Summary Sheet: Governing Body...PAPER 13 1 Part: 1 Paper: 13 Summary Sheet: Governing Body Date Tuesday, 8th July, 2014 Presenter & Organisation Mary Burkett, CSU Author Performance

PAPER 13

1

Part: 1 Paper: 13

Summary Sheet: Governing Body

Date Tuesday, 8th July, 2014

Presenter & Organisation

Mary Burkett, CSU

Author Performance Team , CSU

Responsible Director Sue Jeffers, Managing Director

Clinical Lead NA

Confidential No (items are only confidential if it is in the public interest for them to be so)

The Governing body is asked to:

Note the most recent report and actions in train to improve performance

LAS Cat A performance remains a concern with YTD (68%) and weekly (61%) performance continuing below target (75% within 8 minutes). Senior level discussions have taken place between LAS, the TDA and NHS England (London). A special meeting of the Strategic Contract Management Board is taking place on 30th June to discuss and agree the options for improving performance.

Maternity performance at WMUH compares favourably to other providers , although the reason for higher than threshold caesarean rates is being queried

18week RTT. Hounslow CCG is to receive approximately £2m to support Trust improvement of 18 week RTT. The plan is to be agreed and submitted by 4th July

Unplanned care has also received additional funding and the plan is to be agreed by the Urgent Care Board

Cancer waits. Previous reports have highlighted the interface between ICHT and WMUH and the 2 Trusts now have plans in place to improve inter-trust working. We are querying with the trust why performance has not improved in line with their plan agreed

Summary of purpose and scope of report

To update the Governing Body on the performance of their main NHS providers

Quality & Safety/ Patient Engagement/ Impact on patient services:

NA

Title of paper Integrated Quality and Performance Report Month 1

2

Financial and resource implications

NA

Equality / Human Rights / Privacy impact analysis

NA

Risk

NA

Supporting documents

- Include only what the meeting requires for decision making/ action, and list documents below

Governance and reporting (list committees, groups, or other bodies that have discussed the paper)

Committee name Date discussed Outcome

Finance and Performance Committee

01/07/2014 Passed to GB for consideration

Quality, Patient Safety and Equality Committee

24/06/2014 Noted report and raised actions for CQGs

Hounslow CCG Integrated Performance & Quality Report

Final

April 2014 (Month 1)

PAPER 13

high quality support to commissioners to improve health and wellbeing 1

Table of Contents

Introduction

Section 1 – CCG Operational Performance

1.1 Operational Performance Overview

1.2 NHS Performance Standards – 18 Weeks RTT

1.3 NHS Performance Standards – Cancer Waits

1.4 NHS Performance Standards – Other Acute Measures

1.5 NHS Performance Standards – Out of Area Providers

1.6 NHS Performance Standards – Mental Health

1.7 NHS Performance Standards – Community Services

1.8 CCG Quality Premium

Section 2 – Quality & Safety Performance

2.1 Provider Quality & Safety Overview

2.2 Acute Provider Quality Performance

2.3 Community Provider Quality Performance

2.4 Mental Health Provider Quality Performance

Section 3 – Out of Hospital Services Performance

3.1 GP Out Of Hours (OOH) Services

3.2 NHS 111 Pilot Services

Section 4 – Appendices


Introduction

The Hounslow CCG Integrated Performance & Quality Report is aimed at providing a monthly update on the performance of the CCG based on the latest performance information available, and reporting on actions being taken to address any performance issues with progress to date. The content of the report are defined by the CCG’s priorities which are informed by nationally defined objectives for commissioners - the NHS Constitution, Everyone Counts Guidance for 2014-15 (operating framework) and the NHS Mandated Outcomes Framework. The report is split into 3 sections. Section 1 of the report provides an update on CCG and related providers’ operational performance against national standards. This includes 18 weeks RTT, cancer waits , A&E waits and ambulance handover times. Detailed information on underachieving indicators including trends and action log are also provided. Provider Quality and Safety issues are covered in section 2 of the report. The key areas highlighted in this section are Serious Incidents, Never Events, SHMI, maternity services, complaints and patient experience. These are presented in trend charts and tables with commentary and actions for areas of concern. Section 3 provides an update on performance of out-of-hospital services namely Out of Hours (OOH) service, the NHS 111 Pilot Service including service governance and London Ambulance Service (LAS).


