Appendix 5.2 MEETING: Haringey Clinical Commissioning Group Governing Body Meeting DATE: Thursday, 15 March 2018 TITLE: LEAD DIRECTOR: AUTHOR: CONTACT DETAILS: Performance & Quality Summary (P&Q) Alex Smith, Director of Planning, Performance & Delivery, Haringey and Islington CCGs Jennie Williams, Director of Nursing and Quality, Haringey and Islington CCGs Seonaid Henderson, Head of Strategy and Performance Rosie Peregrine-Jones, Head of Quality seonaid.henderson1@nhs.net SUMMARY: The Performance & Quality Summary (P&Q) provides an overview of the performance of Haringey Clinical Commissioning Group (Haringey CCG) and its main providers in relation to performance and quality key indicators. As the Governing Body will be aware (due to reporting timetable differences) the performance and quality sections of the report contain different months activity. This is stated within the relevant sections of the P&Q summary. SUPPORTING PAPERS: Performance & Quality Report RECOMMENDED ACTION: The Governing Body is asked to NOTE the contents of this report. Objective(s) / Plans supported by this paper: Our objective is to commission highquality, valued and responsive services working in partnership with the public to make the best use of resources.
Audit Trail: The P&Q summary report is a standing item on the agenda of the Governing Body. Patient & Public Involvement (PPI): There was no patient involvement in this paper. Risks: As set out below. Resource Implications: There are no particular resource implications.
1. Executive Summary The Performance & Quality (P&Q) summary report provides an overarching picture of the performance of Haringey Clinical Commissioning Group (Haringey CCG) and its main providers in relation to performance and quality key indicators. The detail is held within the content of the report. Key points for the Governing Body are highlighted below. It should be noted that the performance and quality sections of the report contain different months activity, due to the reporting timetable. This is stated as clearly as possible within the report and near-time local intelligence is also included, where relevant. 2. Haringey CCG Performance 2.1 18 and 52-Week Referral to Treatment Time (RTT) The 18 Weeks Referral to Treatment Incomplete Pathways standard was met by Haringey CCG in December 2017 with a performance of 92.2%. Haringey CCG continues to have a number of patient s waiting over 52 weeks for treatment and the figures have been steadily increasing since July 2017 with nine breaches in December 2017. Five of these were at the Royal Free London, two at Imperial College Healthcare NHS Trust, one at University College London Hospital and the remaining one at Kings College London Hospital. Systems are in place to receive feedback from trusts about clinical reviews, treatment plans and clinical harm reviews. Royal Free London has not achieved the Referral to Treatment 18 week target since August 2017. There have been complications associated with the implementation of the new reporting system and Barnet CCG, as lead commissioner is working closely with Royal Free London to agree and monitor the recovery plan. 2.2 Diagnostics Haringey CCG achieved the diagnostic target in December 2017 with performance of 0.6%. Performance in this area has been consistently successful since May 2017. North Middlesex University Hospital and Whittington Healthcare are consistently managing the flow of patients requiring CT and MRI scans well. North Middlesex University Hospital December 2017 performance was 99.77% whilst Whittington Healthcare performance in December 2017 was 99.07%. 2.3 Cancer Haringey CCG achieved seven out of the eight national cancer standards in December 2017. Haringey CCG did not achieve the 62-Day Cancer Wait: GP Referral standard (81.25%, target 85%). Six Haringey CCG patients breached this standard; four due to exceptionally complex diagnostic pathways, one due to capacity, and one beach due to
inter-trust transfer (ITT) issues. A weekly NCL teleconference call has been established where issues regarding ITTs are resolved. At a trust level, NMUH achieved all eight national cancer standards in December 2017. The NCL Cancer Performance Leadership group meets fortnightly to review sector cancer performance. These meetings support the London-wide regulatory process by NHS England and NHS Improvement in providing assurance that Trusts and CCGs are taking all necessary actions to improve cancer performance. 