NHS Ashford Clinical Commissioning Group Integrated Performance Report November 2013 Page 1
Contents Executive Summary... 6 Assurance Framework Overview... 10 Are local people getting good quality care?... 11 Has local provider been subject to enforcement action by the Care Quality Commission (CQC)?... 14 Friends and Family Test... 15 NHS Choices... 16 MRSA... 17 C difficile... 17 Hospital Acquired Infections... 18 Mixed Sex Accommodation... 18 Serious Untoward Incidents... 18 East Kent University Hospital Foundation Trust... 18 Kent Community Health Trust (KCHT)... 19 Kent and Medway NHS and Social Care Partnership Trust... 20 SECAMB... 21 Never Events... 22 Are patient rights under the NHS Constitution being promoted?... 23 Number of patients waiting more than 52 weeks... 25 Emergency access - A&E 4 hour waits... 25 Performance data... 25 Outcome measures... 26 Cancer waiting time standards... 27 Page 2
Ambulance response times... 28 Mental Health Key Performance Indicators Q2 13/14... 29 Cancelled operations... 30 Are health outcomes improving for local people?... 31 Ashford Referrals Analysis Month 7... 33 Primary Care Referrals per 10,000 Weighted Population... 34 CQUIN achievement... 40 18 week update... 45 Areas of non-compliance... 45 Improvements in performance... 46 Outcome measures... 46 Diagnostic Waits... 46 KCHT... 48 Quality... 48 Contract Performance... 50 Activity... 52 SECAMB... 54 NHS 111... 55 PTS... 55 Out of hours... 56 IS Providers... 56 Mental Health... 57 KMPT... 57 Primary Care Psychological Therapy Q2 2013/2014 (aged 18-65)... 57 Older People Services Q2 - KMPT... 58 Page 3
Talking Therapies Q2 year to date... 59 Independent Funding Requests... 61 Continuing Healthcare... 63 Page 4
Key to RAG rating, trend information and abbreviations used in the report Equal to or better than target BHD Buckland Hospital, Dover Within 5% of target EKHUFT East Kent Hospitals University NHS Foundation Trust >5% below target ECK NHS East Kent (former PCT) 5% better than previous position KCH Kent and Canterbury Hospital Within 5% of previous position KCHT Kent Community Health NHS Trust 5% worse than previous position KMPT Kent and Medway NHS and Social Care Partnership Trust Standards met QEQMH Queen Elizabeth the Queen Mother Hospital, Margate Improvement required RVH Royal Victoria Hospital, Folkestone SECAMB South East Coast Ambulance Services NHS Foundation Trust WHH William Harvey Hospital, Ashford Page 5
Executive Summary Please refer to the relevant report section for details of each issue, and actions being taken where appropriate All material issues are raised with Providers at monthly performance meetings and escalated by way of Performance letters and Contract query notices (as appropriate). Breaches which are subject to Contract penalties are raised with the Trust and charged accordingly. Challenges in respect of Technical queries, which include levels of activity which exceed contract tolerances or coding errors, are raised with the Trust on a monthly basis. Where clawback of costs are agreed these will be debited by the CCGs. In cases where clinical investigation of pathways or coding is required to assess the appropriateness of activity or costing the Trust will be asked by the host CCG to provide additional analysis to support a CCG investigation. This could include a clinical audit of hospital and patient records. For example; an audit of levels of internal Consultant to Consultant referrals is about to commence at the Trust. In some cases metrics in respect of key indicators at risk (that may be available beyond month 5) are provided to give an early warning to the CCGs of deterioration in services (MRSA, SI s and 18 weeks by speciality for example). Organisation Issue CCG Number of CCG patients waiting over 52 weeks for treatment (Zero-tolerance) CCG Percentage of patients in Q1 waiting less than 62 days from a cancer screening referral to first treatment 100% for Q2, (Target 90%), 85.70% YTD). CCG SECAMB has breached 1 response time standards in respect of CCG patients, but has improved on all three response time for the CCG CCG Ashford CCG s year-end limit of pre and post 72hr cases of C.difficile is 10. As at the end of October 2013 there have been 14 cases thus breaching the year-end limit. The CCG s Chief Nurse is working closely with the Trust and clinical chairs to understand the root causes of these cases and form action plans for resolution which are closely monitored within CCG quality meetings. Page 25 27 28 17 Page 6
CCG The CCG has breached the 2013/14 zero tolerance for MRSA with 1 reported case as at the end of October 2013. 17 Organisation Issue EKHUFT As of the end of October 2013, EKHUFT has breached the zero tolerance for MRSA, with six cases reported on the national system. The Trust is currently disputing the number of cases reported on the national system for April 2013, claiming one attributable case against the two reported. Enhanced surveillance of cleanliness standards is in progress at each site Page 17 EKHUFT As at the end of October 2013, EKHUFT had breached the year end C.difficile trajectory with 35 cases against a limit of 29. 17 EKHUFT 8 new Serious Incidents have been received for the month of October. There were 2 at William Harvey Hospital and 1 at Kent and Canterbury Hospital. None were allocated to Ashford CCG. Root cause analysis is conducted on all SIs with lessons learned informing action at ward and department level. 18 EKHUFT There was a Never Event reported at the Trust in October 2013 relating to a retained swab. The swab was left in the patient after a C-section in June 2013. Another Never Event has been reported in November 2013 relating to a misplaced naso-gastric tube. The member of staff involved has since been suspended pending investigation. 22 EKHUFT Unify 2 is showing that for April-September 2013 EKHUFT had not had any mixed sex breaches. However EKHUFT's local quality reports are showing mixed sex occurrences within CDU. Current national guidance does not consider CDU to be exempt from mixed sex breaches. There are ongoing discussions between the Trust and East Kent CCGs in relation to penalties for breaches in CDU. 18 EKHUFT Number of CCG patients waiting over 52 weeks for treatment (Zero-tolerance) 25 EKHUFT The Trust has achieved overall RTT targets for Admitted, Non-Admitted and Incomplete pathways. However breaches of the 52-week target continue in T&O and Oral surgery specialities. See page 59 for a breakdown. The report also provides a detailed analysis of movement in RTT ratings (positive and negative) by speciality. In cases where performance has 24 Page 7
