RTT Recovery Planning and Trajectory Development: A Cambridge Tale

RTT Recovery Planning and Trajectory Development: A Cambridge Tale Linda Clarke Head of Operational Performance Addenbrooke s Hospital I Rosie Hospital

Apr 2014 May 2014 Jun 2014 Jul 2014 Aug 2014 Sep 2014 Oct 2014 Nov 2014 Dec 2014 Jan 2015 Feb 2015 Mar 2015 Apr 2015 May 2015 Jun 2015 Jul 2015 Aug 2015 Sep 2015 Oct 2015 Nov 2015 Dec 2015 Jan 2016 Feb 2016 83.5% 84.0% 84.7% 89.2% 88.9% 88.2% 90.3% 90.5% 90.6% 89.6% 89.3% 89.0% 88.1% 88.5% 89.90% 92.1% 96.2% 97.8% 98.0% 97.9% 97.4% 97.2% 97.5% The need for RTT Recovery at CUHFT The Trust had a background of delivery of the RTT Incomplete Standard, averaging 97% against the 92% standard. The Trust has failed to achieve the RTT performance standard since December 2014. Less than half the reportable specialties were achieving the required 92% standard. Referral to Treatment Incomplete Standard (92% < 18 weeks) 100% 98% 96% 94% 92% 90% 88% 86% 84% 82%

Causes of the deterioration in performance We engaged the Elective Care Intensive Support Team to help us with recovery planning in March 2015. Below was their assessment of the causes of our position: Data quality Despite significant preparatory work at CUHFT, the introduction of a new clinical information system has led to reductions in data quality as far as waiting times reporting is concerned. Planned activity reductions associated with new EPR implementation CUHFT quite correctly took the decision to reduce activity immediately prior to, during, and after the implementation of Epic. However, this has necessarily contributed to the increase in the number of patients waiting. Continuing pressure on resources as with any health system, if capacity does not match or exceed demand, then waiting times and numbers will increase. CUHFT has clearly encountered issues with both sides of this equation: referral demand has increased beyond expected levels in a number of specialties; capacity has been constrained, particularly in terms of admitted care as a consequence of the emergency demand on bed capacity from the frail elderly population, which has led to higher levels of elective cancellations. In addition to these issues, in order to support the financial challenges facing the Trust, in June 2015 a reduction in premium rate payments to staff was implemented. This reduced the volume of waiting list initiatives undertaken, and impacted on Theatre s ability to staff all elective capacity whilst faced with high vacancy rates.

Overview of Session Why are we failing? Action planning Trajectory Setting Financial Consequences Stakeholder Agreement Monitoring the plan

Why are we failing? Action planning Trajectory Setting Financial Consequences Stakeholder Agreement Monitoring the plan

Why is the Trust not delivering referral to treatment (RTT) in 18 weeks? You cannot begin to outline your recovery plan until you know what the causes of your underperformance are: Which specialties are not consistently delivering the 92% standard? For those that are not: Is capacity and demand in balance in those specialties (sub specialties)? Are the pathways deliverable in 18 weeks? Are the waiting lists a manageable size?

Is capacity in balance with demand? Using the NHS IMAS Intensive Support Team Capacity and Demand Models you can identify if there is an imbalance in your services. Models are available for the different stages of the pathway: Outpatients, Inpatients and Diagnostics. In the summary of the outputs from the models below, which service is more sustainable? ENT Outpatient Model Urology Inpatient Model Indicator Per Week Mean Capacity 70 Mean Decisions to Admit 79 Of Which Urgent 34 Of Which Routine 46 Mean Removals without Treatment (ROTT) 9 Mean Net Change on Waiting List 0 65 th Percentile of DTAs - ROTT 75 85 th Percentile of DTAs - ROTT 91 Indicator Mean referrals Received Of Which Urgent Routine Paper/Fax Routine Choose & Book Mean DNAs (routine referrals) Of Which Reappointed Of Which Discharged Mean Rearranged Slots Mean Core Capacity Mean Ad-hoc Capacity Mean Total Capacity Net Weekly PTL Size Change Per Week 193 50 64 79 11.4 3.4 8.0 0.0 163 0 163 +33

Are the pathways deliverable in 18 weeks? For common high volume conditions you should have a clear idea of what a typical pathway should look like. In simple terms this should set out what should happen to the patient and in what order. There should also be clarity as to the required timing of the following events : First outpatient appointment; Diagnostic test; Decision to admit; The capacity and demand models require these parameters to help determine the appropriate waiting list size. For example, in general we recommend to our surgical specialties to work to a 5 week maximum outpatient wait, and to allow a maximum of 8 weeks for treatment following decision to admit.

