Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group Governing Body Meeting In-Common

Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group Governing Body Meeting In-Common Date: Tuesday 7 th November Time: 13.30 Location: Cleve Rugby Club, The Hayfields, Mangotsfield, BS16 9EN Agenda item: 11.1 BNSSG Performance Report Report Author: Report Sponsor: Janine Bentley, Performance Analyst Claire Thompson, BNSSG Delivery Director Penny Harris, Programme Director, Commissioning 1. Purpose To inform the Governing Body of the year-to-date performance position (August 2017 data). 2. Recommendations To note the performance position of the CCG and that of our key providers, including the risks, mitigating actions and responsibilities as appropriate. To note the ongoing changes to this report in response to feedback from the Governing Body. 3. Background The performance in this report focusses on the national indicators within the NHS Constitution and the metrics against which NHS England monitor and assure the CCG. 4. Key performance metrics at August 2017 A&E performance is not being delivered to the national standard of 95% for BNSSG CCGs, however there is a continued upward improvement for UHB. WAHT performance has dropped by 2% following last month s improvement

Public Governing Body Meeting In-Common and NBT performance has further declined from an existing underperformance of 76% to 73% and is a very significant risk to delivery of this standard. 18 week elective referral to treatment times are being delivered at 90.3% in line with the CCG plan, which is an under achievement against the national standard of 92%. However there has been a further increase in patients waiting over 52 weeks for planned care which gives significant cause for concern. This is driven in the main by NBT orthopaedic waits, an issue which is now subject to a Remedial Action Plan that gives commissioners some confidence that the deteriorating position will be reversed. UH Bristol has improved their position from 45 to 32 patients in the last month. 62 day cancer performance was delivered for BNSSG CCGs for the first time this year in August. Consistent and sustained delivery is anticipated from March 2018. 5. Financial/resource implications None 6. Legal implications None 7. Risks/mitigations Key risks and mitigations in relation to each of the performance standards are noted within the report. Improvement trajectories and contractual notices in place where these are warranted reflecting the level or duration of underperformance. Where appropriate further detail of the intervention and responsibilities for these are included in the commentary of the report. The improvement plans and contractual sanctions are managed through the appropriate governance route for that work area. 8. Implications for health inequalities None 9. Implications for equalities (Black and Other Minority Ethnic/Disability/Age Issues) None 10. Consultation and Communication including Public Involvement Bristol, North Somerset and South Gloucestershire Clinical Commissioning Groups 2

Public Governing Body Meeting In-Common Not applicable 11. Appendices Appendix 1 BNSSG Performance, Quality & Activity Report Glossary of terms and abbreviations Please explain all initials, technical terms and abbreviations. For guidance please refer to the Jargon Buster and the CCG s Master Glossary both are available on the website. BNSSG NBT UHB WAHT Bristol, North Somerset & South Gloucestershire North Bristol NHS Trust University Hospitals Bristol NHS Foundation Trust Weston Area Health Trust Bristol, North Somerset and South Gloucestershire Clinical Commissioning Groups 3

Item 11.1, Appendix 1 Governing Body In-Common, 7 th November 2017 BNSSG Performance, Quality and Activity Report Month 5 2017/18

Contents Ref. Theme Page 1.0 Executive Summary 3 2.0 Operational plan activity CCG Position 4 3.0 Constitutional Standards 3.1 A&E 7 3.2 Planned Care 10 3.3 Cancer 14 3.4 Quality 17 4.0 Southwest Ambulance Service Foundation Trust (SWASFT) 26 5.0 Provider dashboards 28 2

1.0 Executive Summary The table below identifies the highest priority performance failures for the BNSSG population and key action to address: Issue Action By Whom/When A&E performance deterioration RTT 52-week wait MRSA To end of month 5 a total of 25 cases have been reported across BNSSG against a zero target. Agreed six week improvement plan for NBT performance recovery given critical nature of performance position, to be delivered in September & October. Detailed interventions include: Changes to ED / acute medicine staffing model to better match demand Executive decision makers at internal flow meetings Changes to leadership & internal communications plan to drive home is best expectation Additional on and off site capacity, flexible use of community capacity between providers to reduce discharge delays Daily tracking and review of stranded patients (> 7 day length of stay) Establishment of control centre within trust to manage operations and daily partner discharge meetings Director level oversight of these interventions and system-wide Chief Executive scrutiny and challenge weekly. UH Bristol & NBT performance on >46 week waiters monitored weekly. UH Bristol reducing, NBT off trajectory. Specific actions to deliver improvement at NBT now include: 1) Waiting list pooling & list closures for specific surgeons / procedures 2) Amendments to job plans 3) Redirection of referrals 4) Additional theatre capacity & staffing These are being monitored through the contract access & performance meetings A multi-agency task and finish group will deliver the following key actions to reduce these infections: 1) targeted screening in the community, 2) hospital admission screening, 3) health education, 4) enhanced wound care 5) enhanced clinical awareness Anne Morris (Claire Thompson) October 2017 David Jarrett (David Moss) December 2017 (UHB) March 2018 (NBT) Anne Morris March 2018 3

