QUALITY & SUSTAINABILITY PERFORMANCE & MONITORING FRAMEWORK

INTRODUCTION

This paper covers 2 main performance measures for NHS Highland

1. Measuring Peformance Integration The data source for these performance measures is ISD and therefore includes any Highland residents treated anywhere in NHS Scotland. These series of charts do not include non Highland residents treated in NHS Highland.

2. Quality and Sustainability Plan The data source for the graphs and tables in this section are from a variety of sources including EDIS, NHS Highlands Data Warehouse fed by TrakCare PMS, EDISON, CareFirst, Care at Home, and some manual collection procedures.

1.0 Measuring Performance Under Integration

All 6 Performance indicators have been analysed by ISD and include any Highland residents treated anywhere in NHS Scotland. Note : this does not include non NHS Highland residents treated in NHS Highland. The HLVS Adult Social Care is collecting data locally on a weekly basis and is displayed in NHS Highland. This data is currently not reconciling to the Nationally submitted data, and a piece of work is required to understand the validation processes involved in both sets of data.

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Table 1 - Overview of Performance Area Baseline*

(31/3/16) Target* A&B

Performance (28/2/17)

North Highland (28/2/17)

NHS Highland (28/2/17)

RAG*

Unplanned admissions 2,752 2,302 G

Occupied Bed Days for Unscheduled care 20,789 12,931 G A&E Performance – attendances 5,386 4,487 G

A&E %age seen within 4 hours 93.6% (A&B)

93.9% (Highland) 95.2% 90.2% To follow Y

Delayed Discharges – bed days all reasons 4,392 486 3,438 3,924 G Delayed Discharges –bed days code 9 1,747 51 1,013 1,064 G End of Life care – large hospital (all age groups) 7.9% G

Balance of spend across institutional and community services

*The baseline has been taken as at the end of March 2016. This needs further consideration as some of the indicators will have seasonal variation that will need to be taken into account. Targets are to be agreed. Performance has been “RAGed” with regard to current performance in comparison to the baseline.

See Annex 1, Section 1 for detailed graphs.

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2.0 NHS Highland Quality and Sustainability Plan 2.1 Financial This framework is intended to have measures which can be monitored to track whether the proposed changes are in place and having the required impact on reducing costs. It does not replace other performance management processes. Over the next three years it is estimated that NHS Highland will need to deliver efficiencies of around £100 million with around £47million in 2017/18 (around 7% of the baseline budget). The plans sets out the governance arrangements including actions that will be taken to deliver a break-even position and the associated monitoring.

Initiative Total

Highland Health and Social Care Partnership

Central/

Corporate

Argyll & Bute

£million £million £million

Savings target 47.00 27.67 11.93 7.40

Total savings identified 32.02 13.59 11.93 6.50

Shortfall 14.98 14.08 0.00 0.90

Data source: Director of Finance

NHS Highland have identified 7 Initiatives and associated Work Streams within the Quality and Sustainabilty Plan. This paper now describes the High Level Performance Indicators to provide assurance to NHS Highland that these iniatives are progressing as planned.

• Adult Care • Adult Flow

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• Models of Care / Professional Roles • Drug Costs & Effective Prescribing • Remodelling Assets • Quality Improvement Initiatives. • Realistic Medicine – N.B. no financial target set

Table 1b Breakdown of savings for Highland Health and Social Care Partnership and central / corportate services, by initiative

Initiative Total (*) Highland Health and Social Care Partnership Central/Corporate

£million £million £million

Adult Care 1.56 1.56

Flow 0.14 0.14

New Models of Care 1.17 1.17

Drug Costs 1.20 1.20

Remodelling Assets 1.31 0.81 0.50

Continuous Quality Improvement, Local Initiatives and Opportunities 20.46 9.03 11.43