fallen but metrics remain above thresholds these are being included in Contract Performance letters. The CCG has issued a contract query and is invoking breach penalties. Percentage of patients in Q2 waiting less than 62 days from consultant upgrade to first treatment EKHUFT cancer screening referral to first treatment 93.24% (Target 90%) EKHUFT The Trust has breached 2 metrics for the 6-week diagnostic standard, although these were small numbers. Overall the standard has been achieved 27 45 Organisation Issue KCHT An analysis of the 10 red-rated areas on the Trust Corporate scorecard is supplied. KCHT The Trust is forecasting a breach of its internal C.difficile trajectory for 2013/14. There was one case of C.difficile in September 2013 but this did not relate to an East Kent patient. 47 KCHT The trust is working to improve its workforce metrics as detailed in the report. KCHT Due to safeguarding training figures being too low, commissioners have asked the Trust for a breakdown of risk by staff group and service area. 48 Page 48 47 Organisation Issue KMPT There were 7 SIs reported by KMPT in October, which is a slight decrease from the 10 reported in September, and a clear decrease from 15 reported in August and 24 reported in July. 19 Page KMPT Inpatient occupancy was at 99% in Q1 2013. This reduced to 96.70% in September 2013. The commissioner target is 85-95%.The Trust is focusing on length of stay, and a discharge coordinator has been put in place to facilitate clients discharge by liaising with community services such as Crisis Resolution Home Treatment Team (CRHT), social services, and housing. 56 KMPT Page 30 provides an Exception report in respect of KMPT Quality exceptions and action being supervised by CCG lead Nurses and IPM Quality team 29 Page 8
Organisation Issue SECAMB Page There were 2 SIs reported by SECAmb in October, both under the category Ambulance (general). This is a reduction in the number of SIs reported by SECAmb in September, which was a total of 7. 21 SECAMB SECAmb has a backlog of complaints that have not been responded to within the required time period. The Trust advises that steps are now being taken to reduce this backlog, and additional support has been enlisted to provide support to the Patient Experience Team in terms of checking investigating managers reports and drafting response letters to complainants. 21 SECAMB SECAMB SECAMB is compliant in all response times for October for the Trust as a whole for October. Year to date for Cat A Red 2 calls is at 72% (Target 75%) The Trust is significantly over performing against forecast. Page 68 also provides details of activity and performance in respect of the NHS111, PTS and Out of Hours services. 28 53 Organisation Issue Primary Care A new schedule of Primary care referrals is supplied on page 33. It should be noted that a number of the red-rated metrics, especially for the smaller practice populations, may not be statistically significant and apply to small numbers of patients. Page 33 Organisation Issue Page Independent Please refer to report for detailed analysis of IS providers. This includes analysis by provider of Sector Providers over performance, challenges and actions being invoked by IPM. 59 Page 9
Assurance Framework Overview Balanced Scorecard The scorecard below reflects the assessed status of the CCG by NHS England following the October assurance meeting. The two amber red and red values relate to Health Care Associated Infections (HCAI) performance, access time performance and the Friends and Family test performance at East Kent Hospitals University NHS Foundation Trust. Actions to address these issues are detailed in the performance report. Are local people getting good quality care? AMBER-RED Are patient rights under the NHS Constitution being promoted? Are health outcomes improving for local people? Are CCGs delivering services within their financial plans? Are conditions of CCG authorisation being addressed and removed (where relevant)? AMBER-RED RED AMBER-GREEN No RAG Page 10
Are local people getting good quality care? The provider summary table is presented below: Indicator Period EKHUFT KCHT KMPT SECAMB Has local provider been subject to enforcement action by the CQC? Has local provider been flagged as a 'quality compliance risk' by Monitor and/or are requirements in place around breaches of provider licence conditions? Has local provider been subject to enforcement action by the NHS TDA based on 'quality' risk? Does feedback from the Friends and Family (F&F) test (or any other patient feedback) indicate any causes for concern? Has the provider been identified as a 'negative outlier' on SHMI or HSMR? Apr-Oct 2013 N N N N Apr-Oct 2013 N - - N Apr-Oct 2013 N N N N Apr 13 Sep 13 N N N N Jun-13 N - - - Do provider level indicators from the National Quality Dashboard show that: MRSA cases are above zero? April- Oct-13 Y Y N - The provider has reported more C. difficile cases than trajectory? April- Oct-13 Y - - - MSA breaches are above zero? Sep -13 Y N N - Does the provider currently have any unclosed Serious Untoward Incidents? Sep-13 Y Y Y Y Has the provider experienced any 'Never Events' Oct-13 Y N N N Page 11
during the last quarter? Page 12
The CCG summary table is presented below: Clinical Governance Does the CCG have any outstanding conditions of authorisation in place on clinical governance? Has the CCG self-assessed and identified any risks associated with the following: Concerns around quality issues being discussed regularly by the CCG governing body? Concerns around the arrangements in place to proactively identify early warnings of a failing service? Concerns around the arrangements in place to deal with and learn from serious untoward incidents and never events? Concerns around being an active participant in its Quality Surveillance Group? EPRR If there was an emergency event in the last quarter, has the CCG self-assessed and identified any areas of concern on the arrangements in place for dealing with such an event? Winterbourne View Has the CCG self-assessed and identified any risk to progress against its Winterbourne View action plan? CCG [N] [N] [N] [N] [N] [N] [N] The overall assessment is [G/AG/AR/R note is Amber/Green based on provider section] based on the following rationale: Green Amber/Green Amber/Red Red All NO responses One or more YES responses but action plan in place that successfully mitigates patient risk One or more YES responses and no action plan in place / plan does not successfully mitigate patient risk Enforcement action is being undertaken by the CQC, Monitor or TDA and the CCG is not engaged in proportionate action planning to address patient risk Page 13
