3.5 COUNCIL OF GOVERNORS MEETING Thursday, 20 April 2017 PERFORMANCE ASSURANCE REPORT Non-Executive Directors PURPOSE OF THE PAPER: The National Health Service Act 2006 (as amended) places a general duty on the Council of Governors to hold the Board to account via the Non-Executive Directors for the performance of the Trust. The Board of Directors receives a performance report at each of its meetings that contains more detailed information and analysis. The report is integrated and includes quality, workforce, finance and activity indicators. The report is publically available as part of the Board papers on the website. In addition, the Board of Directors maintains a governance structure of committees who scrutinise the performance and risks associated with the delivery of the services. This is all co-ordinated within the Board Assurance Framework which is scrutinised by the Audit Committee and recommended to the Board of Directors for approval. The Council of Governors, need to be provided with a report that offers assurance that there are sound governance structures in place and need to have the opportunity to consider and give a view on any performance matters. This report provides information on those areas of performance which is of concern along with an explanation of the Board of Directors approved to address these concerns. For information the Chairs of the sub-committees of the Board are: - Malcolm Burch, Chair of the Strategic Change Committee gains assurance on plans, strategy, business developments, capital and business cases for service developments; Mary Dowglass, Chair of the Quality Committee gains assurance on all aspects of patient safety, experience and effectiveness across a broad range of services; Philip Jackson, Finance and Performance Committee. Tim Ludlow, Chair of the Audit Committee gains assurance on all aspects of corporate governance including finance and internal/external audits. ACTION REQUIRED BY GOVERNORS: The Governors are asked to receive this report. 1
NHS Improvement Key Performance Indicators Key Performance Indicators Trust Target Achieved - February 2017 % of CPA patients receiving a follow up within 7 days of discharge 95% 90.9% % of CPA patients with a formal review within the last 12 months 95% 95.0% % of patients on CPA whose Accommodation status is known 73.3% % of patients on CPA whose Employment status is known Combined 50% 72.1% % of patients on CPA with a HoNOS assessment recorded within the last 12 months 79.6% % of admissions to inpatient services that have had access to Crisis Resolution Home Treatment teams 95% 96.7% Early Intervention - % of patients seen within 2 weeks from referral to treatment 50% from April 2016 100.0% % of patients with a delayed transfer of care No more than 7.5% 10.8% MHSDS - Identifier Metrics: NHS no., DOB, postcode, current gender, reg GP org code, commissioner org code 97% until October 2016 95% from November 2016 MHSDS - Priority Metrics: ethnicity, employment status (for adults only), school attendance (for CYP only), accommodation status (for adults only), ICD10 coding 85% Year end 69.5% (New KPI from November 2016) Self-certification against compliance with requirements regarding access to healthcare for people with a learning disability IAPT Wait from Referral to Treatment (Patients that were discharged in month) 75% within 6 weeks 86.6% IAPT Wait from Referral to Treatment (Patients that were discharged in month) 95% within 18 weeks 100.0% Outpatients % of patients on waiting list waiting within 18 weeks 92% 93.9% Information governance tool kit subset 90% Total membership figure 10,357 by year end 9992 99.6% 2
NHSI Exception % of CPA patients receiving a follow up within 7 days of discharge % of CPA patients receiving a follow up Expected to be within 7 days of discharge was below the target of 95% in February. This equates to 30 out of 33 eligible patients. In the future those transferred to prison or on remand will be communicated with via the relevant penal in-reach mental health service. compliant by March 2017 data Observations: All 3 breaches emanated out of Conolly ward. Two of the breaches were due to the individuals being in police custody and the 3rd would not agree with the location of the follow up. The current quarterly figure for the 2 months out of the 3 is 94.3%. It is vital that March performance improves to ensure compliance against this metric. 3