Section 1 – CCG Operational Performance

For Finance & Performance Committee


CCG Operating Framework: • Hounslow CCG is not meeting the 18 weeks RTT performance standards overall and did not achieve the 52 weeks wait or specialty standards in

M1. The CCG specialty performance was largely impacted by performance at Imperial Healthcare (ICHT) and WMUH. • Hounslow CCG did not meet the cancer 62 days to urgent treatment and 62 days referral from screening in M1 (83.3% and 75.0% respectively).

Quality Premium – Hounslow CCG performance against potential funding of £1.5M is being monitored from month 1. Assessments will be made in-year as more performance data becomes available.

Areas where provider performance (trust-wide across all CCGs) is below standard: • 18 weeks RTT: ICHT and ASPH did not meet the admitted RTT standard in M1 and ICHT also did not meet the non-admitted RTT standard.

WMUH, ICHT and ASPH did not meet RTT standards at a speciality level. In addition, ASPH and WMUH did not meet the 52 weeks RTT standard for M1 and have impacted the CCG.

• Cancer: WMUH did not meet the 62 days to treatment in M1 (81.6%). • HCAI: ICHT exceeded their C. Diff Tolerance for M1 and 2013/14 with 7 cases reported against a tolerance of 5 cases. ICHT also did not meet the

“zero tolerance” MRSA bacteraemia standard in M1, reporting 1 breach. • LAS arrival to handover waits : 130, 130 and 41 patient breaches > 30 minutes reported at WMUH, ICHT and ASPH respectively. WMUH also

reported 1 patient waiting over 1 hour to hospital handover. • HRCH achieved 5.7% against 5.0% target for the did not attend (DNA) rate for M1. • At M1 WLMHT did not meet the <15.0% DNA First Appointment target with performance of 15.3%.

1.1 Operational Performance Overview


1.2 NHS Performance Standards – 18 Weeks RTT

18 Weeks RTT Performance Dashboard

In mth/qtr YTD In mth/qtr YTD In mth/qtr YTD In mth/qtr YTD

18 weeks RTT - Admitted Pathway 90.0% 90.0% 91.7% 91.7% 88.3% 88.3% 81.3% 81.3%

18 weeks RTT - Non-admitted Pathway 97.0% 97.0% 96.9% 96.9% 94.4% 94.4% 96.0% 96.0%

18 weeks RTT - Incomplete Pathway 94.6% 94.6% 95.9% 95.9% 92.9% 92.9% 94.6% 94.6%

Number of 52 week RTT Waiters - Admitted Pathway 0 3 3 1 1 1 1 Not Reported Not Reported

Number of 52 week RTT Waiters - Non-admitted

Pathway0 1 1 0 0 3 3 Not Reported Not Reported

Number of 52 week RTT Waiters - Incomplete Pathway 0 2 N/A 0 0 0 N/A 23 N/A

Threshold

92%

Performance

MeasureDescription

Reporting

Frequency

Reporting

Period

95%

18 weeks RTT Monthly M1

90%

Imperial College Healthcare NHS

Trust

Ashford & St. Peter's Hospitals NHS

TrustNHS HOUNSLOW CCG

West Middlesex University Hospital

NHS Trust

• Hounslow CCG met RTT performance standards overall but did not achieve the 52 weeks wait or specialty standards in M1. 6 patients waited over 52 weeks. Of which 5 were reported by ASPH within T&O (1 admitted, 1 incomplete), Ophthalmology (1 non-admitted, 1 incomplete) and ENT (1 admitted) and 1 was reported by WMUH within ENT (admitted). Providers have been asked to confirm treatment plans are in place. Summary of specialty performance includes:

o Admitted speciality performance in M1 was largely driven by WMUH within Gynaecology, ICHT within Neurosurgery, both WMUH and ASPH within General Surgery and T&O, both WMUH and ICHT within ENT and both ASPH and Moorfields Eye Hospital within Ophthalmology.