Has local provider been subject to enforcement action by the Care Quality Commission (CQC)? The CQC carried out a further visit on September 24 th to the Neuro-rehabilitation Unit in Sevenoaks further to compliance actions put in place for Kent and Medway NHS and Social Care Partnership Trust (KMPT) following an inspection in December 2012. All standards were met during this visit - the latest report is available here. On 24 October the CQC published for the first time the results of new surveillance model, also known as the Intelligent Monitoring tool, which sets out a range of information which the CQC will hold on each of the 161 acute and specialist trusts. All trusts will have access to their individual reports via the online Quality and Risk Profile System. The CQC have announced the next 19 acute and specialist trusts* to be inspected (starting in January 2014) as part of CQC s new hospital inspection programme under the direction of the new Chief Inspector of Hospitals (Link). The new intelligent monitoring system arranges the 161 trusts into six bands based on whether they scored highly in the intelligent monitoring tool; are a foundation trust applicant that Monitor have asked the CQC to look at or were inspected by Sir Bruce Keogh. They have also selected eight mental health trusts and community health services. In the Kent and Medway area East Kent Hospitals University NHS FT has been selected as one of the 19 Trusts as a Band 3 intermediate for inspection. The intelligent monitoring system is based on 150 indicators (Link) that look at a range of information including patient experience, staff experience and statistical measures of performance. The indicators relate to the five key questions the CQC will ask of all services. The indicators are used to raise questions, not to make judgements about the quality of care. The CQC s judgements will always follow inspections, and take into account the results of the intelligent monitoring and reports from other organisations. CQC Inspections of East Kent Hospitals NHS Foundation Trust (EKHUFT) A summary of the CQC inspections across the East Kent Hospitals University NHS Foundation Trust (EKHUFT) sites is presented below: KCH QEQMH WHH Standards of treating people with respect and involving them in their care Standards of providing care, treatment and support that meets people's needs Standards of caring for people safely and protecting them from harm Standards of staffing Standards of quality and suitability of management Latest report Jul-13 Jul-13 Jan-13 Page 14
Friends and Family Test EKHUFT have continued to show an improvement in the % response rate for inpatients and are now achieving a year to date average response rate above the national 15% benchmark. The first results of FFT for maternity services will be announced towards the end of January 2014 when three months worth of feedback has been gathered and analysed. NHS England started gathering the views of women from October 1, asking them to express their views at three touch points: 1. Antenatal care to be surveyed at the 36 week antenatal appointment. 2. Birth and care on the postnatal ward to be surveyed at discharge from the ward or birth unit or following a home birth. 3. Postnatal community care to be surveyed at discharge from the care of the community midwifery team to the care of the health visitor or GP, usually at 10 days postnatal. Page 15
NHS Choices William Harvey Hospital, Ashford Other sources of patient feedback include the NHS Choices website. The latest NHS Choices users ratings for the William Harvey Hospital (Ashford) are presented below: Page 16
MRSA The table below presents the MRSA cases by provider where the cases are above zero. The Commissioner level position for Ashford CCG is also shown: Provider / Commissioner 12/13 Total 13/14 Limit Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Trend YTD Actual YTD Limit EKHUFT 4 0 2 0 0 1 1 2 0 6 0 Ashford CCG 3 0 1 0 0 0 0 0 0 1 0 Ashford CCG has breached the zero tolerance for MRSA for 2013/14. EKHUFT has breached the zero tolerance for MRSA, with six cases reported on the national system. The Trust is currently disputing the number of cases reported on the national system for April 2013, claiming one attributable case against the two reported. C difficile The table below presents the C.difficile cases by provider where the cases are above zero. The Commissioner level position for Ashford CCG is also shown: Provider / Commissioner 12/13 Total 13/14 Limit Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Trend YTD Actual YTD Limit EKHUFT 39 29 6 7 5 3 3 4 7 35 17 Ashford CCG N/A 10 4 4 0 2 1 1 2 14 6 Ashford CCG s year-end limit of pre and post 72hr cases of C.difficile is 10. As at the end of October 2013 there have been 14 cases thus breaching the year-end limit. EKHUFT have breached their year-end trajectory limit for C.difficile of 29. As at the end of October 2013 the figure was 35 cases. Page 17