NHSI Exception Delayed Transfers of Care The Trust DToC position although improving (10.8%) this month, is still above the target The Admission and discharge coordinator attends ward rounds and reviews all estimated discharge dates to support timely discharge Ongoing process to reduce delayed threshold of 7.5%, due to the higher than average delayed discharges in 3 out of the 4 Older Adult inpatient wards (25.3%). The Division is working with Adult social care in regards to ensuring consistent social work attendance at multi- disciplinary team meetings (MDT) to agree DToC classification. bed days. Timely assessments to support identification of needs and appropriate intervention and support required by ward staff. MDT to agree DToC and reasons for DToC to be clearly recorded on SILVERLINK. This has been added to reviewed MDT paperwork. Ward Staff to agree DToC social care and escalate via social care with principal practitioners. Service Manager has established regular meetings with Social Care Area Manager to follow up on potential blocks in the process. This has been picked up by the new Acting Service Manager Issues discussed in band 7 supervision and escalated through Divisional Management Team to have oversight of issues. Regular meetings with Social Care Area Manager to review DToCs that are a result of social care issues. NHSI Exception MHSDS Priority Metrics The Trust s compliance has improved at The Older Adult teams have started to update the patients clinical record. Expected to be 69.5%, but is still below the expected level required to achieve the target (85%) by the There has been a request for clinician name to be added to the report so that this work can be carried out by clinicians as well as administrative staff spreading the work load. compliant by March 2017 end of the financial year. Older Adult team s recording of employment and accommodation status is the main reason for this figure due to 3 community teams having administrative staffing issues. The Lincoln and Boston teams have completed their updating 4
Local Key Performance Indicators Key Performance Indicators No. of KPI s achieved No. of KPI s off track Total KPI s Steps2Change 4 0 4 Inpatients 5 0 5 Older Adults 8 0 8 Learning Disabilities Services 1 2 3 Policy Implementation Guidance Services 4 0 4 Lincolnshire Child and Adolescent Mental Health Service 1 5 6 Lincolnshire County Council Adult Section 75 1 0 1 North East Lincolnshire Child and Adolescent Mental Health Service 2 1 3 Access and Waits 0 1 1 Total 26 9 35 Local Exception Learning Disabilities Services Waits The routine waits have seemingly deteriorated, with February performance being 73.6% against a target of 95%. On further analysis the reported over target waits were due to data inputting errors, data migration issues, duplicate referrals and patients not attending their first appointment. Training is still There are now fewer than 40 duplicate referrals still to process. This work is on target to be completed at the end of March 2017. The inputting errors have been resolved with the personnel responsible. Compliant by March 2017 required within the service to ensure that all staff are There is a team of 2 Learning Disabilities staff who work solely on working in new ways to ensure no further data data cleansing. This is being reviewed on a weekly basis and fed cleansing issues. back to the Service Manager. Urgent Community Home Assessment and Treatment Team (CHAT) Waits - In February the service saw 3 out of the 4 patient within the 4 hour triage target. The remaining patient was brought to the Section 136 suite by the Police during the early hours of the morning. There was no evidence of a Learning disability for this patient and therefore it was not accepted by the CHAT team. The breach of the 4 hour triage was not completed because at the time (00:50), it was not deemed appropriate to make contact with the patient s parents. 5
Lincolnshire Child and Adolescent Mental Health Service waiting times Waiting times for the Lincolnshire Child & Weekly monitoring of waits and number of assessments offered. Reduced waiting list Adolescent Mental Health Services are off target. Weekly reporting by Team Coordinators to the Service Manager Confidence in level of Re-iterate the need for accurate inputting of offered appointments. data quality Actively manage patients that persistently don t attend appointments through the safeguarding policy. Increased utilisation of capacity Lead Administrator to monitor via weekly self-service reports. Ongoing monitoring Training needs identified to ensure accurate recording when a case is already being supported within the service. to reduce waiting times. North East Lincolnshire Child and Adolescent Mental Health Service (NEL CAMHS) In February 90% of urgent referrals were seen within 5 days against the target of 95%. This equates to 9 young persons out of 10 being seen in the month. Patient offered an appointment within 2 days but did not attend. Patient subsequently attended appointment within 6 days of initial appointment at a date and time convenient to the patient. Ongoing waiting list management to reduce waiting times. 6