2.0 Operational Plan Activity Sparklines show trend from April 2016 to July 2017. Direction of travel arrows show trend from April 17 to date. YTD Variance DOT YTD Variance DOT YTD Variance DOT 122897-6284 Co 98971-5289 Nu 28762 230 Total Referrals (G&A) Consultant Led First Outpatient Attendances (Specific Acute) Number of Completed Admitted RTT Pathways Total GP referrals (G&A) Total Other referrals (G&A) Total Non-Elective Admissions (Spells) (Specific Acute) Co YTD Variance DOT YTD Variance DOT YTD Variance DOT 78127-5880 Co 186055 26129 Nu 63054 2142 Co YTD Variance DOT YTD Variance DOT 36999 2169 To Consultant Led Follow- Up Outpatient Attendances (Specific Acute) YTD Variance DOT YTD Variance DOT YTD Variance DOT 44770-404 To 43266-2739 Nu 128528-2447 Total Elective Admissions (Spells) Number of new RTT (Specific Acute) clockstarts [Ordinary Electives + Daycases] To Nu Total A&E Attendances excluding planned follow ups 122351-1458 Nu Nu Number of Completed Non-Admitted RTT Pathways To 4

BNSSG CCGs Position Referrals continue to be significantly below plan with total referrals -4.9% below and GP referrals 7% below plan. Reductions are consistent across all three CCGS. As a result first outpatient appointments are also 2.6% below plan and all trusts are showing reductions on last year. The most significant of these are at Weston (-10.3%) and at private providers (12.6%). There are particular decreases at all trusts in trauma & orthopaedics (T&O) as a result of IFR policies. Year to date outpatient follow up appointments are 16.3% (26129 appointments) over plan. Significant reductions have been built into the plan from Q2 onwards getting steadily more challenging as the year progresses. Across BNSSG the number of Follow up outpatients is 3% higher than last year. Weston is the only trust to see a significant (14.1%) increase in follow up appointments which is related to the planned backlog clearance programme which is subject to a contract performance notice (CPN). There have been reductions in T&O follow ups (-5% or 1434 fewer appointments) across all trusts as a result of reduced elective admissions however there have been increases in other specialties; ophthalmology follow ups have increased by 8.5% (2623 additional appointments) linked to a reduction in new appointments and addressing backlogs. Actions to deliver reduced follow up activity through new ways of working (e.g. Patient Initiated follow up) have not delivered year to date and so the requirements of provider partners have been escalated to STP Directors of Finance and CEOs to address and unblock. There is a 6.2% increase in the number of non-elective admissions compared with the operational plan equating to an additional 2169 admissions over plan. The operational plan built in reductions in non-elective activity to take effect from the start of quarter 2. The Control Centres are progressing plans including those identified in Right Care analysis, but these do not remove non-elective activity to this level at this pace, which will further exacerbate the increase in the coming months. The financial impact of over-performance is offset by a recharge for zero length of stay activity at NBT. Due to the closure of Weston ED emergency admissions at Weston have fallen by 7% and emergency admissions at UHB and NBT are up by 3% and 4% respectively. Elective Admissions are currently 6% below plan and are showing reductions at NBT and Weston compared to last year. There is a small (2%) increase at UHB. Specialties showing large decreases include T&O which is down by 27% at NBT (687 fewer admissions) and 22% (422 fewer admissions) at other providers including private providers. There are also significant reductions in plastics at NBT and private providers. The T&O reductions at NBT and private providers relate to changes to IFR policies and are supporting delivery ahead of plan. A&E attendances across BNSSG are 1.2% below plan. This is largely driven by reductions at Weston due to the overnight closure which was not accounted for in the plan. Weston is down by 6.4%, 1118 fewer attendances compared to last year. UHB is up by 0.9% (444 more attendances) 5

and NBT has seen an increase of 3.2% (1071 attendances) on last year. We are therefore holding the position on A&E demand across BNSSG though NBT is also challenged by the growth of non-bnssg activity. We are implementing A&E streaming to reduce the demand from primary care suitable patients on A&E as well as working with out of hours and 111 providers to do more to divert demand from the hospital front door. 6

3.1 A&E A&E Waits 4hr Performance 2016/17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 2017/18 Organisation Indicator Target Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT Trend BNSSG CCGs A&E 4hr Waiting Time Performance 95.0% 83.2% 84.7% 84.3% 86.1% 86.5% 85.5% 85.4% NBT A&E 4hr Waiting Time Performance 95.0% 79.8% 86.2% 78.8% 79.1% 75.7% 73.2% 78.6% UHB A&E 4hr Waiting Time Performance 95.0% 85.0% 82.3% 84.2% 87.9% 90.5% 91.3% 87.2% WAHT A&E 4hr Waiting Time Performance 95.0% 76.5% 82.6% 91.0% 89.2% 90.5% 88.5% 88.3% >12 Hour Trolley Waits in A&E 2016/17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 2017/18 Organisation Indicator Target Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT Trend NBT Trolley Waits in A&E >12 hours 0 65 3 7 3 4 6 23 UHB Trolley Waits in A&E >12 hours 0 40 0 0 1 0 0 1 WAHT Trolley Waits in A&E >12 hours 0 129 0 0 0 0 0 0 BNSSG CCGs Position BNSSG A&E performance for the whole population has been relatively stable to month 5 at between 84-86%. Month 5 has seen a 1% reduction driven by a deterioration at NBT and WAHT, with offsetting improvements at UH Bristol. Only UH Bristol are currently achieving the 90% recovery trajectory for 4 hour performance and all providers have remedial action plans in place which are being managed through the contract access and performance groups. Provider(s) Position NBT: Sustained pressure experienced within both ED and the Trust as a whole during August, despite slightly lower attendances, which led to a further worsening of 4 hour performance. There have been workforce shortages, particularly within the medical grades of ED, and this resulted in delays in assessment. Extremely high bed-occupancy levels within the hospital also limited the flow of emergency patients. UHB: August A&E 4 hour performance improved from 90.5% to 91.3% for the Trust as a whole. This performance was above the 90% STF trajectory but below the 95% national standard. Bristol Royal Hospital for Children has sustained consistently good performance and there has been marked improvement in the BRI with a renewed focus on patient flow out of Emergency Department, and through the ambulatory care assessment units. August performance represents both the best Trust wide performance and the best BRI performance since May 2016 7