The CCG s Chief Nurse is working closely with the Trust and clinical chairs to understand the root causes of these cases and form action plans for resolution which are closely monitored within CCG quality meetings. Hospital Acquired Infections Enhanced vigilance is being applied to infection prevention and control procedures given the current Trust performance against DoH targets. The Trust applies routine surveillance and root cause analysis with post infection review meetings. This work aims to inform subsequent actions in providing support and challenge towards wards and departments. Enhanced surveillance of cleanliness standards is in progress at each site. The Chief Nurse for Canterbury and Ashford CCGs is working closely with the Trust to understand the root causes of HCAI cases and form action plans for resolution which are closely monitored within CCG quality meetings. Mixed Sex Accommodation There were no mixed sex accommodation breaches for KCHT or KMPT in September 2013, (latest figures available at time of this report). Unify 2 is showing that for April-September 2013 EKHUFT had not had any mixed sex breaches. However EKHUFT's local quality reports are showing mixed sex occurrences within CDU. Current national guidance does not consider CDU to be exempt from mixed sex breaches. There are on-going discussions between the Trust and East Kent CCGs in relation to penalties for breaches in CDU. Serious Untoward Incidents SIs are defined as grade 1 or 2 dependent on severity. Grade 1 SIs have 45 days to be investigated, action taken and closed; grade 2 SIs have 60 days. The latest data is for September 2013. East Kent University Hospital Foundation Trust As at the end of October, there were 32 on-going SIs with 1 breaching the closure deadline. 8 new Serious Incidents were received for the month of October with Queen Elizabeth Queen Mother Hospital reporting the highest number of 5, there were 2 at William Harvey Hospital and 1 at Kent and Canterbury Hospital. All SIs are allocated to the CCG where the patient is registered with their GP. The allocation of these to CCGs are 4 for Canterbury CCG, 3 for Thanet CCG, and 1 for South Kent Coast. None of the SIs reported by EHUFT this month have been allocated to Ashford CCG. Page 18
1 Grade 2 serious incident, and 1 Never Event were reported in October 2013 requiring 72 hour reports which have been received within the deadline maintaining 100% compliance. The charts below demonstrates the top 5 serious incidents reported by category, from November 2012-October 2013, the breakdown of all SIs reported between April 2013-October 2013 (allocated by CCG) and the time taken to report. Top 5 Serious Incident Categories within EKHUFT Nov 2012 - Oct 2013 4 14% 8 29% Pressure Ulcer Grade 3 5 24% EKHUFT Serious Incidents by CCG Apr13 - Oct 13 1 5% 5 24% Ashford EKHUFT Time taken to report Si's - October 2013 25% 25% 0-2 Days 4 14% 5 18% 7 25% Maternity Services - Unexpected admission to NICU (neonatal intensive care unit) Maternity Services - Intrauterine Death Unexpected Death (general) Sub-optimal care of the deteriorating patient 2 9% 8 38% Canterbury South Kent Coast Thanet West Kent 37% 13% 3-4 Days 5-10 Days 11+ days The monthly serious incident reports sent out to each CCG gives more detail on category and on-going figures reported by Provider. Kent Community Health Trust (KCHT) As at the end of October, there were 29 on-going SIs with none breaching closure deadlines. KCHT reported a total of 7 new SIs in October 2013. Despite being a concern over the last year, only one SI in October was a pressure ulcer. All SIs are allocated to the CCG where the patient is registered with their GP. The allocation of these per CCGs are 3 for Swale CCG, 3 for South Kent Coast CCG, and 1 for West Kent. One grade 2 serious incident has been reported in October 2013, a 72 hour report has been received within the deadline maintaining 100% compliance. The charts below demonstrate the top 5 serious incidents reported by category, from November 2012-October 2013, the breakdown of all SIs reported between April 2013-October 2013 (allocated by CCG) and the time taken to report. Page 19
13 17% Top 5 Serious Incident Categories within KCHT Nov 2012 - Oct 2013 4 5% 9 12% 23 29% Pressure Ulcer Grade 4 Pressure Ulcer Grade 3 Slips/Trips/Falls Confidential Information Leak 1 2% 7 15% KCHT Serious Incidents by CCG Apr 13 - Oct 13 4 9 8% 2 19% 4% Ashford 6 13% Canterbury Dartford, Gravesham and Swanley Medway 2 South Kent Coast 4% Swale Thanet KCHT Time taken to report SI's - October 2013 29% 29% 0-2 Days 3-4 Days 5-10 Days Delayed Diagnosis Unknown West Kent 14% 11+ days 29 37% 4 8% 13 27% 29% Kent and Medway NHS and Social Care Partnership Trust As at the end of October, there were 48 on-going SIs with 20 breaching the closure deadline. It has been acknowledged that there is a high number of SIs that breached the closure deadline and work is underway to reduce the number of breaching incidents within the trust. There were 7 SIs reported by KMPT in October, which is a slight decrease from the 10 reported in September, and a clear decrease from 15 reported in August and 24 reported in July. The highest number of incidents reported within KMPT in October occurred in patients homes and public places (i.e. outside hospital environments), 5 in total. This equates to 71% of total SIs reported by KMPT, compared to September when patients homes and public places accounted for 60% of their total SIs reported. The highest category reported within KMPT in October was Suicide by Outpatient (in receipt) with a total of 3. This accounted for 43% of the total KMPT SIs logged, compared to September when 4 Suicide by Outpatients were reported by KMPT, accounting for 40% of their SIs reported. This category has been reported at a consistent level of four to five incidences per month since June 2013 which suggests a possible trend and could indicate that this is an area of high risk for the Trust. There has been an abscond action plan in place for some time now and the Trust believes that progress is being made in reducing the number of absconds. The Trust is reviewing how staff are granting the amount of leave permitted and also discharging patients sooner if there is no further therapeutic value in remaining as an inpatient. The charts below demonstrate the top 5 serious incidents reported by category, from November 2012-October 2013, the breakdown of all SIs reported between April 2013-October 2013 (allocated by CCG) and the time taken to report. Page 20