Local Exception Access and Waits Psychology waiting times The Psychology service currently has 422 patients waiting to be seen with the longest wait being 162 weeks. Recruitment of Additional Staff. Whilst the 10.5 WTE additional posts have been recruited to, the service currently has 6 trainee CBT posts within the current complement. This does impact upon Service will be fully staffed More patients will be capacity, as these individuals require lower caseloads, and taken off the waiting increased supervision that is provided from more senior staff. list and treated The service continues to experience a rise in requests for referral discussion which impacts upon capacity of senior staff, and opens the potential for accepted referrals to rise, which will distort any trajectories for reduction of waiting lists The tender exercise to identify contracted independent providers is currently being completed. It is anticipated that we will be in a position to offer access to contracted independent providers from Mid-April 2017. There are still a small number of data quality issues given the use of Silverlink to map the new patient pathway journey that has culminated in a small variance in the total waiting figures, however the correlation coefficient is 95% The service continues to operate a prioritised system of accepting referrals. The process of limiting accepted referrals by highest priority against the capacity of the service has exposed a level of unmet need that will need to be addressed through service redesign. The clear identification of unmet needs is considered preferable to these being masked via a process of being placed on a waiting list for up to 3 years, with no other input being provided. The service is operating a system of re-directing resources from areas with shorter waiting times (Grantham) to areas with longer waits (Lincoln). It is anticipated that redeployment of resources will continue, until waits across all areas become comparative. It has been internally agreed that referrals accepted under the Armed Forces Covenant Pathway will be counted as part of the agreed prioritised system of accepting referrals, as opposed to an additional pressure. All patients on the waiting list are appropriate and want Psychology treatment 7
Care Quality Commission Action Plan Trust Wide Actions Total number of 37 Total number of 8 Completed 28 Completed 7 On track for 9 On track for 1 Adult Inpatient Services Total number of 58 Total number of 17 Completed 45 Completed 16 On track for 13 On track for 1 Adult CMHT s Total number of 14 Total number of 11 Completed 7 Completed 9 On track for 7 On track for 2 Specialist Services Total number of 26 Total number of 12 Completed 24 Completed 12 On track for 2 On track for Older Adult Services Total number of 19 Total number of 23 Completed 16 Completed 11 On track for 3 On track for 12 Well Led Domain Number of 5 Completed 3 On track for 2 All are on track to be completed to deadlines. Evidence to show is documented and reviewed. 8
Trust Financial Indicators Summary Trust Financial Indicators Summary The Table below provides a Year to Date and forecast year end summary of the key financial performance of the Trust Indicator 16/17 YTD Actual 2016/17 YTD Summary 16/17 YTD Plan Variance % Achieved of Plan 16/17 Forecast Outturn 2016/17 Year end Summary 16/17 Planned Variance Outturn % Achieved of Plan '000 '000 '000 % '000 '000 '000 % EBITDA Surplus (-)/Loss(+) Monthly ( 000's) -4,951-4409 -543 112% -5,402-4,896-506 110% Net Surplus(-)/Loss (+) Monthly ( 000's) -1,117-883 -234 79% -1,249-754 -495 60% Use of Resources Rating (UoRR) 1 1 1 1 Cost Improvement Plan Against Delivery (- 000's) - 2,393-2,396 3 100% -2,603-2,607 4 100% Agency Staff Utilisation ( 000's) 1,879 1,994 115-6% 2,113 2,140 27-1% Cash Balance ( 000's) 13,888 10,494 3394 132% 12,047 9,763 2,284 123% Capital Expenditure ( 000's) 2,311 3,713-1,402 62% 3,318 3,986-668 83% Summary of Capital expenditure spend against plan Summary of Cash Balances against planned levels Summary table of Cost Improvement Plan delivery 9