o Non-admitted speciality performance in M1 was largely driven by ICHT within Neurosurgery, and Urology, WMUH within General Surgery and both ICHT and ASPH within T&O.

o Incomplete speciality performance in M1 was largely driven by ICHT within Urology and Cardiothoracic Surgery, WMUH within T&O, both ICHT and CW within Plastic Surgery and ICHT and ASPH within General Surgery. In M1, there have been increasing backlogs in Ophthalmology (Moorfields Eye Hospital, ASPH) and “Other” specialities (WMUH, ICHT). There are currently 27 Hounslow CCG patients waiting over 40 weeks across WMUH (7), ICHT (6), CW (4), UCLH (3), ASPH (2) and EHT, Bart’s Health, The Royal Marsden, The Royal Free Hampstead, and Moorfields Eye Hospitals with 1 patient each. Provider has been asked to clarify treatment plans for these patients


• WMUH met RTT standards overall, but not the 52 week wait or speciality standards in M1. 18 week backlog has reduced in M1 overall and across all challenged specialties.

• ICHT did not meet the non-admitted and admitted RTT standard overall, in addition the Trust did not meet 52 week or speciality standards in M1. The Trust has reported that the Trust was impacted by the implementation of their new patient administration system (PAS) that meant that performance information reported prior to the upgrade in April could not be updated following validation. As a result of this the Trust has also reported an increase in their overall backlog.

18 Weeks Referral To Treatment Performance

1.2 NHS Performance Standards – 18 Weeks RTT (2)

Issue & Root Cause Provider Actions CSU Lead

Original Due Date

Revised Due Date

Status Progress Update

• Mismatch of demand against capacity for some specialities.

• Trust unable to manage its internal capacity.

WMUH Contract query issued. WMUH to resubmit improvement plan following CCG/CSU review

MB 13/03/14 17/06/14 Open

Briefing note on progress to be submitted to June CQG. Trust confirmed specialty performance will be met from July 2014.

• Performance reporting issues following PAS implementation.

• Focus on cancer backlog reduction

• Demand and capacity imbalance

ICHT

Contract query issued. H&F CCG has approved the Trusts revised action plan with the exception of the T&O element due to the planned recovery date. Contract penalties are being applied at a specialty level and for each 52 week breach. CSU to monitor trajectory.

CL 21/03/14 12/06/14 Open

The Trust is required to submit a revised trajectory for T&O and provide assurance that all issues with the PAS upgrade are resolved. Trust requested to provide a response by the 12th June.


1.3 NHS Performance Standards – Cancer Waits

Cancer Waits Performance Dashboard


Percentage of patients seen within two weeks of an

urgent GP referral for suspected cancer93% 94.8% 94.8% 95.9% 95.9% 93.1% 93.1% 94.2% 94.2%

Percentage of patients seen within two weeks of an

urgent referral for breast symptoms where cancer is not

initially suspected

93% 98.3% 98.3% 98.9% 98.9% 93.3% 93.3% 94.1% 94.1%

Percentage of patients receiving first definitive

treatment within one month of a cancer diagnosis96% 100.0% 100.0% 100.0% 100.0% 98.3% 98.3% 100.0% 100.0%

