Ayrshire and Arran NHS Board

Paper 12 Ayrshire and Arran NHS Board Monday 9 October 2017 Planned Care Performance Report Author: Fraser Doris, Performance Information Analyst Sponsoring Director: Liz Moore, Director for Acute Services Date: 18 September 2017 Recommendation The Board is asked to review performance against the national waiting times and access targets. Summary This paper reports on progress towards achieving waiting time and other access targets set by the Scottish Government as well as progress on local targets set by the Board. Latest available information is reported for the following targets and measures: Treatment Time Guarantee 18 Weeks Referral to Treatment Stage of Treatment Targets Unavailability of patients Cancer waiting times Patients awaiting discharge Mental Health Services AHP MSK waiting times targets A summary scorecard is at Appendix 1. Key Messages: At the end of August 2017 there were 552 patients who had waited over 84 days for treatment. 18 week Referral to Treatment performance at 74.4% did not meet the target in July 2017. 4824 outpatients had waited in excess of the 12 week Stage of Treatment standard at the end of July 2017. 654 Endoscopy patients and 2120 Radiology patients had waited in excess of 6 weeks for diagnostic tests at the end of July 2017. The 31 day Cancer target was achieved in July 2017, with performance of 100%. The 62 day Cancer target was 92.4% in July 2017. There were 49 delayed discharges of more than 14 days at the end of August 2017. 1 of 13

Glossary of Terms A&E AHP AHP MSK CAMHS ENT GPSI IP/DC ISD LDP MRI MSK QuEST RTT SGHSCD TTG UH Accident and Emergency Allied Health Professional Allied Health Professional Musculoskeletal Child and Adolescent Mental Health Services Ear, Nose and Throat General Practitioner with Special Interest Inpatient and Day Case Information Services Division Local Delivery Plan Magnetic Resonance Imaging Musculoskeletal Quality and Efficiency Support Team Referral to Treatment Scottish Government Health and Social Care Directorate Treatment Time Guarantee University Hospital 2 of 13

Jun-14 Aug-14 Oct-14 Dec-14 Feb-15 Apr-15 Jun-15 Aug-15 Oct-15 Dec-15 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Apr-17 Jun-17 Aug-17 1 Treatment Time Guarantee Target: The TTG for patients added to the list from 1 October 2012 places a legal responsibility on NHS Boards to deliver treatment to all day case/inpatients within 12 weeks of the patient agreeing to treatment. Performance: At the end of August 2017 there were a total of 552 patients who had waited over 84 days for treatment, the majority in Orthopaedics and Oral & Maxillofacial Surgery. The initial backlog was created in Orthopaedics and was due to the cancellation of elective surgery during the winter of 2014/15 due to significant unscheduled care demand, with similar but lesser issues in subsequent winters. Staffing issues within Oral & Maxillofacial Surgery have added to an increased number of patients waiting over 12 weeks for their planned surgery over recent months. Apr17 May17 Jun17 Jul17 Aug17 Patients who have waited more than 84 559 617 608 592 552 days for treatment at the end of the month Percentage of patients at the month end 81.8% 79.1% 79.4% 80.3% 81.7% who have waited less that 84 days for treatment Patients who breached the TTG during the 245 326 286 224 233 calendar month Patients who were treated after their TTG during the calendar month 192 243 271 212 257 700 600 500 400 300 200 100 0 Monthly Audit of Waiting Times Recording TTG breaches during the calendar month Month end TTG breaches (still waiting) Patients treated in the month who exceeded their TTG Target Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 TTG audit performance 95% 98.9% 99.1% 99.6% 99.4% 99.1% 99.0% Audit results are provided to service managers who develop improvement plans, which are reviewed and monitored by the Director of Acute Services. 3 of 13