2.4 A&E The Haringey CCG wide Accident and Emergency (A&E) standard is underperforming and fell short of achieving the standard at 81.34% in January 2018 (target 95%) North Middlesex University Hospital (NMUH) Performance Update The challenge in performance experienced during December 2017 resulted in unprecedented system working over the festive period. This included a heightened level of CCG staff support on site, with operational and executive leads participating in weekly Multi-Agency Discharge Events (MADE), daily escalation calls, weekend on-call rotas, and weekend on site CCG support to maximise safe patient discharges to maintain flow. Lessons learned from this intensive period of joint working are being incorporated into the existing system wide urgent and emergency care improvement plan. This plan outlines the actions required to support performance improvement and is reviewed by the A&E Delivery Board and managed via the jointly-funded Safer, Faster, Better (SFB) programme steering group. The most recent strengthening of approach is the establishment of the Integrated Discharge Group at NMUH The Integrated Discharge Group is composed of senior leads from NMUH, Haringey and Enfield CCGs, Local Authorities and community services teams. The aim of the group will be to accelerate operational improvement in processes and pathways that enable rapid and safe discharge of patients from hospital. The group is being designed from the outset to provide the local system with agile delivery of improvement initiatives at the acute-community interface. A number of workshops, have taken place to agree how the Haringey and Enfield health economy can work together to support patients attending A&E with primary care needs better. A&E Performance Trends NMUH has an agreed A&E performance trajectory for 2017/18, with the aim that the trust demonstrates a sustainable improvement in performance and achieves 90%+ levels over the winter. Achievement against the Haringey A&E standard has been declining over the winter period due to extreme winter pressures, and this was after reaching a 2017/18 high of 87% in October 2017 (against a target of 90%). The January 2018 figure seen below only represents the first week of the month, and preliminary performance data suggests
things have stabilized since then with the week ending 4 February 2018 performance being 80%+ and week-on-week rises in performance level. Delayed Transfer of Care (DToC) Performance The DToC rate for NMUH is in the top five best performing Trusts across London and the winter period has witnessed a number of joint efforts to improve performance even further. In fact, the week before Christmas saw system partners achieve their Discharge to Assess trajectory for the first time, highlighting how working together supports the maintenance of system flow. Especially crucial in this regard are the Multi-Agency Discharge Events (MADE) that have provided a number of opportunities for crosssystem learning, enabling partners to work together to overcome organisational boundaries that sometimes cause unnecessary delays. Lessons from these events have led to the redesign of DToC meetings to enable safe discharge in a timely way. Partners continue to monitor DToC performance on a daily basis to identify any trends that require further improvement work. During week commencing 12 February, system partners supported NMUH to achieve exceptionally low levels of DTOCs (2). Continuing Healthcare (CHC) in the acute setting We are currently delivering 17% % of CHC assessments in the acute setting compared to a target of 15% by January 2018. In 62% of cases with a positive NHS CHC Checklist, the NHS CHC eligibility decision was made by the CCG within 28 days of receipt of the Checklist compared to a target of 80% by January 2018. A CHC improvement plan is being developed during the coming months which will describe key next steps to address a number of challenges associated with Continuing Healthcare across NCL. Locally, commissioners are discussing with partners implementing the best practice 5Q model, which resulted in a reduction in CHC assessments taking place in acute settings when implemented in Norfolk. 2.5 London Ambulance Service (LAS) LAS handover times remain a challenge for Trusts across the NCL sector. There was improved performance in December 2017 at the North Middlesex University Hospital site for both the 15 minute (decreasing from 41.30% to 32.8%) and 30 minute handovers (decreasing from 96% to 78.3%). Significant challenges on both of these indicators were reported over the festive and early January 2018 period, resulting in a reduction in ambulances available to convey patients. The Haringey and Enfield A&E Delivery Board has agreed a joint plan, between all partners to work together to reduce handover delays over the coming 12 months. LAS Ambulance Response Programme (ARP) The London Ambulance service have confirmed that for November 2017 the total London service achieved the national standards for category 1, 2 & 4 responses. For December 2017 provisional data indicates that the standards were achieved for category 1 & 4 responses.
