 The Committee agreed the need for a high level strategic plan to be developed, with action plans for each of the Operational Units, against which progress with implementation can be monitored and assurances provided to the Improvement Committee in relation to performance. It was agreed an outline plan be prepared for submission to the Improvement Committee meeting on 9 January 22. Action: M Somerville/A MacKiggan c. Breast Feeding Data Margaret Somerville updated the Committee on the position regarding infant feeding data. It was noted that the uptake and reporting on the 6-8 week Child Health Pre-School (CHSP) return will be a key performance indicator for the Lead Agency model, and there is a need to improve the baseline for reporting in the lead up to implementation on April 22. Action: M Somerville/S Amor d. Latest Risk Assessment for NHS Highland The Committee noted for information the latest risk matrix showing the position at October 2. 6 FUTURE AGENDA ITEMS Meeting on 9 January 22: 8 Weeks RTT New outpatient waiting times maximum wait 2 weeks (chronic pain service) Highland Ethnicity Recording Dementia Registration Argyll & Bute CHP CAMHS Dental Balanced Scorecard Children s Fluoride Varnish/Childsmile Programme Reduce Carbon Emissions/Energy Consumption Breast Feeding Data Mainstreaming Keep Well in NHS Highland 3

14 IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 3 October 2 Future meetings: New Outpatient Appointment DNA Rates (March 22 meeting) Scottish Patient Safety Programme (March 22 meeting) A&E Attendance (April 22 meeting) Stroke (April 22 meeting) Change Fund Patient Focussed Booking New to Return Ratio EQIA Compliance Better Together Quality Outcomes Framework 7 SCHEDULE OF IMPROVEMENT COMMITTEE MEETINGS 22 The Improvement Committee will meet on the following dates in 22:- (Mondays, 3:3) 9 January 5 March 3 April 2 July 3 September 5 November 4

15 NHS Highland - "At A Glance" HEAT Targets Summary of the Operational Units performance as per the Balanced Scorecard reported to the Improvement Committee on 3st October 2 Targets with a delivery date by the end of March 22 Board Position Target Alcohol \Brief Interventions Aug- N/A Mar-2 Inequalities Targeted Cardiovascular Health checks Sep- N/A N/A N/A N/A Mar-2 Month reported Raigmore SE Highland Mid Highland North Argyll and Bute Delivery Date Financial Performance Aug- Mar-2 Cash Efficencies Aug- Mar-2 Suspicion of cancer referrals (62days) (Due for Delivery Dec 2) Jul- Reported at Board Level only Dec- All Cancer Treatment (3days) (Due for Delivery Dec 2) Jul- Reported at Board Level only Dec- 8 weeks Referral to Treatment (Due for Delivery Dec 2) Aug- Currently reported at Board Level only Dec- Reduction in Emergency bed days for patients aged 75+ Apr- N/A Mar-2 Targets with a delivery date beyond March 22 Board Position Target Child Healthy Weight Interventions Aug- N/A Mar-4 Smoking Cessation - 2 most deprived data zones Jun- N/A Currently reported at Board Level Only Mar-4 Smoking Cessation - general smoking population Jul- N/A Mar-4 N/A Child Fluoride Varnish Applications N/A Currently reported at Board Level Only Mar-4 Month reported Raigmore SE Highland Mid Highland North Argyll and Bute Delivery Date N/A Reduce Carbon emmissions Mar-5 N/A Reduce Energy Consumption Mar-5 Currently reported at Board Level Only Currently reported at Board Level Only N/a Drug & Alcohol Treatment: Referral to Treatment N/A Mar-3 Faster Access to Specialist CAMHS Aug- Mar-3 No Trajectory Faster Access to Psychological Therapies Dec-4 Trajectory in development 9% of patients diagnosed with stroke admitted to a stroke unit Aug- Currently reported at Board Level Only Mar-3 MRSA/MSSA Bacterium: 3% reduction Jun- Currently reported at Board Level only Mar-3 C. Diff Infections: 3% reduction Jun- Currently reported at Board Level only Mar-3 Rate of attendances at A&E Jul- Currently reported at Board Level only Mar-4 NHS Highland - "At A Glance" Standards Board Position Target Quart Breastfeeding at 6-8 week- Target 