(91.66% and 87.73% respectively). The expectation is that quarter 2 will also be above trajectory, however October is expected to be more challenging due to increasing demand going into winter months. WAHT: A&E 4 hour performance worsened again in August, failing both the national standard and the monthly STF trajectory. This was driven by 2 particularly challenging days where flow out of the hospital did not match demand and additional escalation actions were required to restore patient flow. The department remains closed to attendances overnight from 22.00hrs - 08.00hrs, and the Trust are managing a process for repatriation of patients who have been required to attend a different A&E and subsequently been admitted. Medical staffing within A&E remains fragile although vacancies are advertised promptly and recruitment is ongoing. Mitigating Actions for Areas of Poor Performance NBT: As noted in the executive summary, NBT is one of 20 Trusts nationally taking urgent action to remedy their performance in September via a 6 week rapid improvement plan. The aim is to deliver consistent improvement and achieve 90% by the end of October. A Remedial Action Plan is in place for the Trust and shows delivery of the 95% standard by March 2018. The Trust is working with partners to accelerate existing system plans for improvement and they are taking a number of additional internal actions including: aligning ED workforce to demand profiles; setting up a Control Room as a point of escalation for resolving delays in a patient s pathway; introducing a breach spotter in ED and daily reviews of stranded patients. The CCG and partners have also agreed a series of actions to deliver improvement in complex discharges / reduction in delayed transfers of care from the hospital, which is monitored through a weekly Director level group. This is supplemented by Chief Executive oversight on a weekly basis and daily review of all delayed patients at Director / Deputy Director level. The CCG is also fully embedded with the internal work to improve flow and driving the out of hospital provider actions to deliver improvements. Delivery of the required level of improvement is remains challenging for the system. UHB: A refreshed plan, which has been reviewed at the Urgent Care Steering Group (UCSG), is in place showing recovery to national standard by March 2018, as part of the commissioner Contract Performance Notice. A Pilot is underway in AMU to increase ambulatory capacity and a model has been agreed for adult ED streaming and a paper was submitted to the September UCSG. Specialty pathway work in divisions is ongoing. One day a week support from the national Emergency Care Improvement Programme (ECIP) team has started and is focussing on supporting improvements in the Integrated Discharge Service and implementation of Trusted Assessment for discharge. WAHT: A revised Remedial Action Plan is in place for A&E 4 hour waits. The 2017/18 STF trajectory shows achievement of the 95% standard at the end of March 2018. The Trust is committed to achieving 90% for the quarter two period and achievement of the STF trajectory is 8

expected for September. The Trust has an agreed process for managing patients within the four hour time frame. Enhanced management support from the Emergency Directorate has been offered to A&E, with the Deputy General Manager now basing himself within the department each day. In addition, the Clinical Lead post has been accepted by one of the A&E Consultants, with a directive to drive the department and maintain safety by implementing professional standards. Winter planning is under way, with a redesign of the urgent care pathways being worked through as a project to support flow in the peak periods. Primary care streaming is currently Monday to Friday with seven day streaming due to start on 30 th October 2017. All vacant posts have been offered out to suitable candidates and three medical middle grade staff are due to start in December 2017. Owner/Position in BNSSG CCGs Anne Morris, Director of Nursing & Quality 9

3.2 Planned Care RTT Incompletes <18weeks 2016/17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 2017/18 Organisation Indicator Target Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT Trend BNSSG CCGs RTT: Incomplete Pathways 18 Weeks 92.0% 90.9% 91.0% 91.3% 91.0% 90.6% 90.3% 90.3% NBT RTT: Incomplete Pathways 18 Weeks 92.0% 87.6% 87.6% 88.2% 87.8% 87.1% 86.7% 86.7% UHB RTT: Incomplete Pathways 18 Weeks 92.0% 91.1% 91.1% 91.1% 91.0% 90.2% 89.9% 89.9% WAHT RTT: Incomplete Pathways 18 Weeks 92.0% 94.5% 93.0% 94.7% 95.3% 93.9% 94.1% 94.1% Diagnostic Waits <6 weeks 2016/17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 2017/18 Organisation Indicator Target Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT Trend BNSSG CCGs Diagnostic 6 Week Waits 99.0% 99.0% 98.4% 98.9% 98.3% 97.1% 95.9% 95.9% NBT Diagnostic 6 Week Waits 99.0% 99.2% 98.3% 98.6% 97.6% 95.8% 94.3% 94.3% UHB Diagnostic 6 Week Waits 99.0% 98.7% 98.6% 99.0% 98.6% 98.5% 97.6% 97.6% WAHT Diagnostic 6 Week Waits 99.0% 100.0% 99.6% 99.9% 99.4% 96.5% 95.5% 95.5% Cancelled operations not rebooked with a binding date in 28 days 2016/17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 2017/18 Organisation Indicator Target Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT Trend NBT Cancelled Operations not rebooked within 28 days 0 23 0 0 1 2 5 8 UHB Cancelled Operations not rebooked within 28 days 0 72 4 6 2 0 1 13 WAHT Cancelled Operations not rebooked within 28 days 0 8 1 1 0 N/A N/A 2 Number of urgent operations cancelled for a second time 2016/17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 2017/18 Organisation Indicator Target Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT Trend NBT Urgent Operations Cancelled for a Second Time 0 14 0 2 0 2 2 6 UHB Urgent Operations Cancelled for a Second Time 0 0 0 0 0 0 N/A 0 WAHT Urgent Operations Cancelled for a Second Time 0 0 0 0 0 0 0 0 10