The new national ambulance response time standards were established under the Ambulance Response Programme Initiative (ARP) led by NHS England. The aim of the ARP is to ensure that: The sickest patients receive the fastest response All patients get the best response allocated to them No one is left waiting for and unacceptably long time for an ambulance to arrive With the exception of the Isle of Wight Ambulance services across England transitioned into the ARP between 13 th July 2017 and the end of November 2017. The new ambulance response time standards are summarised below: Category Basic definition Response time standard Category 1 Category 2 Category 3 Category 4 Life threatening injuries and illness (e.g. anaphylactic shock or bee sting) Emergency calls (e.g. stroke) Urgent calls (e.g. uncomplicated diabetes some of these may be treated in patient s own home) Less urgent likely requiring transport or hear and treat Response time with an average of 7 minutes Response before 15 minutes for 9 out of 10 calls (90 th centile) Response time with an average of 18 minutes Response before 40 minutes for 9 out of 10 calls (90 th centile) Response before 120 minutes for 9 out of 10 calls (90 th centile) Response before 180 minutes for 9 out of 10 calls (90 th centile) The London Ambulance performance against the national standards is shown in the tables below: Category Measure National Standard November December 1 Mean response time 7 minutes 00:07:03 00:07:24 90 th centile 15 minutes 00:11:28 00:12:04 2 Mean response time 18 minutes 00:18:25 00:24:11 90 th centile 40 minutes 00:36:29 00:51:11 3 90 th centile 120 minutes 02:13:09 02:58:56 4 90 th centile 180 minutes 02:28:48 02:51:49 The London Ambulance Service achieved the national standards for category 1, 2 & 4 responses in November 2017 and category 1 & 4 responses in December 2017.
Although the national standards for category 2 & 3 responses were not met in December 2017 the London Ambulance service was ranked third of the ten ambulance trusts across England for category 2 & 3 responses and also performed better than the England average. In December 2017 only one Ambulance Trust (North East Ambulance service) met the national standard category 1 mean response times and one ambulance trust (West Midlands Ambulance service) met the national standard category 2 mean response times. The table below shows how the London Ambulance Service performance by Sustainability and Transformation Partnerships (STP) area: London Ambulance Service Performance by STP: December 2017 C1 Mean C1 90 th Centile C2 Mean C2 90 th Centile C3 90 th Centile C4 90 th Centile National Standard 7 minutes (00:07:00) 15 minutes (00:15:00) 18 minutes (00:18:00) 40 minutes (00:40:00) 120 minutes (02:00:00) 180 minutes (03:00:00) North Central 00:07:28 00:12:21 00:27:00 00:58:20 03:41:42 03:21:55 North East 00:07:20 00:11:45 00:24:53 00:52:31 03:04:03 02:56:23 North West 00:07:12 00:11:49 00:24:15 00:51:21 03:06:18 02:56:27 South East 00:07:28 00:12:08 00:21:57 00:45:37 02:28:44 02:33:41 South West 00:07:35 00:12:07 00:23:00 00:48:50 02:37:15 02:40:08 Representatives from the LAS will be attending the Haringey CCG Governing Body meeting in May 2018 2.6 Whittington Health (WH) Community Health Services (CHS) Seven of 31 services saw 95% of patients within six weeks and ten of 31 services saw 90% of patients within six weeks in October 2017. There has been a slight improvement in community paediatric services and district nursing. Future reporting arrangements are currently being discussed between commissioners and Whittington Health NHS Trust. It has been agreed that future reporting will show waiting times against targets for routine and urgent referrals once the targets have been agreed in the service specification.