Sustainable Waiting list size More patients waiting means a longer waiting time, and if the number waiting is too large then the standard cannot be achieved even if capacity and demand are in balance. Based on the demand profile and the desired waiting time, the IST Models can advise on maximum waiting list size and therefore what reduction is required. Below is the output from the Urology Inpatient model which had shown the demand and capacity had been in balance. However, the waiting list was too large to deliver a maximum inpatient wait of 8 weeks: Indicator WL consistent with RTT delivery Current waiting list size Required reduction in backlog 337 to 373 677 304 to 340

Outputs of our Capacity and Demand Modeling The outputs of our work identified: Of the 19 services we modelled, 10 had an underlying imbalance in demand and capacity that if left would lead to ever increasing waiting times. These specialties required recurrent actions to be included within their recovery plans, not just backlog reduction. The extent of this was surprising, and reflects the level to which the Trust had become reliant upon additional adhoc waiting list initiative activity to prop up core scheduled capacity. Across the specialties we identified a need to reduce outpatient waiting lists by 8,000 patients, and inpatients waiting lists by 2,000 in order to achieve maximum waiting time parameters consistent with sustainable delivery of an 18 week wait.

Why are we failing? Action planning Trajectory Setting Financial Consequences Stakeholder Agreement Monitoring the plan

Drivers for identifying Appropriate Actions Capacity and demand shortfall versus waiting list reduction Specialties with a capacity and demand imbalance require Recurrent actions. Without them, when fixed term actions cease, the waiting list will increase again. If the service only needs to reduce a backlog then actions should be fixed term or you may be left with costs / resources that are not required. Financial Drivers We all have a responsibility for NHS finances and should seek the most cost effective actions to support recovery. Actions to increase productivity to deliver more activity for the same cost are more likely to be supported, and will be in line with Cost Improvement Programmes. The financial cost to the whole local health system should be considered e.g. Significantly increasing activity may be unaffordable for commissioners, there could be commissioned capacity that is underutilised in other parts of the health system; or there could be initiatives to reduce real demand. Premium rate actions such as agency pay rates and outsourcing to the independent sector would be less favourable. If sufficient actions cannot be found from more cost effective solutions, then it can be helpful to present high cost actions as an optional additional scenario, outlining the cost versus the benefit to the recovery trajectory.

Principles of Action Planning Detailed Quantitative Needs to contain an appropriate level of detail to explain what the action involves. Useful to highlight which pathway stage the action is targeting: outpatient, diagnostic, admitted. Each action should quantify the effect that it will have i.e. how many additional cases per week will be undertaken. Owner Implementation date Risk Assess The role of the individual responsible for the action should be clear, and the responsible Organisation From what date will the action start to deliver benefit. It is also useful to define if this is a recurrent action or time limited Key potential risks to the actions should be identified and the scale of risk. High risk actions might require mitigation plans from the outset. Supported Actions require the support and ownership by Clinical teams and commissioners to be credible.

Themes of Actions Actions to support RTT recovery planning fall into one of the following themes. Demand Management Data Quality Increase Capacity / Improve productivity Recovery Plan

Clinical thresholds Decommission services Fit to refer Waiting list validation Adhere to Access Policy Clinic outcome capture Community providers Referral guidelines Pathway Trackers Referral redirection Clock start capture Patient choice hub Advice and Guidance Ring fence elective capacity Outsource Independent sector Reduce DNA rates Theatre efficiency Nurse / AHP led clinics Job Plan reviews Transfer to other NHS providers Telephone follow up Length of Stay Improvement Outpatient template reviews 1 st /FU ratio Waiting list initiatives 7 day services / extended days Recruit medical / nursing One-stop clinics Expand physical capacity

