Operational Focus: Performance Sandra Iskander
Changes for 2015/16 Change of focus of 18-weeks and A&E 4-hour wait targets as recommended by Sir Bruce Keogh, Medical Director, NHS England. 18-weeks to focus on incomplete pathways (patients still waiting for treatment) A&E target to include Out of Hours and Community Services alongside clinical measures (currently to be confirmed). Three new indicators of patient satisfaction with quality of consultation, overall care received and access to their GP surgeries Six new indicators focusing on reducing the number of people with learning disabilities being admitted to and detained in hospital settings (building upon the Transforming Care / Winterbourne View indicators from 2014/15). The patient experience of primary care indicators will be amalgamated to focus on poor care in GP and out of hours services. The Friends and Family Test indicator will be removed, but will continue to be monitored as part of our quality reporting Two new indicators to monitor six and 18 week waits for psychological therapies 2
Key Risks for 2015/16 Of the indicators where poor performance was identified in 2014/15, the following should be considered as risks into 2015/16: Ambulance response times Over 52 week waiters MRSA & C.Difficile IAPT access and recovery A&E 4 hour wait 18 week wait for admitted patients and incomplete pathways 3
CCG Approach to Performance Management Information sharing with partners. Rigorous scrutiny of data applying Business Intelligence techniques. Regular reviews involving Performance and Commissioning Teams with partners. Ensuring contractual processes / levers drive performance / improvement. Escalation and assurance process as below: Delivery Group Scrutiny of action plans. Notes performance. Agrees actions for improvement Escalates to Management Team / Integrated Governance Committee. Management Team / Integrated Governance Committee Agrees further escalation, e.g. Board to Board discussions, penalties, other potential escalation routes (e.g. NHS England / Tripartite) CCG Board Notified of performance issues. Assures performance managment process. 4
CCG Assurance Framework Key Service standards May 2015 Service Standard KPI Wandsworth CCG Provider* Target Comments Issues Actions Recovery Date The Joint Investigation is an eight week piece of work and Type 1 93.3% 92.9% 95% National St George s failed the A & E The joint investigation is the remedial action plan is in target in May with Urgent & continuing and is focusing on the process of being finalised. performance of 93.8%. May Emergency Care three key areas: ED flow, AMU The plan is linked to the St performance remains off target (A&E) and discharge and intra George's capacity plan which but it is the best monthly All Types 94.1% 93.6% 95% National hospital flows. includes the opening of position year to date. additional beds to support TBC capacity. RTT (18 Weeks) Cancer Access Admitted 85.2% 84.3% 90% National Non-Admitted 95.8% 95.1% 95% National Incomplete 92.2% 89.0% 92% National 2-week wait (all) 92.8% 92.5% 93% National 2-week wait (breast) 81.5% 78.4% 93% National 31-day wait (all) 98.5% 96.6% 96% National 31-day wait (surgery) 100% 96.9% 94% National 31-day wait (drug) 100% 100% 98% National 31-day wait (radiotherapy) 100% 100% 94% National 62-day wait (all) 91% 85.2% 85% National 62-day wait (screening) 100% 90% 90% National Performance against admitted and incomplete targets is lower than expected, mainly due to performance issues at St. George's. The CCG and St. George's have struggled to meet the 2-week wait targets for April 2015. The joint investigation is focusing on the referral processes, OP booking and elective pathways. In addition, the investigation is reviewing the capacity at the trust and the level of additional activity that will be required for the trust to both meet the target and to bring their waits to best practice. The joint investigation into St George's RTT performance has concluded and the remedial action plan is being monitored. The Trust is working with St. George's highlighted that services to better prepare for Trust lost 2 days of clinics due impact of public holiday to public bank holidays/ Easter, capacity and discussing with also suffered uptick in referrals services the need for possible for Breast and Lower GI. increase in service provision. TBC Jun-15 5