2.7 Barnet, Enfield & Haringey Mental Health Trust (BEH MHT) Out of area placements This relates to people being admitted to an adult acute bed out of the Barnet, Enfield and Haringey area, and is an area of particular focus with NHS England. It also has significant impacts on North Central London s Sustainability and Transformation Partnerships (NCL s STP) aim of staying within the current mental health acute bed base, and for Haringey CCG and BEH in terms of quality and finance. Barnet Enfield Haringey Mental Health Trust (BEH MHT) are waiting for finalised figures as this is a new indicator, but it is a long-standing system performance concern. The rolling quarter figure for November 2017 was 1250 days; 40 new patients. NCL are working with NHS England, BEHMHT and Camden and Islington Foundation Trust (CIFT) to agree a trajectory so that there are no out of area treatments, but these negotiations have not yet been concluded. Delayed Transfer of Care (DToC)/Length of stay on acute wards Haringey Mental Health Delayed Transfer of Care (DToCs) have escalated again and were at 14% in December 2017 against a target 2.5%. The CCGs have appointed a System Resilience Manager for BEHMHT who will focus on DToC and flow issues, which is expected to support the Trust performance to return to target this year. Memory Clinic Service (MCS) Against the six week wait from referral to diagnosis, Haringey continue to perform at 25% in September 2017 against a typical 95% target. The Trust believe this is largely a funding issue, which appears to be supported by the recent independent Pricing Review of BEH MHT services. The tri-borough CCGs have prioritised the Memory Clinic as a service to be re-specified as part of the implementation of the BEH MHT Transformation Plan and will draw on learning from Barnet and national best practice. The Memory Clinic re-specification will be completed by April 2018. Early Intervention Psychosis (EIP) The Haringey service continues to meet the two week Referral To Treatment (RTT) target of 50%, with performance of 87% in October 2017. Crisis Response and Home Treatment team (CRHT) The work to develop a specification for the Crisis Response and Home Treatment team (CRHTs) is planned for April 2018. The specification for a review of the model has been agreed and will inform the future development of the service in light of wider North Central London (NCL) discussions about the crisis and acute pathway. Children and Young People Mental Health (CYPMH) NHSE data indicates that Haringey has not met its access targets for CYPMH. We are working towards a 35% coverage by 2020, and consequently have a target of 1630 for 2017/18. The data provided by NHS England shows 380 children and young people accessing services in first two quarters but local data indicates there were 1167. NHS
England has been alerted to these data quality issues and there is a sector wide group investigating the causes and the corrective action to be taken. Increasing Access to Psychological Therapies (IAPT) The service continues to meet the targets for recovery rates, patient access and waiting times, though waiting times have been increasing over winter. The NHS England funded pilot of integrating Increasing Access to Psychological Therapies (IAPT) into the pathway for diabetes and Chronic Obstructive Pulmonary Disease (COPD) has launched and is meeting its trajectory numbers after significant work from the teams to promote the project and embed it. 2.8 E-Referral Services (e-rs) Wave One Early Adopters of e-rs, North Middlesex University Hospital (NMH) Trust and Whittington Hospital NHS Trust went live at the beginning of January 2018, with full Paper Switch Off occurring in March 2018. This position has changed because NHS England were concerned about possible delays in the full Paper Switch Off programme (PSO). NHS England have issued a formal change notice to the North Middlesex University Hospital and Whittington Health stipulating that in order to avoid any drift in Wave 1 Providers not moving to full PSO, the date for Wave One has now been set for the 28 February 2018. Wave One Providers and local CCGs are agreeing amendments to the roll-out plan and revised communication to practices. In addition, joint weekly CCG/Provider e-rs GP referral monitoring meetings have been established in order to identify practices having difficulty using the new processes. 3. Quality 3.1 North Middlesex University Hospital Trust (NMUH) The Governing Body is asked to note that the Trust remains on enhanced surveillance by the regional Quality Surveillance Group (QSAG). On Friday 1 December 2017 the General Medical Council (GMC) undertook a visit to the A&E department to review the learning environment for trainees. The outcome of the visit, which was detailed in a letter to the Trust, confirmed that improvements had been made and that no regulatory sanctions would be implemented at this time. The ongoing requirement for the Trust to submit weekly evidence to the GMC to demonstrate that trainees in the Emergency Department (ED) are receiving appropriate supervision and education continues until further notice. A pack of evidence is reviewed by the Trust, Health Education England (HEE) and commissioners prior to the weekly submission. The Haringey CCG and Islington CCG Director of Nursing and Quality represents the NCL Accountable Officer at this meeting. On Tuesday 6 February 2017, the Trust and commissioners were informed of the outcome of the GMC and HEE (and NHSI) Peer review visit to ED held the previous day. General feedback was of overall improvement in trainee satisfaction. In terms of recruitment to the Substantive ED Clinical Director post, this is in progress with interviews imminent.
