Sutton CCG Clinical Commissioning Group Governing Body Date Thursday, 06 September 2018 Document Title Lead Director (Name and Role) Clinical Sponsor (Name and Role) Performance and Quality Report Sean Morgan Director of Performance and Delivery Mary Hopper Director of Quality Dino Pardhanani, Clinical Director Author(s) (Name and Role) Sean Morgan, Director of Performance and Delivery Richard Simon, Performance Assurance Manager Agenda Item 9 Attachment 07 Purpose (Tick as Required) Executive Summary Approve Discuss Note Background: This is the regular monthly Performance and Quality Report Purpose: This report is to inform and provide assurance to the Governing Body about the performance, quality and safety of service provision commissioned by NHS Sutton CCG. Reason for Governing Body Review: ED 4-hour maximum wait standard was achieved at Epsom and St. Helier in June, with performance of 95.3%, although emergency pressures remain significant, partly due to the recent heatwave, and performance remains fragile at times. Efforts are focussed on work to optimise the discharge process, including through regular multi-disciplinary review of patients with a length of stay of 21 days with senior decision makers to take action to expedite discharges. Performance against referral to treatment time (RTT) incomplete pathway target at aggregate level was not met by the CCG in June, with performance of 90.3% against the 92% standard (excluding St. George s which is not reporting RTT performance in the national returns). Planning for RTT for 2018/19 was aligned with the refreshed planning guidance ask of addressing the upward trend in the overall waiting list size by undertaking increased activity to ensure that the incomplete pathway size is no higher at March 2019 compared with March 2018. Cover Sheet Template for Committee Meetings Final Version 1.2 July 2018 Page 1 of 7
The total incomplete pathway list size was 13,291 at end June compared with the planned trajectory of 12,698. Table 1 below shows the waiting list figures against plan and Table 2 has the activity against plan for both Outpatient and Elective activity. Table 1 Total Incomplete Pathways Mar. '18 Apr. '18 May '18 Jun. '18 Mar. '19 Plan 12730 12714 12698 12557 Actual 12891 13222 13245 13291 Variance 492 531 593 % Variance 3.9% 4.2% 4.7% Table 2 Planned Care Activity First Outpatient Attendances Plan 4406 4634 4634 13674 Actual 4579 5234 4789 14602 Variance 173 600 155 928 % Variance 3.9% 12.9% 3.3% 6.8% Follow-Up Outpatient Attendances Plan 11987 12603 12603 37193 Actual 12807 14234 13447 40488 Variance 820 1631 844 3295 % Variance 6.8% 12.9% 6.7% 8.9% Elective - Day Cases Plan 1565 1643 1643 4851 Actual 1539 1887 1717 5143 Variance -26 244 74 292 % Variance -1.7% 14.9% 4.5% 6.0% Elective - Ordinary Admissions Plan 295 310 310 915 Actual 247 286 303 836 Variance -48-24 -7-79 % Variance -16.3% -7.7% -2.3% -8.6% Cover Sheet Template for Committee Meetings Final Version 1.2 July 2018 Page 2 of 7
The CCG is 4.7% above its RTT waiting list trajectory at end June. The largest increase in the waiting list size since the March 2018 baseline has been at Royal Marsden Community Services, due to some capacity issues, including maternity leave, in the Community Musculo-skeletal (MSK) service. Epsom and St. Helier is not achieving the 92% standard but is below its incomplete pathway list size trajectory at end June, and therefore on target to meet the refresh planning guidance requirement to stabilise the size of the total waiting list this year. The Trust s plan for the year assumed a mix of ad hoc additional activity (mostly on Saturdays), insourcing, and temporary staff increases in the first nine months, with recruitment in several specialties (i.e. Cardiology, Dermatology, ENT, Gastroenterology, Neurology) resulting in permanent capacity increases from later in the year. The Trust expects to experience a seasonal increase in the waiting list size and backlog in August (the backlog is expected to increase by 200) offset by further improvement in September and October. The planned care activity to month 3 is shown in table 2. There has been a significant overperformance in Outpatient activity against plan (+6.8% for first attendances and +8.9% for follow ups) partly due to Epsom and St. Helier bringing forward some of the activity to the first four months prior to implementation of Paper Switch Off on 1 August to ensure that sufficient first appointment slots would be available on e-rs within the target polling lengths. However, there has been an increase in referrals, from GPs, consultant-to-consultant and self-referrals in some specialties which has driven some of this activity increase. There has been an overperformance against plan for Elective activity, which is in Day Cases only and much of which is for endoscopies. To summarise the key points on RTT and planned care activity: Epsom and St Helier is on plan to