Total – Excluding A&B 25.84 13.91 11.93

Target 39.60 27.67 11.93

Shortfall (13.76) (13.76) 0.00

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Performance Managment Indicators and Bench Marking Indicators Measures have been indentified from the Scottish Goverment under integration and data are available to compare Health and Social Care arrangements. These will provide a baseline going forward. These measures have been aligned to our initiatives, as appropriate, alongside some other local measures (Table 1). Scottish Government have also produced some Bench Marking Indiators for NHS Highland (Table 2). Performance measures supporting monitoring of how much and by when are summarised in (Table 3). Table 1 Examples of performance measures aligned to initiatives Initiatives • Example of measures Initiative Example of measures Adult Care • Emergency admissions

• Occupied bed days • Emergency four-hour target • Increased age on admission to care home • Occupancy of bed days in last six months of life • Percentage of people cared for outwith

institutional settings

Remodelling Assets

• Number of out-of-hours centres • Number out-patient appointments • Number of Buildings • Number of staff • Costs per case • Running costs • Backlog maintenance

Flow • Length of stay • Hospital Readmissions • Emergency four-hour target • Waiting times

Local Initiatives and Opportunities

Safety and Quality Indicators • Length of stay • Falls • Hospital Readmissions • Pressure Ulcers • HSMR • Complaints & Feed-back

Efficient and Effective • Procurement • Carbon emissions • Allocations • VAT savings on locums • Active monitoring of spend

New Models of Care

• Use of technology • Face-to-face appointments • Medical Locums • Nurse Bank • Agency Use • Day Case • Cost per case • Place of death

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Table 2 Bench Marking Indicators Data Source: Discovery

NHS Highland: Areas for Improvement InvestigationBased on 2015-16 figures

Potential Productive Opportunity (‘000s)

Inpatient cost per case – move to Scottish average 9,861Day Case cost per case– move to Scottish average 4,052Day Patient cost per case– move to Scottish average 0Outpatient - Consultant cost per attendance– move to Scottish average 3,326Outpatient - Nurse cost per attendance– move to Scottish average 1,867Outpatient - AHP cost per attendance– move to Scottish average 6,090A&E cost per attendance– move to Scottish average 0Ambulatory Care Amenable Conditions -– move to Scottish average 389BADS - move to Scottish average 109Procedures of Limited Value - move to Scottish average 1,637New Outpatient DNA - move to Scottish average 21Theatres Efficiencies - eliminate cancellations due to capacity reasons 2,585

Medical Locums – reduce by 20% 2,446Nurse Bank - reduce by 10% 650Nurse Agency - reduce by 20% 203Admin - move to Scottish mean performance per £1K gross hospital costs 545Catering - move to Scottish mean performance per hospital inpatient week 0Cleaning - move to Scottish mean performance per SqM 0Portering - move to Scottish mean performance per SqM 0Laundry - move to Scottish mean performance per Inpatient week 0Energy – move to Scottish mean performance per SqM 0

It should also be noted that where there is a zero against any indicator, this does not mean

that improvement is neither possible nor achievable. For most of these indicators, there are also examples of what a move to the Upper

Quartile performance in Scotland would achieve.

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Table 3 Performance measure to support monitoring of the delivery plan

Measure Target Baseline (31/3/17)

Financial Year Detail Q&S Plan Q1 Q2 Q3 Q4 Initiative: Adult Care

1

Emergency admissions

Reduce 2,352 Annex 1, 2.1.1

Occupied bed days

Reduce 19,560 Annex 1, 2.1.2

Emergency four-hour target

Increase 96.8% Annex 1, 2.1.3

Mean age of admission to long term care

Increase 82 years Annex 1, 2.1.4

Occupancy of bed days in last six months of life

Percentage of people cared for outwith institutional settings

Increase Annex 1, 1.5

No. of Anticpatory Care Plans

Increase 18,814 Not Available

Virtual Wards Increase 0 Not Available

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Measure Target Baseline (31/3/17)

Financial Year Detail Q&S Plan Q1 Q2 Q3 Q4 Initiative: Adult Flow

2 Length of stay – emergency in all hospitals

Reduce 5.9 days

Annex 1, 2.2.1

Length of stay – elective in all hospitals

Reduce 4.1 days

Annex 1, 2.2.2

2

Length of stay – adult social care in care home

Reduce 2.7 years Annex 1, 2.1.5

Hospital Readmissions within 7 days of an elective or emergency discharge

Reduce 4.75%

Annex 1, 2.2.3

Emergency four-hour target

Increase 96.8% Annex 1, 2.1.3

Delayed Discharge Overview

Reduce 126 Annex 1, 2.2.4

Waiting times

See LDP Annex 1, 2.2.5

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Measure Target Baseline (31/3/17)