36% N/A MMR uptake rates - target 95% at 5 years old Jun- N/A Month reported Raigmore SE Highland Mid Highland North Argyll and Bute Sickness Absence - 4% target Jul- N/S SMR return rate - 9% of SMR returns received within 6 weeks Jul- Complaints - 8% of complaints completed within 4 weeks Aug- Complaints - No. over 4 working days - Target Aug- Complaints - No. of complaints received Target less than 5 Aug- Complaints - No. categorised as High Risk - Target less than 2% Aug- Day case rates - Target 78.9% Jul- N/A Outpatients - DNA rate - Target 6.9% Jul- Reduce Pre Operative stay - Target.65 days Jul- N/A New to Return Outpatient attendance Ratio - Target 2.2 Jul- eksf & PDP's - Target 8% Sep- New Outpatient Waiting times - 2 weeks (all referral sources) Sep- N/A N/S Inpatient/Day Cases Waiting times - 9 weeks Sep- N/A N/S Cataract Waiting Times - assessment - 9 weeks Sep- N/A N/A N/A Hip surgery - 98% of patients treated within 24 safe operating hrs Sep- N/A N/A N/A N/A Angiography - 4 week waiting time Sep- N/A N/A N/A N/A Daignostic tests waiting times - 4 weeks for 8 key tests Sep- N/A A&E Waiting times - 4 hours Jul- N/S Annual Advance Booking - GP's N/S N/S : National Standard Cervical Screening - 8% uptake of 2-6 yr old women screened N/A Reduce Occupied Bed days for long term conditions N/A Balance of care for Older People with complex care need Reported at Board Level only Delayed Discharges - no clients waiting over 6 weeks Sep- N/S Dementia (Unvalidated - validated position available annually) Aug- N/A N/S

16 NHS Highland - Review of Timeliness of Data for Balanced Scorecard Targets with a delivery date by the end of March 22 Target MAY BSC Data Period Time Lag NHSH Updated Reported to SGHD Alcohol Brief Interventions Feb- 6 weeks Inequalities Targeted Cardiovascular Health checks Mar- 2 weeks Financial Performance Mar- 2 weeks Cash Efficencies Mar- 2 weeks Suspicion of cancer referrals (62days) (Due for Delivery Dec 2) Dec- 3 months All Cancer Treatment (3days) (Due for Delivery Dec 2) Dec- 3 months 8 weeks Referral to Treatment (Due for Delivery Dec 2) Feb- 3 weeks Reduction in Emergency bed days for patients aged 75+ Dec- 3 months Targets with a delivery date beyond March 22 Target MAY BSC Data Period Time Lag NHSH Updated Reported to SGHD Child Healthy Weight Interventions Feb- 6 weeks Smoking Cessation - 2 most deprived data zones N/A 6 weeks Smoking Cessation - general smoking population Feb- 6 weeks Child Fluoride Varnish Applications Sep- 6 months Reduce Carbon emmissions Dec- 3 months Reduce Energy Consumption Dec- 3 months Drug & Alcohol Treatment: Referral to Treatment Dec- 3 months Faster Access to Specialist CAMHS Feb- 3 weeks Faster Access to Psychological Therapies N/A 3 weeks 9% of patients diagnosed with stroke admitted to a stroke unit N/A 2 months MRSA/MSSA Bacterium: 3% reduction Dec- 3 months C. Diff Infections: 3% reduction Dec- 3 months Rate of attendances at A&E Feb- 3 weeks Data Source Scottish Cancer Waiting Times System Scottish Cancer Waiting Times System Local Data used ISD data used Data Source ISD data used Environment Monitoring & Reporting Tool (emart) Environment Monitoring & Reporting Tool (emart) Drug & Alcohol Treatment Waiting Times Database Scottish Stroke Care Audit Health Protection Scotland Health Protection Scotland NHS Highland - "At A Glance" Standards MAY BSC Data Period NHSH Updated Target Time Lag Breastfeeding at 6-8 week- Target 36% Sep- 6 months MMR uptake rates - target 95% at 5 years old Dec- 3 months Sickness Absence - 4% target Jan- 6 weeks SMR return rate - 9% of SMR returns received within 6 weeks Feb- 6 weeks Complaints - 8% of complaints completed within 4 weeks Feb- 6 weeks Complaints - No. over 4 working days - Target Feb- 6 weeks Complaints - No. of complaints received Target less than 5 Feb- 6 weeks Complaints - No. categorised as High Risk - Target less than 2% Feb- 6 weeks Day case rates - Target 78.9% Jan- 2 months Outpatients - DNA rate - Target 6.9% Feb- 6 weeks Reduce Pre Operative stay - Target.65 days Feb- 6 weeks New to Return Outpatient attendance Ratio - Target 2.2 Feb- 6 weeks eksf & PDP's - Target 8% Mar- 2 weels New Outpatient Waiting times - 2 weeks (all referral sources) Mar- 3 weeks Inpatient/Day Cases Waiting times - 9 weeks Mar- 3 weeks Cataract Waiting Times - assessment - 9 weeks Mar- 3 weeks Hip surgery - 98% of patients treated within 24 safe operating hrs Mar- 3 weeks Angiography - 4 week waiting time Mar- 3 weeks Daignostic tests waiting times - 4 weeks for 8 key tests Mar- 3 weeks A&E Waiting times - 4 hours Mar- 3 weeks Advance Booking - GP's Mar- 3 months Annually Cervical Screening - 8% uptake of 2-6 yr old women screened Dec- 3 months Reduce Occupied Bed days for long term conditions Dec- 3 months Balance of care for Older People with complex care need Sep- 3 months Delayed Discharges - no clients waiting over 6 weeks Mar- 3 weeks Dementia (Unvalidated - validated position available annually) Feb- 6 weeks Data Source ISD data used Health Protection Scotland ISD data used National Audit data used Health Protection Scotland ISD data used Local data + Local Authority data Local unvalidated data used

17 IMPROVEMENT COMMITTEE - OCTOBER 2 2/2 BALANCED SCORECARD Highland Sheets Raigmore Sheets North Highland CHP Mid Highland CHP South East Highland CHP Argyll & Bute CHP Highland HEAT Raigmore HEAT North HEAT Mid HEAT South East HEAT A & B HEAT Highland Cancer Raigmore Standards North Standards Mid Standards South East Standards A&B Standards Highland Standards Pharmacy Facilities Corporate HEAT Dental eksf Please click on the hyperlinks to be taken to each worksheet

18 NHS HIGHLAND BALANCED SCORECARD 2/2 TOTAL NHS HIGHLAND HEAT TARGETS Outturn Date of outturn Health Improvement Alcohol Brief Interventions Achieve 382 brief interventions in line with SIGN 74 guidelines by March Mar- Inequalities Targeted Cardiovascular Health Checks Achieve 45 inequalities targeted cardiovascular Health Checks during 2/2 23 Mar- Healthy Weight of Children Achieve 887 interventions for child healthy weight intervention programme for 2-5 year olds over 3 years ending March Mar- Smoking Cessation 55% of the smoking population in the 2 most deprived data zones in the NHS Board successfully quitting (at one month post quit) from April 2 to March 24 - Equates to 2358 quits over the period Smoking Cessation 7.5% of the general smoking population target in the NHS Board successfully quitting (at one month post quit) from April 2 to March 24 - Equates to 4288 quits over the period 547 Mar- Reporting Indicator HEAT Measure & Detail APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR Period Cumulative Comments Revised data has been updated from April. Trajectory for Aug = 895 Cumulative Trajectory for Sep = 9 Cumulative Trajectory for Aug = 64 Quartely Trajectory for qtr ending June = 98 Cumulative Trajectory for July = 479 Efficiency Child Fluoride Varnish Applications Achieve at least 6% of 3 and 4 year old children in each SIMD quintile to receive at least 2 applications of fluoride varnish per year by March 24.52% Dec- Reporting on a quarterly basis and shows the worst performing quintile. Reports received 4 months in arrears - June data available end Oct 2. Trajectory for March =.5% Financial Performance Operate within agreed revenue resource and capital resource limits, and meet cash requirement. 57k Mar- Cash Efficiencies Deliver a 3% efficiency saving to reinvest in frontline services % Mar- 84% 84% 8% 82% 97% Preceding Operational forecast at 3th September 2 is showing a 5.7m overspend. With management actions planned/in place to meet LDP target of Breakeven for Revenue and Capital. Savings to September 2 are showing 97% achieved to date against trajectory. Plans being developed to ensure delivery of year end target. Reduce Carbon Emissions To reduce CO 2 for oil, gas, butane and propane usage by 3% each year to 3,94 tonnes by 24/5. 9.5% Mar- Reduce Energy Consumption: To reduce energy consumption by % each year to 293,94kWhs by % Mar- As per previous years the quarterly reports will be one quarter in arrears. Bill are not received until mid October for September. Additional work in accessin A&B invoices still ongoing As per previous years the quarterly reports will be one quarter in arrears. Bill are not received until mid October for September. Additional work in accessin A&B invoices still ongoing