RTT 52 week waiters 2016/17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 2017/18 Organisation Indicator Target Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT Trend BNSSG CCGs RTT: Incomplete 52 Week Waits 0 30 34 52 86 95 109 109 NBT RTT: Incomplete Pathways 52 Week Waits 0 44 43 53 84 97 111 111 UHB RTT: Incomplete Pathways 52 Week Waits 0 2 5 11 46 45 32 32 WAHT RTT: Incomplete Pathways 52 Week Waits 0 0 0 0 0 0 0 0 BNSSG CCGs Position The BNSSG 52 week position has deteriorated attributable to Orthopaedics at NBT in the main. Commissioners requested and receive weekly numbers of those patients waiting 46-52 weeks, 52 weeks and over (booked and unbooked) which are being monitored closely. In addition Remedial Action Plans (RAP) continue to be monitored at Access Performance Group contract meetings. Referral to treatment has deteriorated performance by 0.3% (90.6% to 90.3%). This position is driven by a combination of reduced open pathways associated to reduced referrals and higher numbers of non-admitted clock stops, and extended surgical waiting times in Orthopaedic services at NBT. Reduced pathways under 18 weeks reduce the denominator and therefore adversely affect overall RTT performance against the 92% standard. Provider(s) Position NBT: The Trust overall 18 week RTT performance dropped a little in August and fell below its internal trajectory for the first time in 2017/18. Trauma & Orthopaedics is the most challenged specialty in relation to both the 18 weeks standard and the 52 weeks standard, with particular capacity issues in regards complex upper arm surgery. Neurosurgery, Gastroenterology and Respiratory Medicine also fell below recovery trajectories. Performance in regards the Diagnostics 6 week wait standard has continued to drop in August, with DEXA scans a particular issue in relation to prolonged staffing shortages. UHB: August diagnostics performance deteriorated from 98.6% to 97.6%, below the 99% national standard and the locally agreed 98.8% trajectory which should have seen recovery by the Trust by end of September. The Trust has outlined to commissioners that recovery to national standard by end of September will be challenging and have now re-forecast recovery in December. The Trust has shared with commissioners a revised trajectory for review and to agree next steps. The main underlying causes remain Sleep Studies and CT. The additional capacity is taking longer to implement than expected but is now starting to take effect. 11

RTT 18 week performance continued its recent decline, falling from 90.2% to 89.9%; below the 92% standard. An STF trajectory is in place but is not being met. Rising demand and high elective and outpatient waiting lists are the main drivers. Commissioners have reviewed the improvement plan and confirmed that it has been updated to key areas and issues. The number of 52 week waiters have reduced from 45 to 32 in August with those still waiting being a result of capacity pressures in Women s & Children s, a re-validation of some RTT pathways within the Dental Hospital following admin errors having been identified and with more patients exercising their rights to patient choice. WAHT: RTT Incomplete national standard continues to be achieved since September 2014 and the monthly STF trajectory (set higher than the national standard) continues to be achieved. However, both General Surgery and ENT continue to fail at a specialty level. >52 week waiters remain at zero. Diagnostic performance worsened slightly and the standard was failed again in August. Failure is due to continued pressure on the Endoscopy service because of the planned refurbishment. This has been further impacted by the failure of the arrangement to transfer services to the independent treatment centre at Emerson s Green this is being addressed through transfers via Bristol Trusts. There are currently 300 patients waiting over 6 weeks, with a longest wait of 14 weeks, none of these are cancer patients. Operations cancelled for a second time remains at zero. 28 day rebooking breaches are reported on a quarterly basis. Mitigating Actions for Areas of Poor Performance NBT: The Trust have developed a new RAP for musculoskeletal (orthopaedics) over 52 week waits, showing actions they will take to reduce the longest waits to zero by end of March 2018. Recruitment of Gastroenterology medical staff is also underway which would improve both the RTT waits and the Diagnostics waits. Endoscopy waits are expected to improve in September. Additional DEXA slots have been arranged in partnership with other providers and it is anticipated that the backlog will improve; we are awaiting a refreshed diagnostic Remedial Action Plan to indicate the date for recovery of this standard. UHB: A Contract Performance Notice (CPN) for 52 week waits was issued in September and a Remedial Action Plan (RAP) with trajectory received and approved by commissioners. Commissioners are monitoring weekly patients waiting more than 46 weeks. Indications are that the diagnostic recovery trajectory may not be met in September, if this is the case Commissioners will issue a CPN. Current actions to address 12

the poor performance include additional GP (with specialist interest) capacity for sleep studies as well as waiting list initiatives and increased administrative support. Extra Cardiac CT sessions are being run, where possible and a mixture of outsourcing and insourcing is being used to address adult endoscopy capacity. Commissioners have also requested from the Trust an internal RTT recovery trajectory, based on current performance. The improvement plan actions will be received and discussed at the next Access Performance Group meeting to determine whether the proposed trajectory is acceptable and supportive of the CCG plan to maintain elective waits within financial limits. WAHT: RTT General Surgery failure is due to very small numbers waiting which the team are working to resolve and ENT failure is due to ongoing operational issues with a shortage of consultant clinics which is being worked through with UHB. For Diagnostics, the Trust is looking to use an external provider during October and November and there are discussions with UHB to assist. Recovery is expected by December. Owner/Position in BNSSG CCGs David Jarrett, South Gloucestershire Area Director 13