Financial Year Detail Q&S Plan Q1 Q2 Q3 Q4 Initiatives: New Models of Care

3

Use of technology – remote consultations

Increase New – 274 Return – 439

Annex 1, 2.3.1a & b

Use of Technology – nos of clients by type

Increase 2,478 Annex 1, 2.3.1 c & d

Use of Technology – nos of new referrals by reason

Increase 250 Annex 1, 2.3.1e & f

Advanced Practitioners

3

Salaried GPs

16.94 WTE Not in Annex

Consultants (employed by NHS Highland)

225.6 WTE Not in Annex

Medical locums (Consultants)

Reduce 7.1 WTE Not in Annex

Locum spend (agency)

Reduce £11.7M Not in Annex

Nurse Agency spend

Reduce £1,296K Not in Annex

Nurse bank use

Reduce £6,547K Not in Annex

Day Case

Increase 66% Annex 1, 2.3.2

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Measure Target Baseline (31/3/17)

Financial Year Detail Q&S Plan Q1 Q2 Q3 Q4 Cost per case

Place of death (community)

Increase 90% (of popualtion)

Annex 1, 1.5

Acute beds

Reduce 599 Not in Annex

Community beds

Reduce 384 Not in Annex

New Craigs beds

Reduce 134 Not in Annex

Care at Home Capacity

Increase 716k Hours Annex 1, 2.3.3

Number of Social Care Day services/Hubs

36 Not in Annex

3 Flexible use beds

Increase To follow Not in Annex

Co-location of teams

Increase To follow Not in Annex

Initiative: Realistic Medicine

4 New consent

Increase 0 (none) New consent process under development

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Measure Target Baseline (31/3/17)

Financial Year Detail Q&S Plan Q1 Q2 Q3 Q4 Initiative: Drug Costs & Effective Prescribing

5

Branded to generic prescribing - Require all prescribing to move to generic name unless contraindicated - as per Board policy.

80% conversion

£625k

Melatonin – switch all patients on Bio-melatonin tablets and melatonin liquid to melatonin capsules in line with revised Board clinical guidelines

90% conversion

£335k

Seretide 250 Evohaler Inhaler – switch to Relvar Ellipta in COPD or Fostair in Asthma In line with Board clinical guidelines

80% conversion

£800k

Tiotropium Inhalers – switch to Incruse Ellipta in COPD in line with Board clinical guidelines

80% conversion

£1.3m

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Measure Target Baseline (31/3/17)

Financial Year Detail Q&S Plan Q1 Q2 Q3 Q4 Initiative: Remodelling Assets

6

Number of out-of-hours centres

Reduce

To follow Not in Annex

Number out-patient appointments (new)

Increase 5990 Annex 1, 2.4.1a & b

Number of staff Reduce Not in Annex Running costs

Backlog maintenance

Reduce £237 per sq metre (2015 figure)

Not in Annex

6

Non clinical buildings owned

Reduce 2 Not in Annex

Non clinical buildings leased

Reduce 3 Not in Annex

Initiative: Local Initiatives and Opportunities - Safety and Quality Indicators

7 Falls

Reduce 177 Annex 1, 2.5.1

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Measure Target Baseline (31/3/17)

Financial Year Detail Q&S Plan Q1 Q2 Q3 Q4 Hospital Readmissions

Reduce 4.75% Annex 1, 2.2.3

Pressure Ulcers

Reduce 4 Annex 1, 2.5.2

HSMR

Reduce To be agreed

Not in Annex.