19 Access to Services Outturn NHS HIGHLAND BALANCED SCORECARD 2/2 TOTAL NHS HIGHLAND HEAT TARGETS Date of outturn All Cancer Treatment (3 days) For 95% of patients diagnosed with cancer, the maximum wait from first decision to treat will be 3 days from Dec 2 95% Dec- Suspicion of cancer referrals (62 days) For 95% of patients referred urgently with a suspicion of cancer, maximum wait from referral to treatment is 62 days from Dec 2 96% Dec- 8 Weeks Referral to Treatment 9% of combined admitted & non-admitted patient pathways to be treated within 8 weeks of referral from 3 December 2 7.4% Mar- Drug & Alcohol Treatment: Referral to Treatment By March 23, 9% of clients referred for treatment will wait no longer than 3 weeks from referral Faster access to Specialist Child & Adolescent Mental Health Services (CAMHS) By March 23 no one will wait longer than 26 weeks from referral to treatment for CAMHS 44 Mar- Faster access to Psychological Therapies By Dec 24 no one will wait longer than 8 weeks from referral to treatment Treatment Appropriate for Patient Reduction in Emergency Bed Days for Patients Aged 75+ Reduce emergency inpatient bed days to 548 per, population for aged 75+ by Mar 22 Stroke Unit 8% of stroke patients admitted to a stroke unit on day of admission or day following presentation at hospital by March 22 (9% by March 23) MRSA/MSSA Bacterium: Reduce all staphylococcus aureus bacteraemia (including MRSA) down to.26 or less per acute OBD's by March 23 C. Diff Infections Reduce the bed day rate for age 65+ to.39 per total OBD or less by March Dec- 6 6 Mar-.2 Mar- Rate of Attendance at A&E Agreed reduction in number of attendances to A&E by March 24 to,75 per, population per month 2 Mar- Reporting Indicator HEAT Measure & Detail APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR Period MAR 95.% MAR 98% 87.5% ,28 (estimate) 48.% APR MAY JUN 94.9% APR MAY JUN 86.3% % 95.5% % ,494 (Traj =,427) 93% 96.7% %,528 (Traj =,465) JUL AUG SEP OCT NOV DEC JAN FEB JUL AUG SEP OCT NOV DEC JAN FEB 95.2% %,537 (Traj =,494),52 (Traj =,434) Annual Annual Preceding 4 Quarters Rate/obd Count Comments 282 out of 297 patients = 94.9% Qtr 2 2 (Apr-Jun) figures are validated Screening included from Qtr 3 f 2 onwards Cancer data is monitored by CALENDAR YEAR an not by financial year 47 out of 58 patients = 93% Qtr 2 2 (Apr-Jun) figures are validated Screening included from Qtr 3 f 2 onwards. Cancer data is monitored by CALENDAR YEAR an not by financial year 45.2% linked pathways Data from the new ISD system is currently only available at Highland level.however, no data is available at the moment. It is hoped to be able to show data at CHP level in the near future. No trajectory set. Services not yet reporting are NHSH Occupational Health, EMDR, IPT, Psychodynamic Therapy, Art Therapy. Estimated Figure. Under-reporting due to current in-patients not being reported until discharge. This figure includes an estimated under-reporting of 5% (provisional figure = 4,884). Trajectory April 2 = 52 Hospitals included in target are - Raigmore, Belford, Caithness General and Lorn and Isles The most recent HPS figures are for period Apr-Jun 2. There were SABs =.64 per AOBDs. From Apr - Mar there have been 58 SABs. =.25 per AOBDs The most recent HPS figures are for period Apr-Jun 2. There were 4 cases in patients over 65 =.24 per bed days. Apr - Mar the rate was.39 per bed days Hospitals included in target are - Raigmore, Belford, Caithness General and Lorn and Isles. Issues with extracting data from recently introduced EDIS system in Belford and Caithness General. Seasonal variation is significant; reported beside each monthly figure is the trajectory.