3.3 Cancer Cancer Waits - 2 Week Waits Organisation Indicator Target 2016/17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 2017/18 DoT Trend Value Value Value Value Value Value Value Value Value Value Value Value Value Value BNSSG CCGs Cancer 2 Week Wait - All 93.0% 93.0% 90.0% 92.4% 93.5% 92.9% 91.8% 92.2% NBT Cancer 2 Week Wait - All 93.0% 92.1% 86.5% 89.0% 91.4% 91.6% 89.8% 89.7% UHB Cancer 2 Week Wait - All 93.0% 94.8% 95.1% 95.6% 94.3% 93.4% 93.2% 94.2% WAHT Cancer 2 Week Wait - All 93.0% 91.5% 92.6% 96.9% 98.9% 95.2% 93.9% 95.7% BNSSG CCGs Cancer 2 Week Wait - Breast symptoms 93.0% 91.2% 83.5% 93.0% 95.1% 92.9% 95.0% 92.4% NBT Cancer 2 Week Wait - Breast symptoms 93.0% 94.1% 82.1% 91.3% 95.1% 94.9% 98.0% 92.9% WAHT Cancer 2 Week Wait - Breast symptoms 93.0% 89.1% 95.2% 96.7% 100.0% 87.5% 89.4% 93.8% Cancer Waits - 31 Days 2016/17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 2017/18 Organisation Indicator Target Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT Trend BNSSG CCGs Cancer 31 Day first treatment 96.0% 97.7% 93.3% 97.2% 96.3% 98.3% 98.3% 96.7% NBT Cancer 31 Day first treatment 96.0% 97.3% 93.6% 96.6% 96.6% 98.3% 98.4% 96.7% UHB Cancer 31 Day first treatment 96.0% 96.8% 91.2% 96.5% 95.1% 97.1% 97.9% 95.7% WAHT Cancer 31 Day first treatment 96.0% 99.6% 100.0% 100.0% 98.3% 100.0% 100.0% 99.6% BNSSG CCGs Cancer 31 day subsequent treatments - surgery 94.0% 97.7% 93.1% 95.2% 96.9% 96.5% 97.1% 95.7% NBT Cancer 31 day subsequent treatments - surgery 94.0% 97.3% 94.2% 97.1% 97.5% 95.7% 97.5% 96.5% UHB Cancer 31 day subsequent treatments - surgery 94.0% 94.2% 82.6% 92.0% 93.2% 90.7% 96.0% 91.0% WAHT Cancer 31 day subsequent treatments - surgery 94.0% 96.8% 100.0% 60.0% 100.0% 100.0% 100.0% 92.0% BNSSG CCGs Cancer 31 day subsequent treatments - drugs 98.0% 98.6% 99.2% 97.6% 99.4% 98.6% 98.6% 98.7% NBT Cancer 31 day subsequent treatments - drugs 98.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% UHB Cancer 31 day subsequent treatments - drugs 98.0% 98.5% 99.1% 97.4% 98.7% 98.6% 98.6% 98.5% WAHT Cancer 31 day subsequent treatments - drugs 98.0% 99.5% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% BNSSG CCGs Cancer 31 day subsequent treatments - radiotherapy 94.0% 96.3% 97.6% 96.3% 95.5% 94.8% 97.2% 96.2% UHB Cancer 31 day subsequent treatments - radiotherapy 94.0% 96.6% 98.1% 96.6% 95.9% 95.4% 97.3% 96.6% 14

Cancer Waits - 62 Days 2016/17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 2017/18 Organisation Indicator Target Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT Trend BNSSG CCGs Cancer 62 day referral to first treatment - GP referral 85.0% 83.8% 82.1% 77.7% 82.5% 83.2% 86.6% 82.3% NBT Cancer 62 day referral to first treatment - GP referral 85.0% 85.7% 87.5% 80.4% 85.6% 90.2% 87.2% 85.9% UHB Cancer 62 day referral to first treatment - GP referral 85.0% 79.3% 76.7% 78.0% 81.7% 74.7% 85.1% 79.3% WAHT Cancer 62 day referral to first treatment - GP referral 85.0% 77.7% 78.4% 70.2% 65.8% 76.3% 75.4% 72.7% Cancer 62 day referral to first treatment - NHS Screening BNSSG CCGs 90.0% referral 88.6% 97.3% 90.5% 100.0% 94.7% 94.3% 95.3% NBT Cancer 62 day referral to first treatment - NHS Screening 90.0% referral 91.9% 100.0% 96.1% 100.0% 97.7% 93.8% 97.5% UHB Cancer 62 day referral to first treatment - NHS Screening 90.0% referral 68.9% 66.7% 44.4% 100.0% 87.5% 100.0% 81.4% WAHT Cancer 62 day referral to first treatment - NHS Screening 90.0% referral 100.0% N/A N/A 100.0% 100.0% N/A 100.0% BNSSG CCGs Position There was significant improvement in performance across BNSSG in August in respect of the 62 day standard, which was achieved at BNSSG level, with UHB hitting the standard for the first time this year. Issues remain at WAHT and UHB in respect of this standard so there remains a risk of delivery against the national expectation of every trust meeting 85% by September 2017. Contract Performance Notices and Remedial Action Plans are in place and being closely monitored as well as whole system working to identify and action issues arising across shared pathways. Sustained achievement is not expected until March 2018. The 2WW standard was not met due to short term capacity issues at NBT. There is a Remedial Action Plan in place. The key issues are now resolved and recovery is expected from September. All 31 day standards were achieved. Provider(s) Position NBT: The 31 days and 62 days cancer standards and the 2ww (breast symptoms) have all been met in June, July and August. However the 2 week wait standard for GP referral is still not being met in August and has dropped down a little compared to June and July. Skin referrals remain a particular problem area. The 2WW Skin service at NBT has seen an increase of 18% in referrals from 2015/2016 to 2016/2017 and a further increase of 14% in the first five months of this financial year. Skin referrals are typically seasonally higher in summer. UHB: The Cancer 62 day standard was met in August for the first time since March 2017 with performance of 85.1% and the standard was also exceeded for internally managed pathways with 94.9%. Achievement was despite staffing issues in Gynaecology, high Histopathology demand 15