CCG Assurance Framework Key Service standards May 2015 Service Standard KPI Wandsworth CCG Provider* Target Comments Issues Actions Recovery Date Diagnostics Waits Health Visitor Establishment IAPT 6-week wait 97.0% 96.9% 99% National NHS England Access 2.80% 2.80% 15% Operating Plan Recovery Rate 50.2% 50.2% 50% Operating Plan Dementia Diagnosis Rate 69.1% N/A 67% Operating Plan Transforming Care Care plan review within last 6 months 2 / 2 Planned discharge date 2 / 2 The main areas where breaches occurred were in MRI, endoscopy and non-obstetric ultrasound. St George's originally anticipated achieving the target from April but the trust does not anticipate achieving until the end of July now. Long waits are primarily due to non-obstetric ultrasounds (staff shortages), MRIs and cystoscopies (increased demand). NHS England are responsible for delivering this target nationally. Access performance is forecast for Q1. Quarterly target is 3.75% of population need met. Target is being met from 1st April 2015 due to change in denominator to focus on patients over 65 The CCG currently has 2 patients admitted before 1st April 2014, all of whom have been reviewed within the last six months. 1 patient expected to be discharged in January 2016. Data not currently available for GP practice based counsellors, therefore performance is slightly under-reported. The CSU will be monitoring their performance against the trajectory on a weekly basis. In addition, a weekly breakdown of their expected capacity, split by established and additional and then their actual capacity played alongside it week by week has been requested. CCG continues to work with Wandsworth IAPT service. Action plan to review capacity an expedite recruitment of staff to provide capacity requried to meet target. Under-reporting due to issues updating practice registers with List validation complete in all details of patients diagnosed but 2 practices. by the Memory Assessment Service. None Regular reviews of patients ongoing. Jun-15 Jun-15 N/A 6
Are patient rights under the NHS Constitution being promoted? Indicator Referral To Treatment waiting times for non-urgent consultant-led treatment Admitted patients to start treatment within a maximum of 18 weeks from referral Non-admitted patients to start treatment within a maximum of 18 weeks from referral Patients on incomplete non-emergency pathways (yet to start treatment) should have been waiting no more than 18 weeks from referral Number of patients waiting more than 52 weeks Diagnostic test waiting times Patients waiting for a diagnostic test should have been waiting less than 6 weeks from referral A&E waits Operational Standard Lower Threshold CCG Assurance Reporting Period Actual Performance R/A/G Rating 90% 85% May-15 85.2% Amber 95% 90% May-15 95.8% Green 92% 87% May-15 92.2% Green 0 10 May-15 0 Green 99% 94% May-15 97.0% Amber Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department St. George's 95% 90% May-15 93.6% Amber CCG Overall 95% 90% May-15 94.1% Amber Cancer waits 2 week wait Maximum two-week wait for first outpatient appointment for patients referred urgently with suspected cancer by a GP Maximum two-week wait for first outpatient appointment for patients referred urgently with breast symptoms (where cancer was not initially suspected) Cancer waits 31 days Maximum one month (31-day) wait from diagnosis to first definitive treatment for all cancers Maximum 31-day wait for subsequent treatment where that treatment is surgery Maximum 31-day wait for subsequent treatment where that treatment is an anti-cancer drug regimen Maximum 31-day wait for subsequent treatment where the treatment is a course of radiotherapy 93% 88% Apr-15 92.8% Amber 93% 88% Apr-15 81.5% Red 96% 91% Apr-15 98.5% Green 94% 89% Apr-15 100.0% Green 98% 93% Apr-15 100.0% Green 94% 89% Apr-15 100.0% Green Continued on next slide 7
