SCHEDULED CARE WAITING TIMES REPORT

NHS Lanarkshire Headquarters, Kirklands Fallside Road, Bothwell G71 8BB www.nhslanarkshire.org.uk SCHEDULED CARE 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 September 2014 Progress against national waiting time guarantees as they impact on access to Mental Health Services and local Community AHP targets 2. ACUTE SERVICES l) Treatment Time Guarantee (TTG) Delivery of the Treatment Time Guarantee has continued to be challenging and during the month of September there were a total of 3 TTG breaches. All 3 of the breaches were at Hairmyres Hospital. 2 of the TTG breeches were Orthopaedic Foot and Ankle patients and breached due to lack of Consultant capacity. The remaining 1 breach was a vascular patient and the breach was due to a failure in an administrative process. 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. The pressures in Foot and Ankle surgery are acutely exacerbated as this is a service predominantly provided by one consultant. The SGHD Access Team have been kept fully appraised of the issues during this period and have indicated that discussion is taking place centrally with senior clinicians and managers on the way forward with Foot and Ankle services. Work is continuing within NHS Lanarkshire to review the patients currently on the Foot and Ankle waiting list and, working with the multi disciplinary team to look at both conservative and surgical treatment options for patients. The detailed analysis of all the key components of Orthopaedic Demand, Capacity, Activity and Queue (DCAQ) has been completed and in order to inform this further, work is now nearing completion on the DCAQ for individual consultants. In particular the individual conversions rates from outpatient appointment to surgery are being analysed in conjunction with benchmarking data. 1

As previously mentioned Foot and Ankle surgery remains a significant area of concern and pressure. During the month of October local solutions, in addition to those previously highlighted have included maximising operating capacity and minimising clinic capacity. Again it s predicted that there will be Foot and Ankle TTG breaches during the month of October, to date there have been 5 TTG breaches. NHS Lanarkshire has again sent some patients to the Independent Sector during the month of October. A further verbal update with be provided at the Board meeting. A formal options paper in regard to potential capacity solutions as well as demand management will be presented to the CMT in October such that both can be brought back into equilibrium. Clearly this work must ensure that patients are receiving positive outcomes following surgery and that those in most clinical need are prioritised. 2.2) 18 Weeks RTT The finalised 18 week RTT position for September is 93.4% up from 93% in August. 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. Over the course of September the number of inpatients and day cases waiting in weeks 10 to 12 has stabilised to 441 from a baseline in May of 300. This is demonstrable within the RTT performance. The profile of such waits 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 3 TTG breaches in September in Orthopaedics and this is set in the context of 238 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 ENT both have increasing patient numbers waiting over 9 weeks and as previously reported there are vacancies due to arise in both specialties over the next three months and it is reported to be a challenging market for recruitment into these specialties. In regard to out patients it was reported there are 811 patients waiting over 12 weeks at the end of September, this is an adverse movement of 24 from August (787 in August). The main areas are accounted for as Respiratory (187 and no change from the August position), Rheumatology (228 and an increase of 101 from the August position), Pain Clinic (158 and an increase of 10 from the August position) and Orthopaedic Foot and Ankle (69 a decrease of 6 from the August position). Neurology are also reported as having 13 patients waiting 2

over 15 weeks but on investigation it appears that these are patients who had been sent to Ross Hall for treatment as part of the established contract arrangements but had not been removed from NHS Lanarkshire s data set after being seen. This is therefore a data quality issue which has been notified to colleagues in Information Services and the exclusion of the 13 patients would bring the figure back in line with the August position. The Access Team are continuing to work proactively with the site teams to reduce the numbers of patients waiting over 12 weeks. 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. With regard to Rheumatology there is now 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. It has therefore been agreed with the clinicians that there will be a multidisciplinary clinical review of all patients waiting over 8 weeks. Again regular meetings with the clinical team have been established. The detail of the number of patients waiting over stage of treatment targets, by specialty, is attached as Appendix 1. The Director of Access and the Divisional Medical Director (Acute) are working on producing a paper on Foot and Ankle Services and this paper will be concluded by the end of October. There has been and continues to be a significant input into the operational management of the service. On a positive note the ENT position has improved with only 28 patients waiting over 12 weeks. The Capacity Plan is broadly in financial balance after the first 6 months of the financial year. However the pressures in orthopaedics and scopes may have an adverse impact on this in the next quarter. 2.4) Audit Scotland Reporting As has been previously indicated the Acute OMC and Board will be in receipt of information in regard to the application of Unavailability and also the monthly audit of a sample of records to ensure compliance with TTG and Access Policy guidelines and standards. The unavailability report that is accessed from national data has not been updated since June (Qtr 1 2014/15). The next publication is at the end of November which will give us the end of September (Qtr 2) comparison. The previous unavailability graph Appendix 2) is the latest available which shows the NHS Lanarkshire level of applied unavailability in comparison to NHS Scotland as a whole. The trend graph shows that NHS Lanarkshire has 3

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 statistics will be undertaken for the Acute OMC in November. 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. Compliance remains high at 90%; however the sample continues to show that the main issue is the lack of evidence of a letter in the system that has generated a noncompliance issue. These issues are addressed through the weekly waiting times meetings. The introduction of automatically generated TTG letters is scheduled to go live on 3 rd November and this will eliminate the potential for lack of availability of letters, thus improving overall compliance. 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 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; 62 31 Q1 2014 95.9% 95.9% Q2 2014 95.6% 97.6% Un-validated performance for Q3 (validation - January 2015) July 96% 99.2% August 95.9% 97.6% September 100% 99.1% Q3 97.3% 98.6% 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 under 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. 4