Percentage of patients receiving subsequent treatment

for cancer within 31-days where that treatment is

Surgery

94% 100.0% 100.0% 100.0% 100.0% 98.0% 98.0% 100.0% 100.0%


for cancer within 31-days where that treatment is an

Anti-Cancer Drug Regime

98% 100.0% 100.0%No Patients

Treated

No Patients

Treated100.0% 100.0% 100.0% 100.0%


for cancer within 31-days where that treatment is a

Radiotherapy Treatment Course

94% 100.0% 100.0% 100.0% 100.0% 96.6% 96.6% 100.0% 100.0%


treatment for cancer within 62-days of an urgent GP

referral for suspected cancer

85% 83.3% 83.3% 81.6% 81.6% 89.0% 89.0% 71.8% 71.8%


treatment for cancer within 62-days of referral from an

NHS Cancer Screening Service

90% 75.0% 75.0% 50.0% 50.0% 94.3% 94.3% 100.0% 100.0%


treatment for cancer within 62-days of a consultant

decision to upgrade their priority status

85% 100.0% 100.0% 100.0% 100.0% 93.9% 93.9% 100.0% 100.0%

Threshold

Cancer 31 Day

WaitsMonthly M1

Cancer 62 Day

WaitsMonthly M1

Cancer 2 Week

WaitsMonthly M1

Performance

MeasureDescription

Reporting

Frequency

Reporting

Period


Trust


TrustNHS HOUNSLOW CCG

West Middlesex University Hospital

NHS Trust

• Cancer: Hounslow CCG did not meet the 62 days to treatment and 62 day (screening) for M1 (83.3% and 75.0% respectively). There were four breaches reported for the 62 days to treatment standard in M1, due to an unfit patient at ICHT (1), poor administration (1) and a diagnostic delay (1) at WMUH as well as a delayed referral from WMUH to ICHT (1). The breaches reported for the 62 days (Screening) standard were shared between ICHT and WMUH and were due to capacity issues (2).

• WMUH did not meet the 62 days to treatment in M1 (81.6%). Of the 3.5 breaches (across 5 patient pathways) reported against the 62 days to

treatment standard in M1, there were 2 breaches due to poor administration, 1 delay in diagnostics, 1 late referral from WMUH to ICHT (shared), and 1 due to patient choice.


Action Log

1.2 NHS Performance Standards – Cancer Waits (2)

Issue & Root Cause Provider Actions CSU Lead Due Date Revised

Due Date Status Progress Update

Cancer performance – Not meeting all cancer standards in Q4 2013/14 due to combinations of elective / diagnostic capacity, poor administrative processes, late referrals to the Trust, patient choice and complex pathways.

ICHT

Contract Query issued on 6th

February 2014. A Remedial Action Plan is in place and included within the 2014/15 contract.

CL 30/06/14 N/A Open

Monitoring implementation of action plan through Trust’s CQG. Trust met all standards in M1.

Cancer performance -62 day standards

WMUH CCG approved action plan is in place and progress is being monitored at the June CQG.

MB 17/06/14 N/A Open Progress to be reviewed at CQG on 17 June.


1.4 NHS Performance Standards – Other Acute Measures

Performance Dashboard – Diagnostics, Cancelled Ops, MSA, A&E, HCAI and Ambulance Handover


Diagnostic Waits Patients waiting more than 6 weeks for a diagnostic test Monthly M1 1% 0.5% 0.5% 0.22% 0.22% 2.04% 2.04% 0.70% 0.70%

Cancelled

Operations

Cancelled ops - breaches of 28 days readmission

guarantee as % of cancelled opsMonthly M1 5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Urgent operations

cancelled for a

second time

Number of urgent operations that are cancelled by the

trust for non-clinical reasons, which have already been

previously cancelled once for non-clinical reasons

Monthly M1 0 0 0 0 0 0 0

Mixed Sex Accommodation (MSA) breaches 0 0 0 0 0 0 0 0 0

MRSA Monthly M1 0 0 0 0 0 1 1 0 0

Monthly Target* 10 10 6 6 5 5

Annual Target 55 19 65 9

Actual 3 3 1 1 7 7 1 1

A&E Total time spent in A & E < 4 hours (all activity types) Monthly M1 95% 96.79% 96.79% 95.59% 95.59% 96.26% 95.49%