Are patient rights under the NHS Constitution being promoted? Indicator Cancer waits 62 days Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer Maximum 62-day wait from referral from an NHS screening service to first definitive treatment for all cancers Maximum 62-day wait for first definitive treatment following a consultant s decision to upgrade the priority of the patient (all cancers) Category A ambulance calls Category A calls resulting in an emergency response arriving within 8 minutes (Red 1) Category A calls resulting in an emergency response arriving within 8 minutes (Red 2) Category A calls resulting in an ambulance arriving at the scene within 19 minutes Ambulance Handovers All handovers between ambulance and A & E must take place within 15 minutes and crews should be ready to accept new calls within a further 15 minutes. Mixed Sex Accommodation Breaches Patient Experience: Breaches of Same Sex Accommodation Mental Health Care Programme Approach (CPA): The proportion of those patients on Care Programme Approach (CPA) discharged from inpatient care who are followed up within 7 days. Cancelled Operations Proportion of patients not treated within 28 days of last minute cancellation Operational Standard Lower Threshold CCG Assurance Reporting Period Actual Performance R/A/G Rating 85% 80% Apr-15 91.4% Green 90% 85% Apr-15 100.0% Green None Set None Set Mar-15 100.0% 75% 70% May-15 67.1% Red 75% 70% May-15 66.5% Red 95% 90% May-15 94.6% Amber 0 >10 95% 90% May-15 YTD May-15 YTD 1 Amber 98.0% Green 0% TBC May-15 4.9% Amber Urgent operations cancelled for a 2nd time 0 10 May-15 YTD 0 Green Indicator RAG rating Green - Performance at or above the standard Amber - Performance between the standard and the lower threshold Red - Performance below the lower threshold OR same indicator has Amber performance for two consecutive quarters 8
Are health outcomes improving for local people? NHS Outcomes Framework measures which NHS England and CCGs will use in annual assurance (as described in The Forward View into action: planning for 2015/16) Indicator 1. Preventing people from dying prematurely CCG Assurance Reporting Period Actual Performance R/A/G Rating Comments Potential years of life lost (PYLL) from causes considered amenable to healthcare Under 75 mortality rate from cardiovascular disease (per 100,000) Under 75 mortality rate from respiratory disease (per 100,000) Under 75 mortality rate from liver disease Under 75 mortality rate from cancer One-year survival rate from all cancers (%) Five-year survival rate from all cancers One-year survival rate from breast, lung & colorectal cancers (%) Five-year survival rate from breast, lung & colorectal cancers (%) Excess under 75 mortality rate in adults with serious mental illness Infant mortality (rater per 1,000 live births) Adults 2013 3047 Amber Children 2013 482.8 Green 2013 87.3 Amber 2013 33.6 Amber 2013 15.9 Green 2013 140.2 Green 2011 68.64 Green 2007 47.9 Green 2011 71.28 Green 2007 51.4 Green 2012/13 334 Green 2013 3.7 Green England-wide figure. Reduction on 2012 figure. Wandsworth CCG has seen a deterioration over the 2012 figure of 83.6 Wandsworth CCG has seen a deterioration over the 2012 figure of 30.2 15.9 is an improvement over the 2012 figure of 18 This indicator has been revised. Wandsworth CCG has seen an improvement over the 2012 figure of 147.2. Wandsworth CCG has seen an improvement over the 2010 figure of 68.25 England-wide figure. Increase on 2006 figure. Wandsworth CCG has seen an improvement over the 2010 figure of 68.25 England-wide figure. Increase on 2006 figure. Wandsworth CCG has seen an improvement over the 2011/120 figure of 427.8 Wandsworth CCG has seen an improvement over the 2012 figure of 3.9 Five year survival from all cancers in children 2. Enhancing quality of life for people with long term conditions Health-related quality of life for people with long-term conditions Proportion of people feeling supported to manage their condition (%) Employment of people with long-term conditions (% Difference in employment rate between people with LTCs and the general population) Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults) Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s Health-related quality of life for carers (average health status score (EQ-5DTM)) Employment of people with mental illness (% Difference in employment rate between people with mental illness and the general population) Estimated diagnosis rate for people with dementia 2006 81.3 Green 2013/14 0.0764 Green 2013/14 62.70% Amber Q4 2014 14.20% Amber 2013/14 842.7 Amber 2013/14 257.3 Amber 2013/14 0.817 Green Q2 2014 42.90% Amber May-15 69.1% Green England-wide figure. Increase on 2005 figure. Average: 0.77 2012/13: Score 0.76 Average 0.743 Data from GP Patient Survey. Data from GP Survey There has been an improvement over the previous figure of 61.1%. Average: 65.1% Improvement over Q3 2014 figure of 14.9%. Average 13.2% Provisional figure for 2013/14 is a 10% reduction on 2012/13 figure. Quality premium target is 3.2% Wandsworth has seen a small deterioration from the 2012/13 figure of 256.5. England Average: 313.4 Wandsworth has seen an improvement over 2012/13 score of 0.809. England average 0.804. Wandsworth saw an improvement on the Q4 2013 figure of 45%. England Average: 36.8% Continued on next slide 9