Complaints & Feed-back

61 per month

49 Not in Annex

Initiative: Local Initiatives and Opportunities – Efficient and Effective

7

Procurement

Reduce Not in Annex

Carbon emissions Reduce Not in Annex Allocations

Not in Annex

VAT savings on locums

Increase To Follow Not in Annex

Active monitoring of spend

Not in Annex

7

Out of area clients (Social Work)

Reduce Not in Annex

Standard Business Case

Not in Annex

Initial Agreements

Not in Annex

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Measure Target Baseline (31/3/17)

Financial Year Detail Q&S Plan Q1 Q2 Q3 Q4 Outline Business Case

Not in Annex

Full Business Case

Not in Annex

5S roll out

Not in Annex

Roll out of value managment

Planned to roll out to 3 areas

Ward 7A, Raigmore

Not in Annex

Public events on realistic medicince

Not in Annex

Staff Suspensions

Reduce To follow Not in Annex

Sick leave

Reduce 3.67% Not in Annex

Increase accommodation on Raigmore campus

Increase Not in Annex

*Annual state of NHS assets and facilties report 2015

(*) Refer to Table 3b for description of each output

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Table 3b Descriptions and sources of information

Outputs Description Source How counted Responsible Officer No. of Anticpatory Care Plans (ACP)

A process designed to support patients living with a chronic long-term condition to help plan for an expected change at some time in the future. ACP’s are generated from the Key Information Summaries (KIS).

Emergency Care System

Number of active KIS generated as a proxy for ACPs.

P&PM

Flexible use beds A time limited episode of intermediate care commissioned and supported by the partnership and provided in dedicated capacity within a care home. This may be as step up beds (admitted to home for assessment and rehabilitation as an alternative to acute hospital admission) or as step down beds (transfer from acute hospital or community hospital for further period of assessment and rehabilitation).

Manual count Census count at end of each quarter

P&PM

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Virtual Wards Proactive and coordinated multidisciplinary care and support for people with complex chronic disease or frailty at high risk of future exacerbations and emergency admissions to hospital or to a care home. The episode is not time limited and continues over many weeks to months. The care is generally overseen by a GP and / or community Multi Disciplinary Team. Care and support are coordinated for each individual by a lead professional.

Manual count Not currently counted.

DoO.

Non clinical buildings owned Buildings owned

Estates Manual count HoE

Non clinical buildings leased Buildings leased

Estates Manual count HoE

Co-location of teams An integrated adult social care team. Client-centred care that is more co-ordinated across care settings and over time, particularly for patients with long-term chronic and medically complex conditions..

Out of area clients (adult social care packages)

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New consent (realistic medicine) Remote consultations - Health Any consultation between a health

care professional and patients on a network or video link.

Trackcare PMS Data extract P&PM

Remote consultations – adult social care

Any consultation between an adult social care professional and patients on a network or video link.

Out of Hours bases Primary care out of hours services provided to patients when their registered GP practice is closed.

New Hospitals/Wards Number of new hospitals/wards within the current financial year

Old Hospitals/Wards Number of hospitals/wards closed down within financial year

Small care homes Small (less than 10 residential or nursing beds) closed during current financial year

Care Homes Number of new care homes in current financial year

Acute beds (Raigmore, Caithness, Belford, Lorne and the Isles)

Number of beds for the admission of in-patients and day cases using an in-patient bed. Excluded are: beds in day bed units, temporary beds, labour suite beds, cots for healthy babies, trollies and chairs.

Bed occupancy statistics report

Report extract P&PM

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Community beds Number of beds for the admission of in-patients and day cases using an in-patient bed. Excluded are: beds in day bed units, temporary beds, labour suite beds.

Bed occupancy statistics report

Report extract P&PM

Care at Home Care provided in own home to help maintain independence.

Manual collection Care at home teams

P&PM

Day services/Hubs Adult day care provided both in-house and by the independent sector offering social, recreational and health related service to individuals in a protected setting.

Manual collection Commissioning Team

P&PM

Standard Business Case

Work to be processed and tested with Operational & Corporate Teams

Initial Agreements Outline Business Case Full Business Case 5S roll out Roll out of value managment Public events on realistic medicince Advanced Practitioners Salaried GPs Consultants Locum spend Agency spend Nurse bank use Suspensions Sick leave Increase accommodation on Raigmore Campus

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