Apr-14 Jun-14 Aug-14 Oct-14 Dec-14 Feb-15 Apr-15 Jun-15 Aug-15 Oct-15 Dec-15 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Apr-17 Jun-17 2 18 Weeks Referral to Treatment Targets: the target for 18 weeks RTT is to deliver 90% combined admitted/non admitted performance; to deliver 90% of patients with a total pathway which is linked; and to deliver 90% of completed forms at the end of each clinic outlining the outcome of the consultation. Performance: Target Mar 17 Apr 17 May 17 Jun 17 Jul 17 18 wk RTT performance 90% 73.6% 75.1% 78.1% 76.3% 74.4% Clinic Outcomes 90% 88.7% 87.7% 87.9% 88.1% 88.0% 100% 95% 90% 85% 80% 75% 70% 18 wk RTT performance Outcome recording 18 week RTT performance remains below target, with performance linked to the issues with stage of treatment performance and recruitment difficulties. The lowest performing specialties in July 2017 were the Pain Service at 26.51%, Gastroenterology at 38.10%, Respiratory Medicine 41.88%, Oral and Maxillofacial Surgery at 46.04% and Rheumatology at 46.74%. 3 Stage of Treatment Targets Targets: In addition to the TTG and 18 weeks RTT, NHS Boards are also required to report on stage of treatment waits for inpatient and day cases (12 weeks), outpatients (12 weeks) and diagnostics (6 weeks). Performance: Percentage of outpatients who have waited less than 12 weeks Number of outpatients who have waited less than 12 weeks Number of outpatients whose wait exceeded 12 weeks Percentage of diagnostic patients who have waited less than 6 weeks for their test Number of diagnostic patients who have waited less than 6 weeks for their test Number of diagnostic patients who have waited more than 6 weeks for their test Apr17 May17 Jun17 Jul17 78.4% 76.5% 75.3% 76.4% 16630 15920 15410 15600 4591 4891 5069 4824 58.1% 59.8% 62.4% 64.9% 5039 5098 5415 5122 3627 3434 3267 2774 4 of 13

The Scottish Government sets end of month projections with each NHS Board for the number of patients waiting longer than 12 weeks for an outpatient appointment. The projection for the number of patients waiting longer than 12 weeks at July 2017 was no more than 5240, which was achieved. The projection for the end of September 2017 is no more than 6050 patients, however at the beginning of September 2017 Scottish Government asked for this number to be reduced to 5000. Service Managers are now examining ways to increase activity further to achieve this target. 8000 7000 6000 5000 4000 3000 2000 1000 0 Diag 6wks OP 12wks Outpatients 4824 outpatients waits exceeded 12 weeks at the end of July 2017. Demand, particularly urgent and urgent, cancer is suspected referrals, has increased for a number of specialties, resulting in capacity shortfalls. Recruitment problems remain a major issue, with short term arrangements in place while permanent recruitment continues. The specialties with high numbers of patients waiting over 12 weeks in July 2017 are listed below, with a brief summary of the issues affecting performance and improvement actions. ENT with 910 patients (an increase of 30 from the previous month) Staff turnover over the last eighteen months has resulted in a succession of vacancies. A new consultant took up post in August and outpatient clinic templates have been reviewed to ensure maximum capacity. All available capacity is being utilised and additional sessions are in place. Oral & Maxillofacial Surgery with 667 patients (a decrease of 105) There has been a consultant vacancy for over a year, to which there has been no success in recruiting. The focus has been on using specialty doctors to increase capacity, as well as the community dental service pilot to reduce dental work provided in the acute service. Respiratory Medicine with 537 patients (a decrease of 10) The service is continuing to experience high demand for urgent and urgent cancer suspected appointments. An additional consultant has been recruited and will start in January 2018. Additional consultant led community clinics are being held, with also additional sessions through Medinet. Orthopaedics with 517 patients (an increase of 47) The service is experiencing increased demand in paediatric, knee and foot & ankle subspecialties, as well as with referrals for named consultants. Unexpected absence is also having an impact. There was a vacant post at University Hospital Ayr since April 2017 with a successful candidate in post in July 2017. Cardiology with 457 patients (an increase of 17) Additional sessions have been arranged to reduce patient waiting times. From the end of September a new system for vetting, clinic outcoming and standardised processes will be introduced as part of the Improving Outpatients Programme. 5 of 13