meet the planning guidance requirement to stabilise the size of the total waiting list this year, and this will be kept under review through the year Outpatient activity is increasing, part of which is a result of the additional planned activity having been brought forward by Epsom and St Helier Referrals are increasing, and GP referrals at specialty level will be raised in the practice meetings to review practice variation being held in the Autumn. The CCG achieved seven of the eight cancer waiting time standards in May, including the overall 62-day standard from urgent GP referral to treatment. The symptomatic breast 2 week standard was not met, with performance at 75.6% (with 20 breaches out of 82 patients), with both the Royal Marsden and St. George s not meeting the standard (N.B. Epsom and St. Helier does not provide this service). In July the Improving Access to Psychological Therapies (IAPT) provider, Sutton Uplift, informed the CCG of a serious data quality issue which had led the provider to incorrectly report the number of patients accessing the service. There had been double counting of some patients for two reasons, with some patients who received both IAPT Cover Sheet Template for Committee Meetings Final Version 1.2 July 2018 Page 3 of 7
and well-being support counted twice and some patients receiving multiple interventions were also double counted. The impact is that the reported level of access in 2017/18 and Q1 2018/19 has been overstated, and the access target had not been met in Q4 2017/18 (as had originally been reported) or in Q1 of 2018/19. The provider has confirmed that performance data for recovery and waiting times targets was accurately reported. The CCG has issued a Contract Performance Notice (CPN) requiring the Sutton Uplift service to provide a remedial action plan to recover performance, which has been received and agreed. The CCG has also requested a data quality improvement plan and internally the provider has raised this as a serious incident (SI). The key actions being taken by Sutton Uplift are: additional triage capacity and assessment slots in place improved data reporting and data quality checking processes focused marketing plan to increase new referrals care pathway re-design, to align to a predominately stepped care model RCA (Root Case Analysis) to be shared with CCG, under the SI governance process the RCA will be available in October The national Intensive Support Team has been asked to review data and reporting in South West London and offer support to the IAPT providers. The Sutton Uplift provider is confident that performance against the target for Q1 can be recovered by the end of Q2. The CCG performance on e-referral (e-rs) utilisation has increased to 74% (provisional data) for July following increased awareness raising and GP Practice training sessions attended by all practices. Epsom and St Helier implemented Paper Switch Off from 1 August and whilst there have been a few technical issues with referral letters and two week templates being transmitted these seem to have been resolved in the first week. An additional e-rs training session for practice staff was held on 13 August. Epsom and St Helier continues to not meet its dementia assessment rate targets and also the number of VTE assessments. Monitoring of this required improvement is undertaken through contract arrangements. The CQC published their most recent inspection report on ESTH in May 2018. Improvements have been made but across the number of services inspected the Trust was not able to improve its overall outcome and remains rated as 'requires improvement'. Workforce continues to be the focus of concern across a number of quality domains. Actions plans across a range of workforce issues have been developed by the Trust and the CCG will continue to monitor these closely in order to measure improvements. Cover Sheet Template for Committee Meetings Final Version 1.2 July 2018 Page 4 of 7
Some of the Community Service KPI continue to not be achieved, with one red rated KPI and one amber rated KPIs in April. The red rated KPI in April is: - There were 12 patients whose appointment was cancelled by the provider and who were not subsequently seen within 28 days (the threshold is zero) In addition, the CCG has received confirmation from NHS England of its formal Improvement and Assessment Framework rating for 2017/18 of Requires Improvement, linked to not meeting the financial control total for that year. A detailed report will be presented to the next meeting with a full analysis of the 2017/18 data and highlighting any issues by exception in addition that are not covered in this report. The CCG ratings for 2017/18 for two clinical priorities have also been published, which were Outstanding for maternity and Good for cancer. The excellent rating for maternity was largely due to the improvement in the results of the 2017 national maternity survey compared with the previous survey two years earlier, with a particularly large improvement on new mothers responses to the questions around having the options and being supported to make choices, the midwives and the Head of Midwifery have made a really positive impact at Epsom and St Helier on the support they give to mothers and their babies, and this has been a priority for the CCG quality team and it is very welcome that this has been recognised in the national rating. Key Issues: 1. The IAPT access target was not met in Q1 due to the data reporting incident which has come to light. A Contract Performance Notice has been issued to Sutton Uplift and an action plan is in place. 