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 At present, there are three main areas within the MSK Physiotherapy service which are under waiting time pressures. These areas include Biggar, North Locality and CamGlen. In total there is 229 patients for are waiting beyond the LTTG and 5 patients who are waiting beyond 126 days (18 weeks). In the Biggar area the physiotherapist located at Biggar Health Centre has returned to work following a protracted period of sick leave. The service is making every effort to reduce these waiting times. Patients have been offered alternative appointments at either Carluke or Lanark Health Centres, but unfortunately the 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 2014. The impact of the recruitment process associated with issues in filling acute rotational vacancies, are still having an adverse effect on primary care, particularly in the North Locality Again, patients have been offered appointments an alternative clinic, but all offers of alternative arrangements have been rejected. Within the CamGlen area, the service has been reduced due to two members of staff having taken up posts elsewhere within NHS Lanarkshire. This has created a gap in the treatment provision in this area. However, the vacant posts have been recruited into, and it is anticipated that the service will return to the LTTG in the near future. However, 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 times are all within the North CHP and currently stand at 146 days (20 weeks). However, the total number of patients waiting beyond the LTTG has reduced to a total of 19 patients. Within the North CHP there have been issues with long term staff absences within the service. The service has indicated that these staff members are about to return to work and it is anticipated that upon their return the waiting times situation will resolve. 5

There are no patients waiting above the local waiting time standard across the South CHP. In total, 98% of podiatry patients are being seen within the LTGG. 3.4) Occupational Therapy (OT) The paediatric OT service is within the LTTG. 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. A meeting was held recently with the Director of Access, Acute Services, and the Director for AHPs the Rheumatology Service Manager, and the lead OT Therapist for Rheumatology. This was a positive meeting with a number of avenues being looked at to bring the Rheumatology OT waiting times back into balance. 3.5) Dietetic Services The dietetic service is meeting the local target of 84 days (12 weeks) albeit one patient is recorded as waiting just over the 12 week target. Therefore, 99% of all dietetic patients are being seen within the local target time An area of concern has emerged concerning the funding of the dietetic Bariatric Service. The number of referrals for Bariatric surgery to treat morbid obesity is ever increasing. The service was established approximately 6 years ago. All patients who are undergoing surgery require to see a dietitian who has a key role involving dietetic assessment, supporting behaviour change, and dietary manipulation. Patients receive regular dietetic monitoring to achieve/meet the agreed criteria for surgical intervention. The dietetic interventions are carried out at every stage of the patient journey. Currently there are 115 Bariatric patients who are being treated/monitored by the Dietetic Service. It has emerged that the funding of the dietetic element of this service is at best haphazard. Over the last six years funding has been released in six month blocks which make it particularly difficult to plan any consolidation of the service. Currently, the funding of the services has been agreed to March 2015. It has been intimated that in future surgical sessions may move to a regional service under the National Waiting Time Centre/Golden Jubilee Hospital. However, irrespective of where the surgery sessions are to be carried out an agreed plan requires to be produced to support the patient s journey for this treatment regime. In the meantime, the service continues to receive new referrals and there have been 32 new referrals so far this year alone. Patients who undergo Bariatric surgery effectively need to receive lifelong care and therefore numbers continually increase with minimal discharge rates. 6

4) MENTAL HEALTH SERVICES 4.1) Adult Mental Services In the adult mental health service, the longest waiting time is currently 153 days (22 weeks) within the North Locality. There are 14 patients who are recorded as waiting beyond the LTTG. The August 2014 waiting times indicate that 97% of all patients who are attending the service are seen within the LTTG. The 22 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. The service also highlighted issues in relation to staff familiarising themselves in the use of TrakCare. It was noted that this issue is being addressed by ehealth TrakCare trainers. 4.2) Old Age Psychiatry The longest waiting time in old age psychiatry is currently 90 days (13 weeks). There are 4 patients who are waiting in excess of LTTG. As a result, 99% of all patients are being seen within the 84 days (12week) LTTG. 4.3) Psychological Therapies In the psychological therapy service they continue to meet and maintain the current 26- week NTTG. The longest waiting time for the service has increased slightly from 24 to 26 weeks. At least 90% of patients will be seen within the 18 weeks NTTG by the end of December 2014. As at 31st July 2014, 87.5% of patients within NHS Lanarkshire started treatment within 18 weeks (this information is drawn from the Scottish Government return). For comparison, the performance of other NHS Boards is provided below: Ayrshire and Arran 81.6% Borders 44.8% D&G 78.0% Fife 63.4% FV 52.4% Grampian 45.5% GG&C 94.7% Highland no data Lothian no data Tayside 90.3% Lanarkshire 87.5% 7

5. RECOMMENDATION The NHS Lanarkshire Board is asked to note The on-going relatively positive performance on the Treatment Time Guarantee. The very positive performance on the Referral to Treatment target. 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 6. FURTHER INFORMATION For further information about any aspect of this paper, please contact Alan Lawrie - Telephone: 01698 858088. ALAN LAWRIE DIRECTOR OF ACUTE SERVICES 22 nd October 2014 8