Why are we failing? Action planning Trajectory Setting Financial Consequences Stakeholder Agreement Monitoring the plan

Recovery Trajectories As Recovery Actions are quantitative, with implementation dates, they can define numerically when the waiting list reductions will have achieved the recommended target waiting list size. The IST capacity and demand models support you to record the quantitative impact of your actions This should be operationally realistic for example don't forget that elective activity is always lower at Christmas, and when bank holidays fall. From the examples on your tables, when would the Urology and ENT plans achieve the target waiting list size? You will notice: Each action has it s own planned implementation / start date ENT has split their actions into 2 scenarios: Scenario 1 with all the actions to address the recurrent shortfall in capacity v demand Scenario 2 with additional actions to reduce the waiting list size.

21/9/15 5/10/15 19/10/15 2/11/15 16/11/15 30/11/15 14/12/15 28/12/15 11/1/16 25/1/16 8/2/16 22/2/16 7/3/16 21/3/16 4/4/16 18/4/16 2/5/16 16/5/16 30/5/16 13/6/16 27/6/16 11/7/16 25/7/16 8/8/16 22/8/16 Recovery trajectories cont.. The models also graphically present the trajectory, and allow you to record your actual progress 2500 ENT Outpatient Actual PTL Against Plan 2000 1500 1000 500 0 Scenario 1 Plan Scenario 2 Plan Lower Target PTL Upper Target PTL Actual PTL

Summary of Recovery Trajectories Can achieve recovery by end Quarter 4 with no additional cost Sustainable core capacity but high proportion of overall Trust backlog Significant shortfall in capacity to meet demand and require investment to prevent them from further deteriorating as well as to reduce backlog Diagnostic 6 week wait Service Incomplete > 18 wks Sept 15 Recurrent Shortfall In Capacity Recovery Sustainable RTT 92% Trust Total 3907 Mar-16 Ophthalmology 480 No Feb-16 Feb-16 Dermatology 289 Yes Jun-16 May-16 Rheumatology 115 Yes May-16 Apr-16 General Surgery 140 No Feb-16 Feb-16 Paediatric Urology 52 Yes Feb-16 Jan-16 Gastroenterology 89 No Nov-15 Achieving Orthopaedics 499 No Not achieved Jun-16 Urology 195 No Aug-16 May-16 ENT Incl Paediatric 636 Yes Aug-16 Jul-16 Oral Surgery & Maxillo- 206 Yes May-16 Apr-16 Facial Cardiology 118 Yes Mar-16 Mar-16 Paed Orthopaedics 111 Yes Not achieved Nov-16 Paediatric Surgery 107 Yes Apr-16 Mar-16 Vascular Surgery 89 Yes No recovery* No recovery* Pain Management 78 Yes May-16 Mar-16 HPB Surgery 47 Yes May-16 Apr-16 Gynaecology 103 No Mar-16 Achieving MRI 301 Yes Jan-16 Jan-16 Neurophysiology 250 No Feb-16 Feb-16

Why are we failing? Action planning Trajectory Setting Financial Consequences Stakeholder Agreement Monitoring the plan

Financial Consequences Work with your finance managers and commissioning team to cost the actions in your plans. Consider: Whose cost will it be? Trust or Commissioner? If activity is going to be undertaken by another provider is that a loss of income your Trust has assumed in their financial planning? If the activity is in the activity plan, and budgets have already been set to deliver that at standard cost, are your plans now suggesting you need exceptional / premium rate funding to deliver? If activity is above the agreed activity plan, will the commissioner pay for it, and will the income cover the Trust costs? If you are on a block contract is it assumed the activity volumes have already been paid for. If so, is the full cost to the Trust? Will the cost be recurrent or fixed term? Will the cost span financial years? What is your process to get Board approval for any recovery costs? What are the contractual financial consequences of not recovering?