27 26% Top 5 Serious Incident Categories within KMPT Nov 2012 - Oct 2013 4 3 4% 3% 4 4% 64 63% Abscond Suicide by Outpatient (in receipt) Attempted Suicide by Outpatientt (in receipt) Confidential Information Leak Unexpected Death of Outpatient (in receipt) 1 1% 8 9% 5 5% 16 18% KMPT Serious Incidents by CCG Apr 13 - Oct 13 16 18% 3 3% 8 9% 11 12% 16 17% 7 8% Ashford Canterbury Dartford, Gravesham and Swanley Medway South Kent Coast Swale Thanet Unknown West Kent Outside K&M KMPT Time taken to report SI's - October 2013 29% 29% 14% 29% 0-2 Days 3-4 Days 5-10 Days 11+ days SECAMB As at the end of October, there were 32 on-going SIs with 22 breaching the closure deadline. Of the 22 SIs breaching, 4 are Grade 2s currently with the Area Team awaiting final approval following closure agreement by the CCG. There were 2 SIs reported in October by SECAmb, both under the category Ambulance (general). This is a reduction in the number of SIs reported by SECAmb in September, which was a total of 7. The charts below demonstrate the top 5 serious incidents reported by category, from November 2012-October 2013 and the breakdown of all SIs reported between April 2013-October 2013 (allocated by CCG). The two SIs reported by SECAmb were both reported within 0-2 working days. 13 28% Top 5 Serious Incident Categories within SECAMB Nov 2012 - Oct 2013 3 6% 2 4% 2 4% 27 58% Ambulance (general) Other Confidential Information Leak Ambulance Accidental injury 19 59% SECAmb Serious Incidents by CCG Apr 13 - Oct 13 2 6% 3 10% 2 6% 1 3% 3 10% Ashford Canterbury Medway South Kent Coast Swale West Kent Ambulance Delay 2 6% Outside K&M Page 21
The Trust reported in detail on its management of SI s to the September board. This identified a robust strategy to deal with on-going incidents. As at the end of October 2013 there were 32 active SIRI investigations in progress throughout the Trust. The circumstances surrounding 15 of these occurrences are being examined by the appointed investigating manager and supported by an appropriate Senior Manager. Of the remaining active SIRIs the initial investigation report has been completed and undergone Quality Assurance, Directorate Review or Executive Review. Finalisation actions identified at these review stages are being taken forward and once completed will be submitted to KMCS for initial review prior to being submitted for closure to Swale CCG. There is an aim to improve submission timescales supported by the Senior Clinical Operations Team (SCOT) and Compliance Department via weekly status reporting to Senior Managers. Submission breach rates are to be reported and monitored by the Compliance Working Group. During the second quarter of this year, there have been 18 incidents which required reporting under the National Framework for reporting and learning from Serious Incidents Requiring Investigation (SIRIs). All are being investigated however none of these give risk of a failure to maintain trust registration. All serious incidents are reported to the Risk Management & Clinical Governance Committee and are escalated to the Trust Board if necessary. Never Events There was a Never Event reported by EKHUFT (QEQM Hospital), in October 2013 relating to a retained swab. The swab was left in the patient after a C-section in June 2013. The Trust reported that there has been 18 months of work looking into theatre practice and the Never Event was therefore extremely disappointing. There are spot audits and observations of theatre practice and the use of the WHO checklist. The incident is under investigation. Another Never Event has been reported by EKHUFT (K&C Hospital), in November 2013 relating to a misplaced naso-gastric tube. The member of staff involved has since been suspended pending investigation. Page 22
Are patient rights under the NHS Constitution being promoted? Latest performance against the NHS Constitution standards is presented below: KPI Referral to treatment - admitted patients within 18 weeks Level Full Year Target YTD Target Latest Period Latest Performanc e Trend YTD Performanc e Ashford CCG 90% 90% Sep-13 91.90% 91.60% Referral to treatment - non-admitted patients within 18 weeks Referral to treatment - incomplete pathways less than 18 weeks Number of patients waiting over 52 weeks Diagnostic waiting times - six week breaches Emergency access - A&E 4 hour waits Cancer - two week wait from urgent referral Cancer - two week wait for breast symptom referral Cancer - 31 day diagnosis to treatment Cancer - 31 day subsequent treatment (Surgery) Cancer - 31 day subsequent treatment (Drugs) Cancer - 31 day subsequent treatment (Radiotherapy) Cancer - 62 day urgent referral to first treatment Cancer - 62 day screening referral to first treatment Cancer - 62 day consultant upgrade referral to first treatment Ambulance response - category A all calls in 8 minutes (Red 1) Ambulance response - category A all calls in 8 minutes (Red2) Ambulance response - category A all calls in 19 minutes Mixed sex accommodation breaches Mental Health - Care Programme Approach (CPA) 7 day follow up Cancelled Operations Ashford CCG 95% 95% Sep-13 98.00% 98.10% Ashford CCG 92% 92% Sep-13 93.80% 94.70% Ashford CCG 0 0 Sep-13 2 19 Ashford CCG <1% <1% Sep-13 0.00% 0.60% EKHUFT 95% 95% Sep-13 95.30% 95.00% Ashford CCG 93% 93% Q2 95.01% 95.59% Ashford CCG 93% 93% Q2 92.45% 93.41% Ashford CCG 95% 95% Q2 98.26% 98.79% Ashford CCG 94% 94% Q2 96.67% 97.17% Ashford CCG 98% 98% Q2 100.00% 100.00% Ashford CCG 94% 94% Q2 100.00% 100.00% Ashford CCG 85% 85% Q2 88.41% 87.96% Ashford CCG 90% 90% Q2 Ashford CCG 90% 90% Q2 SECAMB 75% 75% Oct-13 76.00% 76.00% SECAMB 75% 75% Oct-13 76.70% 73.50% SECAMB 95% 95% Oct-13 97.90% 96.90% EKHUFT 0 0 Sep-13 0.00% 0.00% KMPT 95% 95% Q2 97.00% 97.20% EKHUFT Not rated Not rated Q2 86 168 Page 23
The RAG status for the individual indicators is based on the following rationale: Green Amber/Red Red Performance at or above the standard Performance between the standard and the lower threshold Performance below the lower threshold OR same indicator has Amber performance for two consecutive quarters The overall assessment is Amber/Green based on the following rationale: Green Amber/Green Amber/Red Red No indicators rated red No indicators rated red but future concerns One indicator rated red Two or more indicators rated red Where further explanation is necessary this is provided below. Full details of the areas of exception and actions being undertaken to address under-performance are also given. Referral to treatment within 18 weeks Latest performance against the referral to treatment standards is presented below: [UPDATED] KPI Level Target Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Trend YTD Admitted patients within 18 weeks Non-admitted patients within 18 weeks Incomplete pathways less than 18 weeks EKHUFT 90.00% 90.20% 90.90% 91.50% 92.60% 91.00% 91.00% 90% Ashford CCG 88.60% 91.70% 91.00% 91.90% 94.40% 91.90% 91.60% EKHUFT 97.20% 97.80% 98.90% 98.60% 98.40% 98.30% 98.20% Ashford CCG 95% 97.70% 98.00% 98.50% 97.90% 98.30% 98.00% 98.10% EKHUFT 95.00% 95.10% 95.60% 95.70% 95.90% 95.80% 95.60% 92% Ashford CCG 94.30% 95.10% 95.00% 95.30% 94.60% 93.80% 94.70% A breakdown by specialty can be found on page 59. Source: NHS England statisticshttp://transparency.dh.gov.uk/2012/06/29/rtt-waiting-times/ Page 24