Trolley Waits in

A&E

Patients who have waited over 12 hours in A&E from

decision to admit to admissionMonthly M1 0 0 0 0 0 0 0

Number of Ambulance arrival to handover greater than

30minsMonthly M1 0 130 130 130 130 52 52

Number of Ambulance arrival to handover greater than

60minsMonthly M1 0 1 1 0 0 11 11

NHS HOUNSLOW CCGWest Middlesex University Hospital

NHS Trust

Data not available by CCG







Trust


TrustPerformance

MeasureDescription

Reporting

Frequency

Reporting

PeriodThreshold

Ambulance

Handover

EMSA Monthly M1

HCAIC.Diff Monthly M1

Data not available


Action Log

1.4 NHS Performance Standards – Other Acute Measures (3)



HCAI: 7 C.Diff cases against tolerance of 5 for M1 (1 related to Hounslow CCG). 1 MRSA case.

ICHT

Post infection review of the MRSA case submitted and under review by CWHHE infection control lead. Infection control performance to be discussed at the next CQG.

CL 03/07/14 N/A Open ICHT met C.Diff standard for 2013/14.

6 week diagnostic standard ICHT Trust requested to provide an assessment of issues and actions in place to improve performance

CL 14/06/14 N/A Open To discuss at next CQG (03/07/14)

Cancelled operations (for non-clinical reason) standard

ICHT Trust requested to provide an assessment of issues and actions in place to improve performance

CL 14/06/14 N/A Open To discuss at next CQG (03/07/14)

130 breaches of the LAS >30mins handover waits

ICHT

Dual handover process in place and Trust requested to ensure override function used appropriately.

HP 30/06/14 N/A Open

LAS commissioning audit of handover processes underway. In the interim fine to be applied.

• 130 breaches of the LAS >30mins handover waits


WMUH

Trust to improve data quality processes. Contract penalties of £200 per 30 minute breach and £1000 per 60 minute breach is being applied.

MB 30/06/14 N/A Open

LAS commissioning audit of handover processes underway. Contract fines applied.


1.5 NHS Performance Standards - Out of Area Providers


Action Log

1.5 NHS Performance Standards - Out of Area Providers (2)



not meeting the admitted RTT standard overall and is also not meeting the specialty and 52 week standards.

ASPH

A joint NW Surrey CCG and ASPH operational review group and Executive Oversight group are in place. NWL CSU monitors progress via CQG

MB 30/06/14 N/A Open

Trust is reporting that trajectories to meet specialty performance are largely on track other than General Surgery. A revised trajectory for General Surgery is being developed.



ASPH Health economy weekly meeting led by lead commissioner to review system wide issues.

MB 30/06/14 Open A&E improvement plan in place and progress reviewed at Trust’s CQG.


1.6 NHS Performance Standards – Mental Health

Hounslow

West London

Mental Health

NHS Trust

In mth/qtr In mth/qtr

M1 Local Target 1.25% No Threshold

M1 Actual 0.84% 1.00%

M1 Local Target 50.0% No Threshold

M1 Actual 47.8% 47.7%

% DNA 1st appointments Monthly M1 <15% 16.0% 15.3%

CR/HR Teams % Inpatients gate kept by CR/HR teams Monthly M1 95% 92.0% 98.2%

Monthly

Monthly

Reporting

Frequency

Reporting

PeriodThreshold

DNAs

Performance Measure Description

Mental Health - IAPT

Proportion of people with depression and/or anxiety disorders

referred for and receiving psychological therapies

Proportion of people with depression and/or anxiety disorders

receiving psychological therapies who are moving to recovery

Dashboard shows key indicators for 2014-15 reported by exception. Exception reporting against the all core mental health quality requirements will be produced in month 2.


Action Log

1.6 NHS Performance Standards – Mental Health (2)



IAPT – Access and Moving to Recovery: The trust has achieved 0.84% against 1.25 % for IAPT Access and 46.8% against the 50% year end target for Moving to Recovery at M1.

WLMHT

The Trust has been requested to provide a trajectory and update on actions to meet the end of year target.

MC 11/07/14 N/A Open

The Trust will provide an update on actions and issues for M2 if the target is breached again.