2. The CCG is behind trajectory on the RTT incomplete waiting list size at the end of June, although Epsom and St Helier is performing better than its trajectory. 3. The CCG continues to work with Epsom and St. Helier on a number of quality issues, including those raised through the CQC inspection. 4. The CCG has received confirmation of its 2017/18 rating of Requires Improvement, linked to not meeting the financial control total, and of two clinical priority ratings for 2017/18, which were Outstanding for maternity and Good for cancer. Conflicts of Interest: N/A Mitigations: N/A Recommendation: Cover Sheet Template for Committee Meetings Final Version 1.2 July 2018 Page 5 of 7
The Committee is asked to: REVIEW the Performance and Quality Report Corporate Objectives This document will impact on the following CCG Objectives: Objective 1: Ensure patients are at the heart of decision making, working in partnership with individuals, patient representative groups, families and carers to deliver high quality, accessible services that tackle inequalities and respond to personal need. Objective 2: Commission high quality cohesive health services for the population of Sutton through joint working between health and social care organisations ensuring patients physical, mental and social wellbeing needs are met. Objective 3: Maintain an efficient and financially stable, local healthcare system by improving primary care and community services and working closely with secondary care to deliver integrated services that bring healthcare into the community. Objective 4: Work with the local authority to develop an integrated commissioning framework that supports single, pooled budget for health and social care services with planned and agreed delivery across a range of areas. Risks This document links to the following CCG risks: Mitigations Actions taken to reduce any risks identified: Risk number 805 in the BAF/ Risk Register is If providers do not meet national and local quality and performance standards, then the CCG population does not have constitutional pledges honoured by providers. Mitigating actions are set out for each performance and quality KPI in the attached report. Financial/Resource/ QIPP Implications There is no direct impact. Some of the issues which need improvement may require additional investment to support improved performance, although there are no specific recommendations for investment beyond existing budgets at this point in time. It should be noted that additional funding has been included Cover Sheet Template for Committee Meetings Final Version 1.2 July 2018 Page 6 of 7
within the 2018/19 contract with Epsom and St. Helier to deliver the refreshed planning guidance requirement on RTT incomplete waiting list size. Has an Equality Impact Assessment (EIA) been completed? Are there any known implications for equalities? If so, what are the mitigations? No this is a regular monitoring report. The CCG is committed to monitoring the compliance with the Equality duty of the providers from whom we commission services. This is done through the quality and contracting process. The performance and quality data used in the report is aggregate data and commissioners do not routinely receive patient level data. These datasets are often therefore not amenable to a specific equality impact assessment. To the extent that this is possible for individual issues an assessment will be undertaken as part of the root cause analysis process and in the production of improvement plans. Patient and Public Engagement and Communication The performance and quality report includes the results from the Friends and Family Test for the local providers. There are a variety of ways in which patients and carers are asked to feedback on their experience of services. Previous Committees/ Groups Enter any Committees/ Groups at which this document has been previously considered: Committee/Group Name: Date Discussed: Quality Committee Thursday, 16 August 2018 Executive Committee Thursday, 23 August 2018 Click here to enter a date. Outcome: The report was reviewed The report was reviewed Supporting Documents Performance and Quality Report June 2018 Cover Sheet Template for Committee Meetings Final Version 1.2 July 2018 Page 7 of 7