Gastroenterology with 392 patients (an increase of 43) Two consultant vacancies remain unfilled. High numbers of additional clinics have been carried out to help with the current situation and a locum is available from August for three months. The service continues to explore new ways of working with the wider team as part of the Improving Outpatients Programme. General Surgery with 357 patients (a decrease of 16) Unexpected leave has had an impact on the number of patients waiting. Additional sessions continue to be organised. Pain Service with 301 patients (a decrease of 127) Patient focussed booking for pain appointments continues, though the impact is lessening. An additional consultant begins pain training in August 2017 and additional sessions continue to be organised. Rheumatology with 240 patients (an increase of 38) A recent service review has resulted in reduced consultant capacity. All alternative resources are being examined to address the current capacity shortfall. Ophthalmology with 207 patients (an increase of 21) This situation worsened slightly due to unforeseen leave and locum staff being unavailable for two weeks. The situation is expected to improve over coming weeks, though the oculo-plastic subspecialty will remain under pressure. Dermatology with 98 patients (a decrease of 224) There is a dermatology consultant vacancy which it has not been possible to fill and an additional two consultants have left the service, which will increase the pressure on the service significantly. The service continues to explore new ways of working with the wider team and is considering additional nursing support. All available additional clinical support will be utilised over coming months. Diagnostic tests Endoscopy Of the total of 654 (35 unavailable) patients waiting over 6 weeks for endoscopic investigations at the end of July 2017, 371 (8 unavailable) were for Upper Gastrointestinal, 69 (7 unavailable) were for Lower Endoscopy and 226 (10 unavailable) were for Colonoscopies. The improving position is as a result of additional administration support for patient booking, filling all available sessions and the introduction of a nurse-led pre assessment process at UH Ayr. Radiology Of the total of 2120 patients waiting over 6 weeks for imaging investigations at the end of July 2017, 367 were for MRI, 986 were for CT, 765 were for Non Obstetric Ultrasound and the remaining 2 were for Barium Studies. Demand for these diagnostic services continues to increase. There has been a recent success in recruiting 2 additional radiologists and the service continues to use locum Sonographers, when available, to improve the current situation. Plans are also progressing to increase room capacity for Non Obstetric Ultrasound at both Crosshouse and Ayr. 6 of 13

In the meantime a range of initiatives continue to support service delivery: transferring patients to GJNH when capacity is available; continued use of the mobile MRI van until December 2017; ongoing use of Medica and agency consultants to report scans; engagement of locum consultant radiologists when available; and delivery of additional sessions when staff are available. 4 Unavailability of Patients and Full Waiting List Size The number of patients waiting for Inpatient and Day Case treatments or Outpatient appointments is shown below. Total waiting list size Mar 17 Apr 17 May 17 Jun 17 Jul 17 Inpatient and Day Cases 3074 3076 2958 2950 3012 Outpatients 20660 21221 20811 20479 20424 Unavailability of patients is monitored closely based on reasonable offers being made to patients for access to outpatient, inpatient and daycase services. The overall position is detailed below, with the percentage against the total waiting list shown in brackets. Patients unavailable Mar 17 Apr 17 May 17 Jun 17 Jul 17 Inpatient and Day Cases 457 (14.9%) 415 (13.5%) 461 (15.6%) 504 (17.1%) 432 (14.3%) Outpatients 218 (1.06%) 184 (0.87%) 215 (1.03%) 323 (1.58%) 212 (1.04%) 5 Cancer Waiting Times Targets: 95% of all eligible patients should wait no longer than 62 days or 31 days. A 5% tolerance level is applied to these targets as for some patients it may not be clinically appropriate for treatment to begin within target. The 62 day urgent referral to treatment target includes screened positive patients and all patients referred urgently with a suspicion of cancer. The 31 day target includes all patients diagnosed with cancer, whatever their route of referral, from decision to treat to treatment. Performance: Jan 17 Feb 17 Mar 17 Apr 17 May 17 Jun 17 Jul 17 62 days 87.1% 96.0% 92.6% 88.9% 87.6% 88.0% 92.4% 31 days 98.9% 100% 100% 98.8% 96.8% 99.2% 100% The Cancer specialties below the 62 day target in July 2017 were Head & Neck at 60% (2 of 5 patients), Urology at 85.7% (2 of 11 patients), Lung at 88.2% (15 of 17 patients) and Upper Gastrointestinal at 90.0% (1 of 10 patients). NHS Ayrshire & Arran s 62 day performance was above the overall Scottish performance of 88.7% in July 2017. There is no consistent trend across the cancer specialties and drops below target tend to be as a result of specific issues with individual patient journeys. However, public health campaigns in areas including lung cancer have meant that the services are receiving a significant increase in referrals. 7 of 13