Summary of Financial Consequences Can achieve recovery by end Quarter 4 with no additional cost Sustainable core capacity but high proportion of overall Trust backlog Significant shortfall in capacity to meet demand and require investment to prevent them from further deteriorating as well as to reduce backlog Diagnostic 6 week wait Service Incomplete > 18 wks Sept 15 Recurrent Shortfall In Capacity Sustainable RTT 92% Recovery Cost 2015-16 Recovery Cost 2016-17 Recurrent Cost Trust Total 3907 Mar-16 2,252,401 2,137,860 871,356 Ophthalmology 480 No Feb-16 Feb-16 15,349 0 0 Dermatology 289 Yes Jun-16 May-16 Rheumatology 115 Yes May-16 Apr-16 General Surgery 140 No Feb-16 Feb-16 Paediatric Urology 52 Yes Feb-16 Jan-16 Gastroenterology 89 No Nov-15 Achieving Recovery Cost Orthopaedics 499 No Not achieved Jun-16 489,253 297,229 0 Urology 195 No Aug-16 May-16 92,412 30,222 0 ENT Incl Paediatric 636 Yes Aug-16 Jul-16 929,854 926,207 0 Oral Surgery & Maxillo- 206 Yes May-16 Apr-16 107,298 175,886 176,000 Facial Cardiology 118 Yes Mar-16 Mar-16 46,357 120,000 120,000 Paed Orthopaedics 111 Yes Not achieved Nov-16 91,990 225,236 225,236 Paediatric Surgery 107 Yes Apr-16 Mar-16 48,803 65,000 65,000 Vascular Surgery 89 Yes No recovery* No recovery* 70,582 0 0 Pain Management 78 Yes May-16 Mar-16 64,803 12960 HPB Surgery 47 Yes May-16 Apr-16 78,000 Gynaecology 103 No Mar-16 Achieving 6,500 0 0 MRI 301 Yes Jan-16 Jan-16 178,200 285,120 285,120 Neurophysiology 250 No Feb-16 Feb-16 33,000 0 0 * Costing includes the transfer of activity required to recover but alternative provider not yet identified.

Why are we failing? Action planning Trajectory Setting Financial Consequences Stakeholder Agreement Monitoring the plan

Stakeholder Agreement Key stakeholders include: Clinical Teams Trust Board Commissioners Regulators (Monitor / TDA / Care Quality Commission) Engage stakeholders during the development of the plan, do not just present a fait accompli Prepare an RTT Improvement Plan document that can be shared with all stakeholders for agreement. Ours included the following section headings: - Executive Summary Background Data Quality Current Position Mitigating Patient Harm Approach to Recovery Planning Summary of Specialty Action Plans Financial Implications Contractual Consequences Risks Monitoring and Governance

Why are we failing? Action planning Trajectory Setting Financial Consequences Stakeholder Agreement Monitoring the plan

Monitoring and Governance Arrangements Weekly PTL Meeting Patient level discussion of longest waiters, Chaired by Head of Operational Performance Frequency: weekly Attendees : Head of Operational Performance, Divisional Operations Managers Operational Taskforce overarching group, Chaired by Chief Operating Officer Frequency: weekly Attendees : COO, Dir. of Operations, Associate Directors of Operations, Head of Operational Performance Divisional / Executive Performance Meetings: Frequency: monthly Attendees : Executive Board Members, Senior Divisional Management teams RTT Recovery meetings: Frequency: bi-weekly Attendees : Lead CCG, COO, Dir. Of Commissioning, Head of Operational Performance, Divisional Teams as required Finance and Performance (Board sub-committee) Frequency: monthly Attendees - Non- Executive Chair, Executive Board Members Monitor Improvement Board Frequency: monthly Attendees: Executive and Non- Executive Board Members, Monitor, NHS England, Commissioners, CQC,