% DNA 1st

appointments: The trust have reported that the slight over performance of 16% against 15% target could be due to April and the seasonal holidays during April.

WLMHT

The Trust will continue to track performance over the next few months to see if DNA rates worsen to warrant an in-depth review.

MC 07/07/14 N/A Open

Text reminder messages continue to be used to remind patients of their appointments in place so in terms of existing processes there have been no changes.

% Inpatients gatekept by Crisis Resolution/Home Treatment Teams (CRHT): M1 breach equates to 2/25 Hounslow CCG inpatient admissions that were not gatekept by CRHT. Both admissions by-passed CRHT who were not made aware of the admissions. One admission was from the police and other was from a residential care home.

WLMHT The CRHT Manager will liaise with unit staff to remind them that all admissions have to involve CRHT.

MC 01/06/14 N/A Closed

CRHT Manager has liaised with all unit staff and reminded them that all admissions have to involve CRHT.


1.7 NHS Performance Standards – Community Services

Threshold In mth/qtr YTD

Productivity DNA Rate Pre-booked appointments DNA or UTA rate M1 Monthly 5% 5.7% 5.7%

AreaPerformance

MeasureDescription

Reporting

Period

Reporting

Frequency

NHS HOUNSLOW CCG

ID Issue & Root Cause Provider Actions CSU Lead Start Date Due Date Revised


DNA Rate- Trust has reported that from April 2014 data for a number of services has been removed from the Minimum Data Set (MDS) used to calculate the DNA rate, as these services are no longer commissioned by Hounslow CCG. This has caused an increase in the DNA rate previously reported. It is likely that the Easter holidays also had an impact on DNA rates.

HRCH

An audit of patients to look at DNA rates in Musclo-Skeletal (MSK) Service to take place in May. CSU to request update on audit findings and any actions planned as a result.

PF 08/05/14 04/07/14 N/A Open

Audit completed and update on findings requested. On-going use text reminders in MSK service and introduction of texting to children’s therapies as well as posters in the waiting room to inform service users of the lost appointments.


1.8 CCG Quality Premium – 2014/15

Financial

Gateway

2014/15 Target YTD M1 PerformanceMaximum

Available

Potential

Deductions

Reporting

Frequency

1868.2

(per 100,000 population)

Available in summer

2015£222,276 Annual

10% 0.88% £222,276 Monthly

1831

(admissions per 100k

pop.)

Available in summer

2015£370,460 Annual

(i) Improvement & Support of roll-out of

Friends and Family Test (FFT)tbc tbc

(ii) Improvement in 'Patient Experience of

Hospital Care'

Improvement 2013/14 &

2014/15.

Q1 2014/15 data

available in September

Local Providers Target tbc £222,276 Monthly

Hounslow CCG

Local Measure69.78% tbc £222,276 tbc

£1,481,840 £0

£1,481,840

Target YTD M1 Performance

Potential %

Adjustment to

Funding

Potential Adjustment

to Funding

Reporting

Frequency

92% 94.6% - Monthly

95% 97.3% - Monthly

93% 94.8% - Monthly

75% 76.8% - Monthly

£1,481,840Potential Year End Achievement (after Gateway Measures Performance Adjustments)

Total

Total Maximum Funding Available

Constitutional Measures

Gateway

measures

(Penalty)

18 Week RTT (Incomplete Pathway)

A&E waits (CCG mapped from HES provider data)

Cancer waits - 14 days (Urgent GP referral for Suspected Cancer)

Cat A red 1 ambulance calls (LAS performance)

£222,276 Annual

Improving the reporting of medication-related safety incidents

People with diabetes diagnosed less than a year who are referred

to structured education

Operate in a manner consistent with Managing Public Money in

2014/15

Not Incur Unplanned deficit in 2014/15, or require

financial support to avoid unplanned deficitNot incur a qualified audit report in respect of 2014/15

Quality Premium Measures

National

measures

Reducing Potential Years of Life Lost (PYLL) through causes

considered amenable to healthcare and including addressing

locally agreed priorities for reducing premature mortality

Improving Access to Psychological Therapies (IAPT)

Reducing avoidable emergency admissions (Composite Measure)

Improving Patient

Experience:

CCG funding achievement will be based on year-end performance against the pre-qualifying criteria, national and local measures with adjustments for constitutional gateway measures breaches. Data more indicators will be available from month 2 onwards.