and staffing issues in Weston. The Gynaecology position remains dynamic with 3 breaches noted for September with a further 2 or 3 expected in October. However Hysteroscopy delays have reduced and the Trust is able to utilise South Bristol Community Hospital. WAHT: Although improving, the 2ww Breast standard was failed again in August with 5 breaches out of 47 patients treated. The standard continues to be achieved for the year to date. The 62 day standard worsened in August, continuing to fail the national standard, the STF trajectory and RAP trajectory, with 8.5 breaches out of 34.5 patients treated. Mitigating Actions for Areas of Poor Performance NBT: A Contract Performance Notice was issued by BNSSG in September 2017, in regards the 2ww from GP referral standard and a RAP (Remedial Action Plan) has been drafted by the Trust. Actions on skin service include more detailed demand and capacity planning, closer review of any available routine capacity that can be converted to 2ww, recruitment effort re medical staffing, tight control of medical staff leave to avoid periods of low capacity, continued sub-contracting and on-going WLI additional capacity. UHB: A CPN was issued and a Remedial Action Plan has been developed, reviewed and signed off by Commissioners. Commissioners have instructed the Trust to focus on actions within or partially within the Trust s control, particularly avoiding cancellation. The Trust maintains that the majority of breaches are due to unavoidable factors such as late referral and medical deferral. Other initiatives in the RAP includes ensuring there is sufficient thoracic capacity, ensuring adequate elective bed capacity to reduce cancellations, preparation to become lead provider for adult dermatology in Taunton, addressing capacity issues in chemotherapy, colorectal, radiological diagnostics and gynaecology staffing. Formal processes are also being established to better manage the impact of MDT/planning meeting cancellations, for instance due to bank holiday. WAHT: Performance can fluctuate greatly, month to month, due to the small number of patients being treated. More robust reporting and monitoring is now in place with a weekly PTL meeting to review all patients over 30 days. This has led to early identification of issues which can be resolved timely. A revised RAP for the 62 day standard, focussed on recent issues, is being implemented. BNSSG: System working continues in respect of shared pathways with monthly breach review meetings identifying and addressing actions that are common to or affect more than 1 trust. Owner/Position in BNSSG CCGs Peter Brindle, Medical Director (Clinical Effectiveness) 16

3.4 Quality CDIFF cases 2016/17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 2017/18 Organisation Indicator Target Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT Trend BNSSG CCGs Total Number of CDiff Cases N/A 237 16 17 21 16 22 92 NBT Total Number of CDiff Cases N/A 33 2 3 4 3 3 15 UHB Total Number of CDiff Cases N/A 31 2 4 5 6 3 20 WAHT Total Number of CDiff Cases N/A 10 0 0 1 0 0 1 MRSA cases 2016/17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 2017/18 Organisation Indicator Target Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT Trend BNSSG CCGs Total Number of MRSA Cases 0 38 7 2 2 6 8 25 NBT Total Number of MRSA Cases 0 6 1 0 0 0 2 3 UHB Total Number of MRSA Cases 0 1 0 0 1 0 1 2 WAHT Total Number of MRSA Cases 0 0 1 0 0 0 0 1 Mixed Sex Accommodation Breaches 2016/17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 2017/18 Organisation Indicator Target Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT Trend BNSSG CCGs Mixed Sex Accommodation Breaches (CCG) 0 40 11 9 9 9 0 38 NBT Eliminating Mixed Sex Accommodation 0 6 0 0 0 0 0 0 UHB Eliminating Mixed Sex Accommodation 0 12 11 9 10 10 0 40 WAHT Eliminating Mixed Sex Accommodation 0 20 0 0 0 0 0 0 Never Events 2016/17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 2017/18 Organisation Indicator Target Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT Trend NBT Number of Never Events 0 5 0 0 0 1 0 1 UHB Number of Never Events 0 2 0 1 2 2 0 5 WAHT Number of Never Events 0 1 0 0 0 0 0 0 17

BNSSG CCGs Position C.Difficile: All 3 BNSSG CCGs are below the threshold set by NHSE for C. Difficile infections. The first meeting of the C. Difficile Task and Finish Group was held in September 2017. This group is a subset of the BNSSG HCAI group and will report to this group. Terms of reference and objectives for the group have been agreed. Objectives include; evaluating and reviewing the current local enhanced surveillance project; establishing a single system wide process for post infection review; ensuring learning is shared across the healthcare system and reviewing the management of community colonised patients. MRSA: The CCGs continue to see a high level of MRSA cases occurring with 5 cases being provisionally assigned to the CCGs in August 1017. Since April 2017 the CCGs have been finally assigned 4 cases of MRSA (3 Bristol, 1 South Glos) following discussion at the NHSE arbitration panel. To date 8 cases have been assigned to third party. The MRSA Task and Finish Group met for the first time in September 2017 and discussed the findings of the Elizabeth Blackwell Research. Public Health England (PHE) will be publishing the report. A briefing paper will be drafted by PHE to share with the CCG, GPs and provider organisations. The research has identified five areas for action to reduce MRSA bacteraemia relating to intravenous drug users including 1) targeted screening in the community, 2) hospital admission screening, 3) health education, 4) enhanced wound care and 5) enhanced clinical awareness. The next step is to develop an action plan that will be shared with NHSE. Progress against this action plan will be reported to the BNSSG HCAI group. Provider(s) Position UH Bristol: There were zero Never Events and MSA breaches reported in August 2017. There were 3 cases of C.difficile reported. One case of MRSA was reported. This has been confirmed as attributable to the Trust following third party arbitration by NHS England (NHSE). NHSE agreed with the CCG that the key factors of this case were that the patient became dehydrated, her condition deteriorated and she developed urosepsis during her acute inpatient episode. WAHT: There were zero Never Events, MRSA cases or MSA breaches reported in August 2017. One case of C.difficile was reported. 18