20 NHS HIGHLAND BALANCED SCORECARD 2/2 NHS HIGHLAND CANCER SHEET Health Improvement All Cancer Treatment (3 days) For 95% of patients diagnosed with cancer, the maximum wait from first decision to treat will be 3 days from Dec 2 95% Date of outturn Dec- MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB 95.% 94.9% Reporting Period CommentsIndicator HEAT Measure & Det 282 out of 297 patients = 94.9% Qtr 2 2 (Apr-Jun) figures are validated Screening included from Qtr 3 f 2 onwards Suspicion of cancer referrals (62 days) For 95% of patients referred urgently with a suspicion of cancer, maximum wait from referral to treatment is 62 days from Dec 2 96% Dec- 98% 93.% 47 out of 58 patients = 93% Qtr 2 2 (Apr-Jun) figures are validated Screening included from Qtr 3 f 2 onwards Breast Cancer % Dec- 98.% 94% Qtr 2 2 (Apr-Jun) figures are validated Screening included from Qtr 3 of 2 onwards Urology (prostate, bladder/urology-other now combined) % Dec- % 83% Qtr 2 2 (Apr-Jun) figures are validated Screening included from Qtr 3 of 2 onwards Lung Cancer 95% Dec- 95% 84% Qtr 2 2 (Apr-Jun) figures are validated Colorectal Cancer 9% Dec- % 89% Qtr 2 2 (Apr-Jun) figures are validated Screening included from Qtr 3 of 2 onwards Head & Neck Cancer 88% Dec- % 86% Qtr 2 2 (Apr-Jun) figures are validated Skin Cancer % Dec- % % Qtr 2 2 (Apr-Jun) figures are validated Upper GI (HPB/OG now combined) % Dec- 94.7% % Qtr 2 2 (Apr-Jun) figures are validated Upper GI figures combined from this quarter Gynae - Cervical Cancer % Dec- % % Qtr 2 2 (Apr-Jun) figures are validated Screening patients only from Qtr 3 of 2 onwards Gynae - Ovarian Cancer % Dec- % % Qtr 2 2 (Apr-Jun) figures are validated Haematology Lymphoma Cancer % Dec- % % Qtr 2 2 (Apr-Jun) figures are validated

21 NHS HIGHLAND BALANCED SCORECARD 2/2 TOTAL NHS HIGHLAND LOCAL & STANDARDS SHEET Indicator HEAT Measure & Detail Outturn Health Improvement Breast Feeding at 6-8 Weeks New-born babies exclusively breastfed at 6-8 weeks review to increase from 28.8% in 26/7 to 36% in 2/ 32.% Dec- Immunisations - MMR Monitor MMR uptake rates (% at 5 years old). Target 95% uptake nationally 95.4% Mar- Efficiency STANDARD Date of outturn Sickness Absence Achieve a sickness absence rate of 4% from 3 March % 4.8% Mar- SMR Return Rate Monitor % of SMR returns received (2 month lag averaging over 3 month period). National target is 95% complete in 6 wks from end of discharge 9.2% Mar- Completed Complaints Monitor % of completed complaints resolved within 4 weeks. 63% Target = 8% of complaints responded to within 4 wks (3) Mar- Number of complaints over 4 working days old (at time of monthly report) - target 8 Mar- Number of complaints received - Target = 33 per month or less 3. Mar- No of complaints categorised as high risk* - Target - 7 or less Mar- Efficiency Savings: Same Day Surgery Improved efficiencies by March 2 to increase day case rate to 78.9%. The number of BADS surgical procedures performed in a day case or outpatient setting 82.9% Mar- Efficiency Savings: New Outpatient Appointment DNA rates Improved efficiencies by March 2 to reduce st outpatient attendance DNA rate to 6.9% 6.5% Mar- Reduce Pre-operative Stay Improved efficiencies by March 23 to reduce pre-operative stay by 2% to.65 days for elective surgery.58 Mar- Efficiency Savings: Review to New Outpatient Attendance Ratio Improved efficiencies by March 2 to reduce the ratio of return to new outpatient attendances to Mar- KSF and Personal Development Plan 8% of staff to have had a KSF/PDP review, completed and recorded on E-KSF by March % Mar- 4.7% 4.76% 93.2% 74% % 6.4% % APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR 3.94% 4.7% 9.6% 73% % 6.3% % 96% 4.24% 3.97% 4.68% 4.62% 92.