Number of patients waiting more than 52 weeks Latest performance against the referral to treatment standards is presented below: KPI Provider / Commissioner Operational Standard Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Trend YTD EKHUFT 36 11 20 10 9 10 96 Admitted patients 0 Ashford CCG 7 3 4 2 0 1 17 EKHUFT 33 19 1 10 5 2 70 Non-admitted patients 0 Ashford CCG 5 0 0 1 2 0 8 EKHUFT 45 29 18 22 16 4 134 Incomplete pathways 0 Ashford CCG 4 6 1 4 2 2 19 Source: Unify2 The Divisional Director for Surgical Services has confirmed that EKHUFT have an agreed action plan following the contract query notice which the CCGs have accepted. There is an agreed reduction trajectory in place which indicates that the backlog will be cleared by the end of November and details how this will be sustained going forward. Despite the continuously improving position, it was confirmed in the Month 5 Contract Performance Letter that the appropriate breach penalties will continue to be applied until such times as the number of patients waiting beyond 52 weeks reaches zero. KMCS and the CCGs will monitor performance against the agreed reduction trajectory according to the contract query notice issued Emergency access - A&E 4 hour waits Latest performance against the A&E four hour waiting time standard is presented below: KPI Provider / Commissioner Operational Standard Lower Threshold Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Trend YTD A&E 4 hour wait EKHUFT 95% 90% 90.70% 97.20% 97.20% 94.50% 95.30% 95.30% 95.00% Performance data At Trust level (K&M patients and out of area patients), EKHUFT has been struggling to achieve the 95% target for A&E 4 hour waits since April 2013 and have missed the target for September 2013, only achieving 94.9%. Page 25
The Trust have reported that this is partly due to an increase in A&E attendances, having experienced a 2.4% increase in the number of patients conveyed to A&E by SECAmb between April and September 2013 compared to the same period in 2012. The Trust have also seen a corresponding rise in the conversion rate (attendance to admission) for these patients. Outcome measures To address the increase in the number of patients being conveyed to A&E SECAmb have agreed to undertake a detailed conveyance audit. A meeting was planned for November to enable representatives of SECAmb and the Trust to consider the data sets from both organisations, conduct a joint Root Cause Analysis and agree a mutually beneficial way of addressing this issue. The results of the audit and the Trust data will be discussed at a meeting with SECAmb representatives and also reported to the Integrated Urgent Care Board. The Trust has produced a detailed action plan outlining further remedial actions to support recovery and achievement into Q3. Source: NHS England statistics Page 26
Cancer waiting time standards KPI Level Target Q1 Q2 Trend YTD Two week wait from urgent referral Two week wait for breast symptom referral EKHUFT 95.24% 93.12% 94.18% 93% Ashford CCG 96.17% 95.01% 95.59% EKHUFT 94.99% 88.29% 91.64% 93% Ashford CCG 94.37% 92.45% 93.41% EKHUFT 98.75% 99.05% 98.90% 31 day diagnosis to treatment 96% Ashford CCG 99.32% 98.26% 98.79% EKHUFT 97.08% 99.2% 98.10% 31 day subsequent treatment (Surgery) 94% Ashford CCG 97.67% 96.67% 97.17% EKHUFT 100.00% 100.0% 100.00% 31 day subsequent treatment (Drugs) 98% Ashford CCG 100.00% 100.00% 100.00% EKHUFT 100.0% 100.00% 31 day subsequent treatment (Radiotherapy) 94% Ashford CCG 100.00% 100.00% 100.00% 62 day urgent referral to first treatment EKHUFT 86.72% 89.8% 88.30% 85% Ashford CCG 87.50% 88.41% 87.96% 62 day screening referral to first treatment EKHUFT 90.91% 95.59% 93.25% 90% Ashford CCG 75.00% 100.00% 85.70% 62 day consultant upgrade referral to first treatment EKHUFT 70.21% 93.24% 81.73% 90%* Ashford CCG 100.00% 66.70% 87.50% Performance against cancer metrics was discussed in depth at the EKHUFT Quality and Performance Meeting on 24 th October. It was agreed that KMCS and the CCGs would be closely monitoring performance against the cancer standards in the coming months. The Trust has advised that the continued increase in cancer referrals, which it is claimed has contributed to the failures to meet the agreed targets, will be highlighted to the CCGs and it is hoped that close work with GPs may improve the management of referrals. A further capacity review is already taking place and a combined action plan will be monitored closer by the cancer compliance group and the Cancer Board Source: National Cancer Waits Database Page 27
All cancer waiting time standards were achieved in 2012/13 and this has continued into quarter one with the exception of 62 day screening referral to first treatment. The 62 Day consultant upgrade referral to first treatment position has declined, but the 66.7% represents 2 patients being upgraded within the standard and one outside the standard. Ambulance response times Latest performance against the ambulance response time standards is presented below: KPI Cat A Red 1 calls in 8 min Cat A Red 2 calls in 8 min Cat A all calls in 19 min Provider / Commissioner Operational Standard Lower Threshold Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Trend YTD SECAMB 75.60% 79.60% 75.30% 72.90% 74.20% 76.50% 76.00% 76.00% 75% 70% Ashford CCG 64.70% 87.50% 72.70% 75.00% 63.60% 60.00% 83.30% 72.50% SECAMB 72.10% 74.80% 74.20% 71.40% 73.40% 73.10% 76.70% 73.90% 75% 70% Ashford CCG 70.70% 71.30% 69.40% 73.10% 70.00% 72.50% 74.20% 72.00% SECAMB 96.70% 97.20% 96.80% 96.40% 96.80% 97.10% 97.90% 97.10% 95% 90% Ashford CCG 93.80% 95.80% 95.60% 92.90% 94.90% 95.50% 96.00% 95.00% Performance against R1 target (8min) has recovered to meet threshold at 76.0% and year to date also remains above the threshold at 76%. R2 (8min) is narrowly above threshold at 76.7% and year to date of 73.9%. R1 + R2 (19m) target continues to meet threshold and improve at 97.85% with year to date of 97.1% The Trust has a Hear & Treat rate of 12% (best in England) and manages 42.9% of incidents without transportation to A&E against an England average of 36.6%. The provider and Commissioners have jointly appointed Lightfoot to conduct the Capacity review and are meeting on Friday 15th November to agree project plan milestones and timescales. Work on the data gathering has already commenced. It is intended to have an interim report at the end of December and a final report at the end of January. Source: http://info.secamb/ (requires login) Page 28