6 Patients Awaiting Discharge Targets: The current target is that no-one will wait more than 14 days to be discharged from hospital into a more appropriate care setting once treatment is complete. Performance: Feb17 Mar17 Apr17 May17 Jun17 Jul17 Aug17 14 day delayed discharges 34 14 27 16 39 34 49 Of the 49 people who waited more than 14 days in August 2017, 28 were in South Ayrshire, 20 were in North Ayrshire and 1 was in Dumfries & Galloway. 7 Mental Health Services National Targets Targets: 1. The national standard is that 90% of clients will wait no longer than 3 weeks from referral received to an appropriate drug or alcohol treatment that supports their recovery, and noone will wait more than 6 weeks. 2. Deliver 18 weeks referral to treatment for specialist Child and Adolescent Mental Health Services (CAMHS). 3. Deliver 18 weeks referral to treatment for Psychological Therapies. Performance: 1. Drug or Alcohol Treatment performance was 98.1% in July 2017 against the target of 90%. 2. CAMHS 18 week performance was 91.4% in May 2017 against the target of 90%. 3. Psychological Therapies 18 week performance was 78.62% for June 2017 against the target of 90%. Psychological Therapies Psychological therapies are delivered by a number of professions across mental health and physical health services, which leads to complexities and challenges in delivering this target. The target is being met in some services and a significant amount of work continues towards achieving this target over all services. 8 MSK pathway waiting times measurement Target: 90% of patients aged 16 years or over will receive their first clinical outpatient appointment for AHP MSK Services within 4 weeks of referral. Performance: Number of patients who have waited less that 4 weeks for their first outpatient appointment Number of patients who have waited more than 4 weeks for their first outpatient appointment Percentage of patients who have waited less than 4 weeks for their first outpatient appointment Apr 17 May 17 Jun 17 Jul 17 Aug 17 1571 1483 1547 1567 1704 5239 4554 3792 2910 2138 23.1% 24.5% 29.0% 35.0% 44.4% 8 of 13

Jan-14 Mar-14 May-14 Jul-14 Sep-14 Nov-14 Jan-15 Mar-15 May-15 Jul-15 Sep-15 Nov-15 Jan-16 Mar-16 May-16 Jul-16 Sep-16 Nov-16 Jan-17 Mar-17 May-17 Jul-17 Sep-17 Nov-17 Jan-18 Mar-18 Improvement actions, including patient focused booking, GP based physiotherapy and improved pathways for those with Chronic Pain, have reduced the number of referrals received by the service, and the number of people waiting for an appointment has significantly reduced. The reduction in patients being added to the waiting list and increases in the clinical resource available have produced a steady improvement in performance over the last year. Performance increased from 35% to 44.4% during August 2017. There are still a number of vacancies across all of the MSK services which are in the process of being filled and which will increase capacity in the next few months. Within the OT service unforeseen leave has meant that the waiting time situation has not improved in line with the other MSK services over recent months, but this situation is being resolved. Service redesign is ongoing and this aims to support the recent improvements in performance. The demand for services is being very closely monitored as there are some signs that demand may have begun to increase again as the waiting times for routine appointments decrease. The situation will continue to improve, though the rate of improvement is likely to slow down as a result of this. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 12000 10000 8000 6000 4000 2000 0 All MSK 4 wk performance All MSK OP waiting list size 9 of 13

Monitoring Form Policy/Strategy Implications The Patients Rights Act and the Treatment Time Guarantee have a profound effect on waiting times management and monitoring. Workforce Implications Workforce implications identified Recruitment of permanent staff or retention of locum staff where currently being utilised Availability of staff to hold additional clinics Financial Implications There is continuing growth in referrals across a number of specialties in Acute Services. This, along with current financial challenges, has led to bids for Waiting List Initiatives and ongoing service enhancements being reviewed and resubmitted, where appropriate, by service managers. Bids for all further investment are reviewed in light of available funding and the implication of levels of investment on waiting times targets. Additional Scottish Government support is being provided. Consultation (including Professional Committees) This report is compiled by summarising information from a variety of sources and other NHS Ayrshire & Arran reports. A Waiting Times report is reviewed monthly by the Corporate Management Team. Risk Assessment There is a significant risk to the organisation in failing to improve against the waiting times targets, with action plans in place to ensure safety of patient care is prioritised. Risks remain that unforeseen circumstances, e.g. ward closures due to illness, could adversely affect any recovery programme. As all internal relevant staff and facilities are already committed to this effort no contingency plans are possible. Risk mitigation is being delivered by close scrutiny and management. 10 of 13