% 79% % 6.7% % 92.5% 86% % 7.% % 54% % 6.5% % 6.% Reporting Period Preceding 4 Quarters Actual Annual Rolling Preceding Preceding Rolling year Preceding Comments Qtr ending June will not be available until December Qtr ending Sept will not be available until mid December Reporting mid month with a 2 month lag averaging over 3 month period. Reports run on DATIX complaints system on the 29th September Aug 2 provisional figure. Aug 2 provisional figure. Analysis excludes specialties GUM and Child Psychiatry due to system upgrade issues. If all existing reviews were completed and signed off the figure would be 6.88%

22 Indicator HEAT Measure & Detail Outturn Access to Services STANDARD STANDARD STANDARD STANDARD TOTAL NHS HIGHLAND LOCAL & STANDARDS SHEET Date of outturn New Outpatient Waiting Times: Maximum Wait 2 Weeks No patient to wait longer than 2 weeks from referral from all sources to st outpatient appointment from 3 March 2 Mar- Inpatient/Day Cases Waiting Times: Maximum Wait 9 Weeks No patient to wait longer than 9 weeks from being placed on waiting list to admission for an inpatient or day case procedure from 3 March 2 Mar- Cataract Waiting Times (Outpatient) Reduce nos of patients waiting over 9 weeks for outpatient treatment to by Dec 27 Mar- Hip Surgery Waiting Times within 24hrs Monitor % of hip fracture operations performed within 24 hours of admission to orthopaedics. % seen within 24 safe operating hours & numbers who failed to achieve this. Target to be maintained = 98% % Mar- Maximum Cardiac Intervention Waiting Times (Angiography) Monitor number of inpatients/day cases waiting over 4 weeks Mar- 8 Key Diagnostic Tests No patients waiting over 4 weeks by March 2. Mar- A&E Waits To Be A Maximum of 4 Hours Increase nos of patients waiting under 4 hours from arrival to treatment to 98% by March % Mar- Advance Booking - GP By 2/ at least 9% of patients are able to book a consultation with a GP or appropriate Healthcare Professional more than 2 working days in advance 96.4% Mar- Treatment Appropriate for Patient STANDARD Cervical Screening rate Monitor % of 2-6 yr old women screened. Target is 8% Uptake as per smear history within last 5 yrs for women aged 2-6 yrs on the LDP target of 5.5 yrs for women aged 2-6 yrs 8.6% Mar- Reduction in Bed Days For Long term Conditions Reduce admission rates (for COPD, Asthma, Diabetes, CHD) to 9,3/, population by Mar Dec- Balance of Care For Older People With Complex Care Needs Increase the level of older people with complex care needs receiving care at home to 3% by March 2 26% Mar- Delayed Discharges To have no clients waiting over 6 weeks by April 2 7 Mar % 99% 8,676 APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR (March-) 8 3 % 2 99% % 5 98% 8.5% 26.% % 5 99% % % 9 Reporting Period Preceding Annual Preceding Comments Due to some data recording issues this information has not been update - ehealth are investigating No update available for this target - not every practice is included in the survey so cannot compare results year on year. Qtr ending September data will be available in November Data provided is up to March-. More recent figures would be unreliable due to under-reporting (time-lag in coding). Data for the st quarter is not yet available STANDARD Dementia Increase nos of patients' with an early diagnosis & management of dementia to 2659 by Mar Mar- N/A Preceding May figures missing due to incomplete data. QOF Calculator continues to have difficulty compiling figures into single report. This causes extra work manually compiling figures.