Mental Health Key Performance Indicators Q2 13/14 National Mental Health Indicators compared to national target Q2 13/14 Target Actual Q2 13/14 7 day CPA follow up 95% 90% (2 people) CRHT gate keeping 95% 100% Early Intervention caseload 23 13 % delayed transfers* definition to be reviewed <7.5% 2.4 % % on CPA in settled accommodation 60% 80% % of people on CPA in employment 10% 14% % on CPA with HoNOS in past 12 months 50% 85% % with valid ethnicity ( local target 95% ) 85% 94% Local KPI exceptions Q1 - Q2 (Adults) Target Q1 Q2 Patient Rights 1 % accessing adult CMHT within 4 weeks of referral 95% 85% 75% 2 People waited more than 16 weeks for treatment 0 0 1 3 % of referrals not accepted 9% 12% Domain 1. Preventing people from dying prematurely 4 % of people in CMHT physical health check (trust-wide) 31% 30% Domain 2. Enhancing Quality of Life for people with a long term condition 5 % of all patients on open pathway with HoNOS 95% 78% 89% Domain 3. Helping people to recover from episodes of ill health 6 Urgent referrals to liaison within 2 hours 95% 84% 73% 7 Average length of stay adult inpatient admissions 23 (days) 23 44 8 Number of patients in out of area beds (Q2 2 mnths) 0 3 12 9 Number of out of area bed days (Q2 2 mnths) 0 43 181 10 Risk assessment and Management Plan within 24 hours of admission to acute inpatients 95% 100% 79% Ashford CCG is achieving all nationally set mental health targets apart from CPA 7 day follow ups. Two people out of 20 discharged were not followed up in Q2 within 7 days. This is expected to be 95% in Q3. Ashford has had significant problems with sickness levels, actions have been identified to address this. Reported sickness levels have improved The cost risk to Ashford CCG for people admitted out of Kent area Q1-2 may be 128k if contract conditions are met. KMPT have appointed a discharge service manager to monitor overspills out of Kent area. Admission and discharge protocols are to be refreshed including introduction of discharge date set at admission. 66 people were urgent referrals to liaison compared to 62 in Q1. Waiting times are affected by staff dealing with the back-log from the noncommissioned out of hour s service. Page 29
An action plan to address waiting times into adult community access teams is in place. A Senior Practitioner is focusing on managing referral demand more promptly. The majority of mental health CQUIN is on track apart from 1.1 Urgent care assessment and crisis care plans. KMPT expect them to be achieved by year end. Primary care workers are in place to support people discharged from KMPT in clusters 7, 11, 12. Cancelled operations All patients who have operations cancelled, on or after the day of admission (including the day of surgery), for non-clinical reasons should be offered another binding date within 28 days, or the patient s treatment to be funded at the time and hospital of the patient s choice. There has been no operational standard specified for this indicator and information on the hospital s follow up of the patients affected is not yet available. The latest information relating to this indicator is presented below: KPI Provider / Commissioner Operational Standard Lower Threshold Q1 Q2 YTD Urgent operations cancelled EKHUFT Not rated Not rated 78 86 164 Urgent operations cancelled for the second or more time EKHUFT Not rated Not rated 3 2 5 Source: NHS England statistics Page 30
Are health outcomes improving for local people? The table below shows the current baseline for NHS Ashford CCG against the 2013/14 CCG Outcomes Indicators Set: CCG Outcome Indicators Data period Quality premium National National Local average 1 - Preventing people from dying prematurely 1a Potential years of life lost from causes considered amenable to healthcare 2009 and 2010 2,163 1,888 1.1 Under 75 mortality from cardiovascular disease 2011 67.6 56.3 1.2 Under 75 mortality from respiratory disease 2011 28.5 16.4 1.3 Emergency admissions for alcohol related liver disease 2011/12 25.3 11.4 1.4 Under 75 mortality from cancer 2011 122.9 113.9 2 - Health-related quality of life for people with long-term conditions 2 Enhancing quality of life for people with long-term conditions 2011 73% 77% 2.1 People feeling supported to manage their condition 07/2011 03/2012 52.0% 54.0% 2.3i Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults) 07/2011 03/2012 929 935 2.3ii Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s 2011/12 319 261 2.3iii Estimated diagnosis rate for people with dementia 2.4 Reduction of short stay admission from patients in care homes 2.5 Reduction in emergency admissions within 30 days of discharge from hospital 3 - Helping people to recover from episodes of ill health or following injury 3a Emergency admissions for acute conditions that should not usually require hospital admission 2011/12 1,036 823 3b Emergency readmissions within 30 days of discharge from hospital 2011/12 11.8% 11.1% 3.1i Increased health gain as assessed by patients for elective procedures - hip replacement 2011/12 0.40 0.42 3.1ii Increased health gain as assessed by patients for elective procedures - knee replacement 2011/12 0.30 0.37 3.1iii Increased health gain as assessed by patients for elective procedures groin hernia 2011/12 0.09 0.08 Page 31 Ashford CCG