Implementation and audit of an ED Safety Checklist has been recently confirmed by NMUH. The department is currently undergoing a plan, do, study, act (PDSA) cycle and meeting with the Emergency Care Intensive Support Team (ECIST) every Thursday to discuss the implementation of the checklist. The Director of Nursing and Quality at Haringey CCG undertook an assurance visit to review progress of the implementation of the checklist on Thursday 7 December 2017. Commissioners are in liaison with the NMUH Medical Director and planning to review the A&E Quality Dashboard using an NHS Improvement A&E national dashboard that is currently being piloted in a number of trusts. Maternity In addition to ensuring close oversight of A&E, commissioners are requesting assurance on the delivery of safe and high quality maternity care. The last CQC report gave Maternity services Inadequate rating for the Well-Led domain. Implementation of recommendations has been a challenge for the trust. A key priority will be to get maternity leadership from inadequate to requires improvement or better. The service will need to have completed all CQC improvement actions. Key interventions discussed at the meeting with the Trust and NHSI on 15 December 2017 include the new Head of midwifery commencing in April 2018 and a senior midwife funded by NHSI to support the Head of Midwifery, 2-3 days per week. Dermatology service update NMUH has commissioned Concordia services to provide the Dermatology service from 15th January 2018. This contract is for 12 months in the first instance, with a 6 month break clause. The service was transferred to Concordia given concerns regarding workforce sustainability and safety on an on-going basis if Dermatology remained with the Trust. The Trust was unable to identify a long-term workforce plan that would meet the current demand for the service. Concordia are providing care across all the different types of service, which includes: paediatrics, 2 week wait referrals and also support to the cancer multi-disciplinary team. The transfer and continuous provision has worked effectively as Concordia are now providing 11 clinics per week at North Middlesex Hospital. This is an increase on previous numbers of clinics that were run in the department. These additional clinics are held to be able to clear the backlog, particularly follow up patients that have built up over the past few months, and that have previously been reported to CQRG. They are providing a whole day clinic on Saturdays to provide for patients who are unable to attend during the week, as well as a one-stop clinic that wasn't previously available onsite. The Trust will be conducting a monthly clinical governance meeting. The Divisional Director of Operations is also having a monthly performance meeting with Concordia to review performance against their key performance indicators. Discussions continue with Royal Free London regarding the long-term arrangement for Dermatology. Patient Safety A new Never Event (wrong site surgery) was reported on 16 January 2018. This event concerned a patient who consented for left ureteroscopy. The consultant surgeon conducted the diagnostic study on the right kidney. Since 1 April 2017, five Never Events have been reported at NMUH three wrong site surgery and two retained
foreign objects. The CCG has asked the Trust to prepare assurances on actions in place to address root causes of the Never Events including ensuring World Health Organisation (WHO) checklist is applied and followed and audit in place to evidence impact. An Insight visit to theatres and surgery at NMUH to assess compliance of WHO checklist is planned for March 2018. The trust continues to have a number of delayed Serious Incident (SI) reports and Further Information Requests (FIR) responses. The CCG Patient Safety Leads met with the Trust on 15 January 2018 to review the FIRs, the evidence provided by the Trust and were able to close a number of SIs as a result. The Trust also confirmed that the SI pilot will not be continued and the Trust will revert to the national SI assurance timescales and reporting requirements. CQC improvement/action plan This remains a priority as the Trust has recently been given notice of re-inspection by the Care Quality Commission (CQC), which is likely to be around June 2018 and the Trust (and CCG) need assurance that the CQC Must Do and Should Do actions from the last inspection have been delivered. The NMUH risk and quality committee in December 2017 received an update on the progress being made against the CQC must and should do actions. These have been incorporated into the wider Trust quality improvement plan, whilst remaining locally driven. Recent actions include: i) An assessment of assurance against action status for Must and Should Do actions ii) Clear themes from the CQC s report were identified and areas requiring further development across the divisions are: Robust governance Appropriate engagement areas of overlap to establish common actions Alignment of actions to the detailed CQC key lines of enquiry Using data to drive assurance and quality improvement iii) A review of the themes arising against available key performance indicators (KPIs) was undertaken, which identified KPIs monitored routinely (via the integrated performance reports (IPR) and Qlikview), to identify KPI gaps/duplication iv) Key themes arising from the CQC s report and the findings are: Training & further development (including levels of management) Staffing (national challenge) Learning & shared learning across the trust Governance Mortality, emergency department, maternity Records governance & compliance with record keeping standards Access & Flow v) Next steps agreed were: KPIs for each theme (as contained within this report)