23 Indic ator Health Efficiency Improvement Financial Performance Operate within agreed revenue resource and capital resource limits, Cash Efficiencies Deliver a 3% efficiency saving to Access to Services Faster access to Specialist Child & Adolescent Mental Health Services (CAMHS) Treatment Appropriate for Patient Stroke Unit 8% of stroke patients admitted to a stroke unit on day of admission or day NHS HIGHLAND BALANCED SCORECARD 2/2 RAIGMORE HEAT TARGETS Date Outturn of APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR Mar- Mar- 42 Mar- 5 # 75 # 67 # 47 # 5 # Reporti ng Precedi ng Annual Comments HEAT Measure & Detail Forecast position at 3th September 2 is showing a 4.4m overspend for March Saving to September 2 are showing 43% achieved to date No trajectory set Hospitals included in target are - Raigmore, Belford, Caithness General and Lorn and Isles.

24 NHS HIGHLAND BALANCED SCORECARD 2/2 RAIGMORE LOCAL & STANDARDS SHEET Indicator HEAT Measure & Detail Outturn LOCAL STANDARDS Efficiency STANDARDS Access to Services STANDARDS 4.29% 3.97% Jan- Sickness Absence Achieve a sickness absence rate of 4% from 3 March 29 SMR Return Rate Monitor % of SMR returns received (2 month lag averaging over 3 month period). National target is 95% complete in 6 wks from end of discharge 87.2% Mar- Completed Complaints Monitor % of completed complaints resolved within 4 weeks. Target=8% of complaints responded to within 4 wks Number of complaints over 4 working days old Date of outturn 63% (6) Mar- (at time of monthly report) - target 5 Mar- Number of complaints received - Target 5 per month or less 6 Mar- No of complaints categorised as high risk* - Target - 4 or less Mar- Efficiency Savings: Same Day Surgery Improved efficiencies by March 2 to increase day case rate to 82.7%. The number of BADS surgical procedures performed in a day case or outpatient setting 85.% Mar- Efficiency Savings: New Outpatient Appointment DNA rates Improved efficiencies by March 2 to reduce st outpatient attendance DNA rate to 6.6% 5.9% Mar- Reduce Pre-operative Stay Improved efficiencies by March 23 to reduce pre-operative stay by 2% to.67 days for elective surgery.59 Mar- Efficiency Savings: Review to New Outpatient Attendance Ratio Improved efficiencies by March 2 to reduce the ratio of return to new outpatient attendances to Mar- KSF and Personal Development Plan 8% of staff to have had a KSF/PDP review, completed and recorded on E-KSF by March % Mar- New Outpatient Waiting Times: Maximum Wait 2 Weeks No patient to wait longer than 2 weeks from referral from all sources to st outpatient appointment from 3 March 2 Mar- 4.5% 4.6% % 6.2% % APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR 92.% 75% 8 3.6% 4.4% 9.% 8% % 5.5% % % 4.% 9.3% 79% % 6.% % % 3.97% 9.8% 9% % 6.% % % % 6.% % % 9 Reporting Period Actual Annual Rolling Preceding Preceding Rolling year Preceding Comments Reporting mid month with a 2 month lag averaging over 3 month period. Reports from the DATIX complaints system run on the 29th September If all existing reviews were signed completed and signed off the figure would be 6.4% STANDARDS STANDARDS STANDARDS Inpatient/Day Cases Waiting Times: Maximum Wait 9 Weeks No patient to wait longer than 9 weeks from being placed on waiting list to admission for an inpatient or day case procedure from 3 March 2 Mar- Cataract Waiting Times (Outpatient) Reduce nos of patients waiting over 9 weeks for outpatient treatment to by Dec 27 Mar- Hip Surgery Waiting Times within 24hrs Monitor % of hip fracture operations performed within 24 hours of admission to orthopaedics. % seen within 24 safe operating hours & numbers who