NBT: There were zero Never Events or MSA breaches were reported in August 1017. There were 3 cases of C.difficile reported. Two cases of MRSA bacteraemia have been reported by the Trust in August 2017 occurring in the Medicine and Musculoskeletal (MSK) Divisions. A total of three cases of post 48 hour MRSA have been finally assigned to the Trust following post infection review since April 2017 bringing the number of cases of MRSA attributed to the trust to ten cases in the last 12 months. Mitigating Actions for Areas of Poor Performance Never Events: The Contract Performance Notice (CPN) and associated Remedial Action Plan (RAP) remain in place for Never Events at NBT. The latest (and only Never Event for 2017/18) was reported in July 2017 involving insertion of an incorrect prosthesis. A full Root Cause Analysis (RCA) investigation has been completed and submitted to the CCG for review at the serious incident panel. Learning from this latest Never Event will be incorporated into the Never Event RAP which is reviewed at the monthly NBT Quality Sub Group Meeting. An NHS Improvement (NHSI)/NHSE led South West Never Event Review for providers will take place in November 2017 with the goal of establishing an ongoing learning programme. Smaller events with local providers supported by the Academic Health Science Network (AHSN) are also planned and will include representation from NBT, UH Bristol, WAHT and the CCGs. MRSA: A Contract Performance Notice and associated Remedial Action Plan (RAP) in relation to the number of MRSA bacteraemia cases reported by NBT remain in place. The focus is to reduce the incidence of MRSA bacteraemia to zero. Areas of learning highlighted through the Post Infection Review (PIR) process for each case are incorporated into the original RAP. Current focus for NBT is on areas highlighted for improvement from the post infection reviews namely peripheral lines and prompt blood culture sampling of patients presenting with suspected urinary sepsis. The CPN and RAP continue to be monitored through the Quality Sub Group. To improve processes for completing Post Infection Reviews, the Quality Team is meeting with the Infection Control Lead at NBT on 20 October 2017. A meeting is also being planned with UH Bristol. The Quality Team is also meeting with the Bristol Drug Project to assure the CCG of the action being taken with intravenous drug users in relation to safer injecting techniques. The CCG interim Associate Director of Nursing and Quality and Consultant in Public Health South Gloucestershire County Council will participate in an Infection Prevention and Control clinical review of NBT commissioned by NHSI and BNSSG CCG (South Gloucestershire) with 19

the aim of arresting the current upward trend of MRSA bacteraemia and to obtain assurance of the management of infection control within the Trust. The visit is planned for 19 October 2017 and the final report written by NHSE and NHSI will be shared once complete. General Quality Exceptions University Hospitals Bristol Foundation Trust (UH Bristol) Areas of Concern Fractured neck of femur - overall performance for the best practice tariff remained below the national 90% threshold (26.9%). Time to theatre within 36 hours had increased to 84.6% from the previous month. Commissioners have been advised the expected drop in performance against the best practice tariff in August has been attributed to staff annual leave. Actions being taken The recruitment process for middle grade orthogeriatric support has commenced, with interviews planned for October/November 2017. Physiotherapy support will be made available to the orthopaedic wards on Sundays commencing early in 2018. Work arising from the British Orthopaedic Association Review has been shared with the BNSSG group looking at fractured neck of femur. The longer term solution sits within the Musculoskeletal (MSK) work stream. Commissioners undertook a site visit last year to understand and gain assurances around the processes for minimising harm to patients when delays occur. The CCG is assured that, whilst the threshold had not been met, patients had been reviewed and there had been no reported harm to any patients. Weston Area Health Trust (WAHT) Expected outcome / timescale Commissioners noted that achievement of this measure in a sustainable way within the existing set up is difficult for UH Bristol Areas of Concern CQC report receipt of this on 14 June has led to the closure of ED services overnight between the hours of 10pm and 8am (put in place as a temporary measure on 4 July 2017). The report also highlighted three out of the four areas inspected have made significant improvements. 20

SHMI - for January 2017 to March 2017 this is at 105.35, a reduction from the January 2016 - December 2016 figure of 111.06 which removed WAHT from the reported 10 outlying Trusts with higher than expected mortality. Data is reported on the Dr Foster website on a quarterly basis. Discharge letters - the CCG have raised concern regarding the Trust being unable to meet the contractual requirement to issue a discharge letter for every patient within 48 hours. Incidents continue to be reported from GPs pertaining to discharge letters (via the CCG DATIX system) and remain one of the leading themes. Actions being taken CQC Report - a report has been shared with the CCG to provide assurance on progress regarding the Improvement Plan to address the CQC Section 29A Warning Notice received. The four key areas of concern related to patient flow and the requirement to ensure: There are systems/processes to manage patient flow through the hospital ED is reviewed as a single point of entry for both emergency and expected patients There is access to specialist Senior Doctors to review patients in ED overnight The corridor is safe and appropriate for patients to receive care and treatment. A CQC Action Plan has been received and reviewed at the monthly Quality Sub Group. This details both actions and delivery. There are currently 4 overdue items however remaining actions are progressing well. The CCG are supporting the Trust in working in conjunction with NHS Improvement to ensure actions are embedded. This includes an observation visit to the ED in October. SHMI - the GP Clinical Quality Lead attends the Mortality Review Group Meeting. An action plan is in place detailing progression of work being undertaken. It is noted that the meetings are perceived to be high quality by the Clinical Quality Lead and WAHT Medical Director. The CCG s GP Clinical Quality lead is also working with the Medical Director to improve on the medical concerns in the areas flagged up on the Dr Foster National website and will continue to review any new areas highlighted as data evolves. Other crude mortality data produced by the Trust is showing an improved position. A Contract Performance Notice remains in place until the position of the Trust remains in the expected category for a sustainable period Discharge Letters - the Medical Director has changed the process to ensure that duplicate copies of discharge letters are not sent out to GPs and information technology barriers are being reviewed in Expected outcome / timescale Monthly monitoring Monthly monitoring. Next SHMI data due for release in December 2017 Aiming to achieve 100% compliance by end of Q4 2017/18 21