Align KPIs with integrated performance reports (IPR)/Qlikview where possible to reduce over processing The January 2018 CQRG received a presentation demonstrating the progress being made against each of the themes. 3.2 Whittington Health NHS Trust (WH) Verita Investigation The Trust have received the draft Verita report; focusing on several serious incidents involving mental health patients in Whittington Health A&E, the report was found to be a verbatim record of the interviews which included direct quotes. The Trust requested that the document is revised. The re-drafted report has been shared with the Trust and the report is currently being reviewed by Camden & Islington Mental Health Trust before presentation at Whittington HealthTrust Board in March 2018. Lower Urinary Tract Service (LUTs) The CCG view on the readiness of the clinic to open with new patients is primarily determined by progress on actions in response to the Royal College of Physicians (RCP) and the Trust s view on readiness. Since receiving the final report from the RCP Paul Sinden, Director of Performance and Acute Commissioning North Central London CCGs and Jennie Williams, Director of Nursing and Quality Haringey and Islington CCGs, have worked closely with the trust to ensure robust patient safety and governance processes are in place. The Trust has been consistent with the patient group that the LUTs clinic will not open until the Trust board is satisfied that the RCP recommendations have been delivered. Commissioners advised the LUTs patient group that the service cannot be re-opened until the Trust has demonstrated that it can deliver the service in accordance with an agreed service specification. The NCL Joint Commissioning Committee (JCC) on 1 March 2018 will discuss the case for re-opening the LUTS service, along with a draft service specification for the LUTS service. If the JCC approves the proposal for re-opening the clinic and specification. Whittington Health and University College London Hospital (UCLH) will write a joint business case that outlines WH s approach and costs to delivering the service, demonstrating compliance with the commissioner approved service specification. The completed business case will be presented for approval to the Whittington Health Trust board on 28 March 2018. If the service specification and business case are approved by the Trust Board and commissioners are satisfied that the business case and associated protocols meet the service specification, the service will be included in the trusts 2018/19 contract from April 2018 and the service will be re-opened to new referrals.
CQC unannounced inspection The committee is asked to note that on the 31 October 2017 a team of 25 CQC inspectors conducted an unannounced and targeted inspection at Whittington Health. They were on-site for three days; the areas of focus included: Critical care. Selected community services. Outpatients. A&E particularly focussing on mental health patients WH has recently been awarded an overall rating of Good by the CQC. 3.3 Barnet, Enfield and Haringey CCG Mental Health Trust (BEH MHT) CQC Improvement plan update The Care Quality Commission (CQC) undertook a comprehensive Inspection of the Trust during the week beginning 25 September 2017, and the report was published on Friday 12 January 2018. The Care Quality Commission (CQC) rated the Trust as Requires Improvement overall but found that that a number of its services are better than when it last inspected in December 2015. In the latest inspection, BEHMHT was rated Good for being caring, responsive and well-led. It was rated Requires Improvement for being safe and effective. The Trust leadership was felt to be open. The Trust engaged well with staff and encouraged them to raise concerns when they had them. Many staff told the CQC they found the Trust a good place to work. However, CQC inspectors also found that staff found it hard to keep patients safe and protect their privacy and dignity because some of the Trust s buildings were old and did not provide a good environment for patient care. Patients who needed access to seclusion rooms sometimes had to be moved through public areas and had to use bathrooms that contained potential ligature anchor points. The Trust had improved many ward environments since the last inspection and had proposals to rebuild St Ann s hospital, but it needed to continue work to improve all environments. Staff in the acute wards for adults of working age and psychiatric intensive care units did not complete physical health checks for patients following rapid tranquilisation. Community-based services for adults of working age were rated as Requires Improvement overall with concerns highlighted in Haringey community teams. Staff did not always receive regular formal supervision and in some teams managers did not record when staff completed formal supervision or what had been discussed. Care plans were not always patient centred, risk assessment and physical health assessment processes were not embedded. Staff in Haringey community services across all the teams the CQC visited, raised concerns about a culture of bullying and feeling the culture was not open in a way that enabled them to safely raise concerns. Due to the immediate concerns the CQC had, after the inspection they asked the Trust to take immediate action in Haringey West CSRT (Canning Crescent). This was because they were concerned the team were not
identifying, assessing and managing and recording risk. The Trust provided the CQC with a comprehensive action plan which addressed the immediate concerns and the CQC are continuing to monitor this. Further information sharing on the detail of the action plans was requested and has been shared with Haringey CCG.