failed to achieve this. Target to be maintained=98% % Mar- Maximum Cardiac Intervention Waiting Times (Angiography) Monitor number of inpatients/day cases waiting over 4 weeks Mar- 8 Key Diagnostic Tests No patients waiting over 4 weeks by March 2. Mar- A&E Waits To Be A Maximum of 4 Hours Increase nos of patients waiting under 4 hours from arrival to treatment to 98% by March % Mar- Treatment Appropriate for Patient Delayed Discharges To have no clients waiting over 6 weeks by April 2 2 Mar- 7 98% 93% 98% 2 % 3 98% 4 % % % 27 % Due to some data recording issues this information has not been update - ehealth are investigating

25 Health Improvement Alcohol Brief Interventions Achieve 42 brief interventions in line with SIGN 74 guidelines by March Mar- Inequalities Targeted Cardiovascular Health Checks Achieve 45 inequalities targeted cardiovascular Health Checks during 2/2 23 Mar- Healthy Weight of Children Achieve 44 interventions for child healthy weight intervention programme for 2-5 year olds over 3 years ending March Mar- Smoking Cessation 7.5% of the general smoking population target in the NHS Board successfully quitting (at one month post quit) from April 2 to March 24 - Equates to 4288 quits over the period 573 Mar- Efficiency Outturn NHS HIGHLAND BALANCED SCORECARD 2/2 NORTH HIGHLAND CHP HEAT TARGETS Date of outturn Child Fluoride Varnish Applications Achieve at least 6% of 3 and 4 year old children in each SIMD quintile to receive at least 2 applications of fluoride varnish per year by March 24 % Dec- Financial Performance Operate within agreed revenue resource and capital resource limits, and meet cash requirement Mar- Cash Efficiencies Deliver a 3% efficiency saving to reinvest in frontline services 73% Mar- Access to Services Drug & Alcohol Treatment: Referral to Treatment By March 23, 9% of clients referred for treatment will wait no longer than 3 weeks from referral Faster access to Specialist Child & Adolescent Mental Health Services (CAMHS) By March 23 no one will wait longer than 26 weeks from referral to treatment for CAMHS Mar- Faster access to Psychological Therapies By Dec 24 no one will wait longer than 8 weeks from referral to treatment Treatment Appropriate for Patient Reduction in Emergency Bed Days for Patients Aged 75+ Reduce emergency inpatient bed days to 543 per, population for aged 75+ by Mar 22 Reporting Indicator HEAT Measure & Detail APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR Period ,479 (estimate) % % % ,47 47% Cumulative Revised data has been updated from April. Trajectory for Aug = 225 Cumulative Trajectory for Sep = 9 Cumulative Trajectory for Aug = Cumulative Trajectory for July = 56 Reporting on a quarterly basis and shows the worst performing quintile. Reports received 4 months in arrears - June data available end Oct 2. Trajectory for March =.5% Preceding 5692 Dec- Annual Stroke Unit 8% of stroke patients admitted to a stroke unit on day of admission or day following presentation at hospital by March 23 (9% by March 22) Annual Comments Forecast position at 3th September 2 is showing a.47m overspend for March 22 Savings to September 2 are showing 47% achieved to date against trajectory. Plans being developed to ensure delivery of year end target Data from new ISD system is currently not available at CHP level. Estimated Figure. Under-reporting due to current inpatients not being reported until discharge. This figure includes an estimated under-reporting of 5% (provisional figure = 5,28). Trajectory for April Hospitals included in target are - Raigmore, Belford, Caithness General and Lorn and Isles. Data not available at Hospital level currently