Best Value - Vision and leadership - Effective partnerships - Governance and accountability - Use of resources - Performance management Compliance with Corporate Objectives Single Outcome Agreement (SOA) Successful management of waiting times requires leadership, and engagement with clinical staff. The developing Health and Social Care Partnerships have increasing influence on Delayed Discharge performance through patient flow. Local performance management information is used to provide as up to date a position as possible in this report. Some information may change when the data is quality assured by ISD in readiness for publication. The achievement of the waiting times targets set out within this paper complies with a number of the corporate objectives: improving health; safety/outcomes; quality of experience; equality; transforming and patient flow; supply and demand. The achievement of the targets provides better access to healthcare services and should therefore have a positive effect on the health inequalities priority within local SOAs. The achievement of the patients awaiting discharge targets will have a positive contribution towards the Outcomes for Older People priority. Impact Assessment An Equality and Diversity Impact Assessment (EDIA) is not required for this paper. Service improvement plans referred to within the paper will be assessed as appropriate. 11 of 13

Waiting Times Scorecard Appendix 1 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Jun 17 Jul 16 12 weeks TTG compliance Patients who breached the TTG during the calendar month Patients treated in the month who exceeded their TTG Access audit scores 88.4% 86.7% 87.0% 85.4% 83.5% 83.5% 81.1% 83.0% 81.8% 79.1% 79.4% 80.3% 241 286 258 326 268 260 314 231 245 326 286 224 177 213 251 271 221 237 238 270 192 243 271 212 98.7% 98.5% 99.4% 98.1% 99.6% 99.2% 98.7% 98.9% 99.1% 99.6% 99.4% 99.1% 18 week Referral To Treatment performance 18 week RTT clinic outcome recording 73.84% 72.39% 72.29% 71.63% 72.1% 71.83% 71.24% 73.56% 75.13% 78.11% 76.27% 74.4% 89.07% 90.01% 89.18% 89.82% 89.73% 89.73% 89.61% 88.72% 87.67% 87.9% 88.14% 88% New Outpatients - Percentage waiting less than 12 weeks and number waiting over 12 weeks Diagnostic patients - Percentage waiting less than 6 weeks and number waiting over 6 weeks 71.92% 70.47% 71.43% 72.58% 70.68% 70.18% 73.62% 79.82% 78.37% 76.5% 75.25% 76.38% 6906 6859 6691 6195 6562 6435 5495 4169 4591 4891 5069 4824 82.1% 77.8% 72.4% 74.5% 65.4% 57.8% 64.8% 64.0% 58.1% 59.8% 62.4% 64.87% 1,131 1,487 1,938 1,825 2,628 3,384 2,964 3,148 3,627 3,434 3,267 2774 Outpatient waiting list size 24,595 23,230 23,417 22,592 22,379 21,576 20,732 20,660 21,221 20,811 20,479 20424 Unavailable Outpatients 292 298 216 269 271 205 189 218 184 215 323 255 Inpatient/Day case waiting list size 3,011 3,019 3,049 3,034 2,979 2,982 3,121 3,074 3,076 2,958 2,950 3012 12 of 13

Unavailable Inpatient/day case patients 453 485 398 471 497 384 347 457 415 461 504 432 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Jun 17 Jul 16 Suspicion-of-Cancer - Referrals (62 days) All Cancer - Treatment (31 days) 91.3% 85.9% 87.6% 92.3% 90.1% 87.1% 96% 92.6% 88.9% 87.6% 88.0% 92.4% 98.2% 100% 98.4% 100% 100% 98.9% 100% 100% 98.8% 98.2% 99.2% 100% T15.1 Delayed Discharges - 2 week waits 43 27 33 47 53 33 34 14 27 16 39 34 Drug and Alcohol Treatment: Referral to Treatment Faster Access to CAMHS - 18 wks Faster Access to Psychological Therapies - 18 wks 97.2% 95.8% 94.3% 94.2% 96.3% 98.9% 94.7% 96.1% 98.1% 98% 96.8% 98.1% 82.73% 83.1% 82.86% 95.15% 88.79% 92.47% 91.67% 96.67% 98.11% 93.98% 90.91% 91.4% 76.41% 73.72% 69.57% 73.67% 82.93% 72.87% 73.24% 76.6% 71.54% 77.1% 78.62% Adult patients waiting less than 4 weeks for MSK services 20.3% 16.5% 14.9% 17.6% 15.7% 18.5% 21.0% 23.1% 23.1% 24.5% 29.0% 35% 13 of 13