Are health outcomes improving for local people? NHS Outcomes Framework measures which NHS England and CCGs will use in annual assurance (as described in The Forward View into action: planning for 2015/16) Indicator CCG Assurance Reporting Period Actual Performance R/A/G Rating Comments 3. Helping people to recover from episodes of ill health or following injury Emergency admissions for acute conditions that should not usually require hospital admission Emergency readmissions within 30 days of discharge from hospital Emergency admissions for children with Lower Respiratory Tract Infections (LRTI) Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation service (%) Proportion offered rehabilitation following discharge from acute or community hospital Emergency admissions (non-elective, G&A) Delayed transfers of care 2013/14 996.6 Green 2011/12 11.56 Green 2013/14 232.5 Green 2013/14 93% Amber 2013/14 3.30% Amber Apr-15 2095 Amber May-15 18 Amber 2013/14 figure is an improvement over 2012/13 figure of 1041. England average: 1195.7 There has been an improvement over the 2010/11 figure of 12.23. There has been an improvement on the 2012/13 figure of 286.2 Quality premium requires a reduction or 0% change from 2012/13. Small deterioration on 2012/13 figure of 93.4%. England average: 82.5% Small deterioration on 2012/13 figure of 3.5%. England average: 3.3% Monthly target is maxium of 2016 admissions. 4. Ensuring that people have a positive experience of care Patient experience of GP services 2013/14 86.70% Amber Small deterioration on 2012/13 figure of 88.7%. England average: 85.7% Patient experience of GP out-of-hours services Patient experience of dental services Patient experience of hospital care (St. George's) Responsiveness to in-patients personal needs (St. George's) Patient experience of A&E services Access to GP services Access to NHS dental services 2013/14 52.4 Amber 2013/14 76.80% Amber 2013/14 75.30% Amber 2013/14 68.8 Green 2014 82.8 Green 2013/14 77.40% Amber 2013/14 94.50% Amber Small deterioration on 2012/13 figure of 55.4%. England average: 66.2% Deterioration on 2012/13 figure of 80%. England average: 84.2% Improvement over 2012/13 figure of 74.9%. England average: 76.9% Improvement over 2012/13 figure of 66.6. England average: 68.7. Improvement over 2012/13 figure of 80.2. England average: 80.7 Deterioration on 2012/13 figure of 78.3%. England average: 74.6% Deterioration on 2012/13 figure of 94.7%. England average: 94.8% 10
Are health outcomes improving for local people? NHS Outcomes Framework measures which NHS England and CCGs will use in annual assurance (as described in The Forward View into action: planning for 2015/16) Indicator CCG Assurance Reporting Period Actual Performance R/A/G Rating Comments 5. Treating and caring for people in a safe environment and protecting them from avoidable harm Incidence of healthcare associated infection (HCAI) i) MRSA Incidence of healthcare associated infection (HCAI) ii) C.difficile Apr-15 1 Red Number of cases assigned to the CCG by Post Infection Review process. Apr-15 2 Amber Patient safety incidents reported (per 100 admissions) 6. IAPT IAPT Roll-out 2013-14 9.5 Amber Q1 2015/16 2.80% Amber Deterioration on 2012/13 figure of 10.1. Aim is to increase reporting and learning from incidents. Annual performance is assessed based on Q4 performance. Target is for 3.75% during Q4, being 1/4 of the 15% annual target. Actual coverage across the year is 9.4% IAPT Recovery Rate The proportion of people that wait 6 weeks or less from referral to entering a course of IAPT treatment The proportion of people that wait 18 weeks or less from referral to entering a course of IAPT treatment 7. Transforming Care (Learning Disabilities) Total number of patients in in-patient beds for mental and/or behavioural healthcare who have either learning disabilities and/or autistic spectrum disorder (including Asperger s syndrome) Numbers of admissions to in-patient beds for mental and/or behavioural healthcare who have either learning disabilities and/or autistic spectrum disorder (including Asperger s syndrome) Numbers of patients discharged to community settings Patients without a care coordinator Patients not on the register Patients without a review in the last 26 weeks Q1 2015/16 50.20% Green Q1 2015/16 97.00% Green Q1 2015/16 99.60% Green As at 15th June 2015 As at 15th June 2015 As at 15th June 2015 As at 15th June 2015 As at 15th June 2015 As at 15th June 2015 4 Green 0 Green 0 Green 0 Green 0 Green 0 Green 11