03/01/2016 10/01/2016 17/01/2016 24/01/2016 31/01/2016 07/02/2016 14/02/2016 21/02/2016 28/02/2016 06/03/2016 13/03/2016 20/03/2016 27/03/2016 03/04/2016 04/10/2015 11/10/2015 18/10/2015 25/10/2015 01/11/2015 08/11/2015 15/11/2015 22/11/2015 29/11/2015 06/12/2015 13/12/2015 20/12/2015 27/12/2015 03/01/2016 10/01/2016 17/01/2016 24/01/2016 31/01/2016 07/02/2016 14/02/2016 21/02/2016 28/02/2016 06/03/2016 13/03/2016 20/03/2016 27/03/2016 03/04/2016 Total Still Wiaiting Net changes to number of patients over 18 weeks KPIs Using data from the Weekly UNIFY returns RTT Backlog & Still Waiting Volumes - Weekly performance 89.2% (Backlog target <2807, 981 over tolerance to achieve 92%) 8500 500 Trends in Over 18 week waiters 5000 44,000 8000 42,000 40,000 38,000 36,000 34,000 32,000 30,000 7500 7000 6500 6000 5500 35083 5000 4500 3788 4000 3500 3000 Total incomplete Total backlog 400 300 200 100 0 4500 4000 3500 3000 2500 Adm Backlog movement Non Adm Backlog Movement Total Net change to Backlog (>18 weeks) Total Backlog -100 Week 2000 Breach DOH Group Tolerance for 92% Variance in last week X-Other 991 1237 1215 1190 1315 1258 1224 1211 1267 1152 1097 1103 1079 1113 1131 18 Trauma & Orthopaedics 191 656 656 616 601 605 594 606 571 569 536 545 562 574 619 45 ENT 203 689 689 661 687 683 690 708 772 652 593 559 556 572 564-8 Ophthalmology 195 468 416 384 347 315 301 289 287 275 262 235 240 255 224-31 Dermatology 159 253 253 237 222 181 168 166 177 180 188 166 166 185 221 36 Rheumatology 70 93 81 77 90 92 88 107 95 95 79 61 53 57 71 14 Urology 106 233 221 232 228 208 201 209 204 188 186 176 172 169 184 15 Gastroenterology 154 100 115 73 54 58 40 43 33 27 29 26 37 46 63 17 Cardiology 104 115 141 166 153 136 159 126 131 144 140 162 143 163 118-45 General Surgery 86 197 151 116 107 107 101 105 103 107 95 84 81 89 92 3 Oral Surgery 71 205 213 205 218 207 194 197 202 222 234 238 227 243 247 4 Gynaecology 83 36 35 42 42 43 41 25 26 30 35 38 43 46 49 3 Plastic Surgery 63 170 160 168 134 132 142 144 135 126 124 123 128 127 135 8 Neurosurgery 93 105 94 83 95 77 103 120 95 109 120 85 94 106 121 15 Neurology 108 41 46 44 49 59 78 105 103 30 46 60 48 27 19-8 Thoracic Medicine 41 13 10 3 4 7 8 16 17 17 20 26 24 25 31 6 General Medicine 8 14 8 12 13 8 7 9 9 7 0 1 2 2 2 0 Geriatric Medicine 7 5 4 3 2 2 1 2 5 5 3 3 4 2-2 Grand Total 2705 4630 4508 4312 4361 4178 4139 4187 4229 3935 3789 3691 3658 3803 3893 90 "Other" Top Specialties Pain Management 92 200 191 181 217 220 170 158 151 108 78 72 76 83 89 6 Maxillo-facial Surgery 81 144 138 123 121 123 130 130 138 155 155 189 146 170 196 26 Paediatric Orthopaedics 26 119 123 105 112 101 110 106 113 100 102 103 98 93 110 17 Vascular Surgery 34 110 101 95 91 96 85 77 78 70 63 60 60 60 66 6 HPB Surgery 18 105 106 114 122 124 118 122 121 115 115 118 125 115 118 3 120 100 80 60 40 20 0 Over 40 Weeks 52 week + Over 40 wk

Action Plan Monitoring Quantitative Monitoring Waiting List sizes against trajectory using the IST Models Actual weekly activity compared to plan Actual demand compared to plan Actual removals compared to plan Action Plan Progress Update Narrative action plan to provide assurance and explanation on progress with individual actions. Summary of Specialty Plans Each Individual Specialty Plan Risk and Issues Log Quality Impact Assessment

Further Information: Contact details: linda.clarke@addenbrookes.nhs.uk NHS IMAS Elective Intensive Support Team models & Elective Care User Guide can be found at: www.nhsimas.nhs.uk/ist