3.2 Emergency admissions for children with lower respiratory tract infections 2011/12 366 222 4 - Ensuring that people have a positive experience of care 4ai Patient experience of GP services 07/2011 03/2012 88% 89% 4aii Patient experience of GP out of hours services 07/2011 03/2012 70% 72% 4aiii Patient experience of hospital care Jul Sep 83% 83% 4aiv Friends and family test 5 - Treating and caring for people in a safe environment and protecting them from avoidable harm 5.2i Incidence of healthcare associated infection: MRSA 10/2011 09/2012 1.8 4.0 5.2ii Incidence of healthcare associated infection: C difficile 10/2011 09/2012 27.9 8.9 6 Others 6.1 IAPT Coverage performance against plan 10/2011 09/2012 1.8 4.0 The CCG will be expected to show that health outcomes are improving. Progress will be reported once data is available. Mortality data is only published annually so the CCG is exploring the use of local data sources and proxy measures. The outcomes which will attract a quality premium are highlighted in the table. The quality premium is based on 4 national outcomes (or composite outcomes) and 3 outcomes which Ashford CCG members chose as its local priorities: National / Local CCG Outcome Indicators Quality Premium National 1a Potential years of life lost from causes considered amenable to healthcare 12.5% 2.3i Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults) 25% 2.3ii 3a 3.2 Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s Emergency admissions for acute conditions that should not usually require hospital admission Emergency admissions for children with lower respiratory tract infections 4aiv Friends and family test 12.5% (a) Roll-out of Friends and Family Test (b) Patient experience for acute inpatient care and A&E services, as measured by the Test 5.2i Incidence of healthcare associated infection: MRSA 12.5% 5.2ii Incidence of healthcare associated infection: C difficile Local 2.3iii Estimated diagnosis rate for people with dementia 12.5% 2.4 Reduction of short stay admission from patients in care homes 12.5% 2.5 Reduction in emergency admissions within 30 days of discharge from hospital 12.5% Total 100% Page 32
Ashford Referrals Analysis Month 7 Primary care referrals from Ashford CCG for month 7 across all specialties are summarised below. Referrals year to date are slightly above those last year (+3.94%) and are above planned levels (+3.44%), having been above plan consistently for the past six months. Referrals in month 7 are significantly over plan and are in fact higher than any other month seen in the three years previous. The outlying specialties are discussed in more detail below and if referrals in these areas cannot be reduced it will result in an increase in activity levels within these specialties in 6-10 weeks (depending on waiting times). This will of course be a risk to the CCG. Page 33
Primary Care Referrals per 10,000 Weighted Population The below table shows the rate of primary care referrals for Month 7 relative to the weighted population, at a practice level. Areas which are above the average referral rate are highlighted in red. Page 34
Please note that the Total column only includes the specialties shown within this table and is not a reflection of referral levels across all specialties within the contract. It is also important to note that these figures relate to a single month of referrals and do not reflect year to date positions. Orthopaedics There has been a significant increase in Orthopaedic referrals from Ashford in month 7 and in fact this peak is the highest level seen over the past three years. It is worth noting that this is the first month where the QIPP scheme comes into plan and this therefore increases the overperformance further and referrals in month are 16.97% above the QIPP plan. Referrals year to date are now slightly above the QIPP Plan at +0.85%. Page 35
Urology Having been close to plan levels in the previous two months, referrals in month 7 have peaked significantly and are now at the highest level seen over the past three years at 52.81% above the QIPP plan. Referrals year to date are now considerably above target at +14.34% above the QIPP plan. Year to date referrals are also higher than levels seen in the same period in the two years previous at +15.13% and +16.55% respectively. Page 36
Dermatology An increasing trend in Dermatology referrals had been seen from months 2 to 5 with referrals at +38.78% above the QIPP plan in month 5. Month 6 had seen a large reduction back towards planned levels and this lower level has continued into month 7 with referrals slightly above the QIPP plan in month at +5.61%. Despite this reduction, referrals year to date remain significantly above target at +15.88% above the plan and KMCS will continue to monitor this specialty in the coming months. Page 37
ENT Referrals in this specialty are currently at the highest levels seen over the past three years at +22.05% above the QIPP plan in month. Referrals year to date are +7.25% above the QIPP plan are also +8.16% higher when compared with the same period in the previous contract year. Page 38
General Surgery Cons to Cons Consultant to consultant referrals in this specialty remain at the high levels seen over the past 4 months and remain above target levels both in month and year to date, at +17.24% and +30.48% respectively. Performance year to date is also significantly higher than the same period in the previous year at +29.10%. Page 39
CQUIN achievement The tables below show that EKHUFT have been meeting the majority of the targets for both national and local CQUINs. There has been an improvement in performance against the standard Heart Failure (EQ), from 46.94% in July which missed the minimum target of 48.33%, to 70.73% in August. There has been little improvement in performance against the standard CAP (EQ), with July (46.71%) and August (47.83%) both missing the minimum target of 48.08%. This pathway currently has poor performance around recording of CURB 65, referral to the Smoking Cessation Team and antibiotics within 6 hours. The Smoking Cessation Team is working with the Trust to increase ward staff awareness of the importance of referring patients. The Clinical Lead is also planning to increase the awareness of clinical staff around the importance of the other measures. There were also setbacks in performance against the standard Colorectal (EQ). July s data show the Trust performing below target (34.48% against a target of 36.2%). The Colorectal pathway is impacted by a low usage IOFM within the pathway. A review of IOFM usage for all procedures is currently underway by a working party within the Surgical Division and is not expected to be complete for a number of months. In the meantime the Surgical Division is working to ensure that current IOFM usage is clearly documented. There was also a decline in performance against the standard Breastfeeding at 10 days After Birth. Although YTD there has been an improvement in the referral rate, August s data shows a drop in referrals and this is being explored improvement must be shown in Q4. IPM will work continue to work closely with the KMCS Nursing & Quality Team to determine what steps EKHUFT will be putting in place to ensure that quarterly targets are not missed. Page 40