CCG Performance Key Messages Key Service Standards The eight Key Service Standards are the areas of CCG performance on which NHS England are focusing. Urgent and Emergency Care (A&E) May performance remains off target but it is the best monthly position year to date. The trust is seeing the benefit of the work it has done to improve flow, particularly through the Breaking the Cycle initiative, work around earlier discharges and improved flow in their AMU is having an impact. This work is helping to ensure that the trust has better bed capacity to accommodate admissions. The joint investigation has concluded and the CCG is monitoring the remedial action plan around three key areas: ED flow, AMU and discharge and intra hospital flows. The Joint Investigation is an eight week piece of work and the remedial action plan is in the process of being finalised. The plan is linked to the St George's capacity plan which includes the opening of additional beds to support capacity. The trajectory is likely to show a performance improvement in Q2 but with Q3 and Q4 remaining challenged to reflect the significant drop off in performance in Q3 and Q4 2014/15 and the remaining bed capacity gap. Referral to Treatment (18 Weeks) The joint investigation into St George's RTT performance is on-going and is due to deliver an improvement plan and trajectory by the end of June. The investigation is focusing on the referral processes, OP booking and elective pathways. In addition, the investigation is reviewing the capacity at the trust and the level of additional activity that will be required for the trust to both meet the target and to bring their waits to best practice. Diagnostic Waits The majority of breaches for Wandsworth CCG were at St George's. The main areas where breaches occurred were in MRI, endoscopy and non-obstetric ultrasound. St George's originally anticipated achieving the target from April but the trust does not anticipate achieving until the end of July. 12
CCG Performance Key Messages Improving Access to Psychological Therapies (IAPT) Access and Recovery Rates IAPT access rate is forecast to be below target in Q1 2015/16 (2.8% against a target of 3.75%). However, this is under-reported as data is not yet available for practice-based counsellors. Recovery rate is on target at 50% for April. Monthly performance meetings with the Trust continue, and a remedial action plan has been requested by the CCG. Cancer Waiting Times Wandsworth CCG has met 7 of the 9 CWT standards for April 2015, missing the 2WW Urgent Referral Standard & 2WW Breast Symptomatic Standard for this period. 2WW Urgent Referral Standard: This was as a result of 60 breaches from 837 Patient Pathways. 5 of the breaches were due to administrative reasons; 19 were attributed to capacity issues and the remaining 36 were attributed to patient choice. 2WW Breast Symptomatic Standard: This was as a result of 20 breaches from 108 patient Pathways. 17 of the breaches were internal at St. George's and these were attributed to capacity issues. The remaining three breaches were attributed to patient choice. St. George s highlighted that Trust lost 2 days of clinics due to public bank holidays over Easter and also experienced an increase in referrals for Breast and Lower GI. The Trust is working with services to better prepare for impact of public holiday capacity and discussing with services the need for possible increase in service provision. Transforming Care / Winterbourne View Wandsworth CCG is required to ensure that people with learning disabilities receive high quality care in the most appropriate settings. Part of this is a programme to transfer people from inpatient care to a more appropriate setting. On 1 April 2014, Wandsworth had 8 patients (April Cohort). Since then 5 of these patients have been discharged or transferred (62%). The current list has 4 patients, 2 of whom have been re-admitted or transferred to the CCG since April 2014. 13