relation to sending all letters electronically. A presentation undertaken at the July Quality Sub Group meeting showed the actions taken to improve the process and highlighted the continual progression plans. A second Contract Performance Notice (CPN) was issued in March 2017 relating to quality and accuracy of clinical content in the letters. The CCG requested a Remedial Action Plan (RAP) with an improvement trajectory. Monthly monitoring of progress against the RAP continues via the Quality Sub Group. North Bristol NHS Trust (NBT) Areas of Concern Administration Backlog and Delayed Clinic Letters issues are ongoing in relation to the quality and timeliness of outpatient clinic letters and discharge summaries. The Trust has been unable to provide a definitive improvement date. Complaints management - the number of overdue complaints cases has reduced again to 20 cases in August 2017. A RAP is in place in relation to the number of overdue complaints. The expectation is for the Trust to have no more than 10 overdue complaints in any given month. Actions being taken Complaints management - progressing of the RAP continues and improvements have been made in reducing the total number from 37 in July to 20 in August 2017. The Director of Nursing and Quality continues to meet with the Heads of Nursing on a bi-weekly basis to review overdue complaints along with actions required to close the complaint. Administration backlog external support is in the process of being procured in order to improve the situation and to meet the 10 day turnaround target. It may take up to 6 weeks to get the support in a position to improve the situation. As requested by the CCG, the Trust will provide an improvement trajectory and plan at October s Quality Sub Group. The CCG will issue a CPN at this meeting if this is not provided. Expected outcome / timescale Complaints to reduce below 10 by end of October 2017 Recovery timescale for agreement October 2017 22

Mental Health Services: Avon and Wiltshire Mental Health Partnership Areas of Concern CQC - the latest inspection report was published on 3 October 2017. It raised a number of concerns relating to: Health based Places of safety - the warning notice was lifted and replaced by a rating of inadequate for the service. Concerns mainly relate to the service within Devises, where staff had not identified some potential ligature points as part of the risk assessment, and there was a lack of clear plans in place to mitigate the risks. The long waits service users were experiencing within the places of safety were also noted as a concern by the CQC. Crisis management, and Child and Adolescent Mental Health Services (CAMHS). Medication errors - issues persist with the number of missed doses and blank boxes noted on medication charts. CAMHS - a number of issues have been highlighted within CAMHS: Sickness rate is red rated at 5%; Supervision rate is amber rated at 71% (threshold is 85%) dropped from last month; Appraisal rate is red rated at 80% (threshold 90%); Statutory/mandatory training rate is red rated at 81% (threshold 90%) Delayed Transfer of Care (DTOC) - the number of out of area placements has increased and Delayed Transfer of Care (DTOC) remains an issue in five of the six CCG areas covered by AWP despite some improvements in the last two-three months. Against the threshold target of 7.5%, performance rates in BNSSG CCG localities are as follows: Bristol 15%, South Gloucestershire 11% and North Somerset 11%. Actions being taken CQC - a revised action plan, as a result of the new inspection report is pending. The CCGs are working closely with AWP and wider stakeholders regarding implementation of a revised system for crisis management including the Places of Safety. Medication Errors AWP has conducted a deep dive audit analysis and developed an action plan to support improvement. The CCGs are monitoring closely via the Quality Sub Group including triangulation with serious incidents. CAMHS - AWP is implementing a new model of care and a recruitment strategy. Sickness absence is closely managed by team managers. Expected outcome / timescale A recovery date is not clear at this point pending review of the Trusts action plan Recovery expected by March 2018 Recovery date is not yet available 23

All staff are receiving supervision, but IT issues have hampered accurate recording. The transfer to the AWP email system will help to resolve this issue. IT issues has also affected accurate recording of appraisal data. The team have been asked to correct and book in any overdue appraisals. An action plan is in development to address statutory/mandatory training. DTOC - focus continues on internal process and collaborative working with partners. For Bristol, a dedicated Clinical Bed Manager has been introduced who will oversee all admissions and discharges, working across inpatients and community to improve flow, avoid unnecessary admissions, facilitate early discharge, reduce length of stay and delayed transfers of care, thus increasing capacity and reducing the need for out of area placements. An ongoing plan is in progress which will include trajectories PATIENT EXPERIENCE: FRIENDS AND FAMILY TEST (FFT) FFT Inpatient Response Rate FFT ED Response Rate 55% 35% 15% Aug Sep- Oct- Nov Dec- Jan- Feb- Mar Apr- May Jun- Jul-17 Aug 30% 10% -10% Aug Sep- Oct- Nov Dec- Jan- Feb- Mar Apr- May Jun- Jul-17 Aug NBT UHB WAHT Target NBT UHB WAHT Target 24