Section 2 Quality & Safety Performance

For Quality, Risk & Safety Committee


2.1 Provider Quality & Safety Overview

Maternity Indicators • West Middlesex University Hospital NHS Trust (WMUH) and Imperial College Healthcare NHS Trust (ICHT) in month performance is below threshold

for ‘Breastfeeding initiation rate’. • ICHT’s in month performance is below threshold for ‘12 week assessment’ and ‘Home births’. • WMUH’s in month performance is below threshold for both Non-Elective and Elective Caesarean-sections.

The Trusts’ performances in the above maternity indicators will be raised at the relevant Clinical Quality Groups (CQGs) with the Trusts. Safety Indicators • WMUH’s in month performance for the indicators ‘Transient Ischaemic attack (TIA) treated within 24 hours’ and ‘Access to Rapid Access Chest Pain

Clinic within 2 weeks’ was below threshold in month • West London Mental Health NHS Trust (WLMHT) reported a pressure ulcer prevalence rate of 36.36% on the Patient Safety Thermometer, which is

significantly higher than previous months Patient Experience Indicators • ICHT in month performance for the indicator ‘percentage of complaints that were responded to within agreed timescales’ was below threshold. The Trusts’ performances in the above patient experience indicators will be monitored and raised with Trusts if there is no improvement.


2.2 West Middlesex University Hospital NHS Trust (WMUH) – Safety

Indicator Threshold In Month YTD Trend

Standardised Hospital Mortality Indicator (SHMI) Data Released: Apr/14

Coverage Period: Oct/12 – Sep/13

Expected = 100 90.5%


Pressure Ulcer Prevalence (All) National average = 4.64% 7.31%


2.2 WMUH – Quality Exception Report


QS22 % of rapid access chest pain clinic seen within 2 weeks

98% 92% 92%

ID Root Cause Actions CSU Lead Start Date Original

Due Date Revised


QS22 CSU to raise at CQG Sibghat

Ullah 01/06/14 Sep-14 Open


QS23

Stroke TIA - % of people referred with a suspected TIA, who are at high risk of stroke, who are assessed and treated within 24 hours

75% 66.7% 66.7%


Due Date Revised





2.2 WMUH – Maternity Exception Report


QS24 Breastfeeding initiation rate 95% 92.3% 92.3%


Due Date Revised


QS24 Contract managers to discuss at CQG Sibghat

Ullah 01/04/13 Mar-14 Sep-14 Open


QS25 Percentage of women that have elective caesarean sections

12% 12.1% 12.1%

QS26 Percentage of women that have non-elective caesarean sections

12% 13.6% 13.6%


Due Date Revised







2.2 WMUH – Patient Experience: A&E and Inpatient Friends and Family Test ( FFT)

Indicator Threshold In Month Nat Avg Trend

A&E FFT: Score 76 55

QS27 A&E FFT: Response Rate 15% 11.3% 18.6%


Due Date Revised


QS27 Lack of staff resource Trust to recruit more voluntary facilitators

Sibghat Ullah

01/06/14 Sep-14 Open


Inpatient FFT: Score 56 74

Inpatient FFT: Response Rate 15% 39.9% 34.9%


2.2 WMUH – Patient Experience: Maternity FFT

Indicator Threshold In Month Nat. Avg, Trend

Maternity Q2 FFT: Score 59 76

QS28 Maternity Q2 FFT: Response Rate

15% 5% 23.1%


Due Date Revised





2.2 Imperial College Hospital NHS Trust (ICHT) – Safety


Standardised Hospital Mortality Indicator (SHMI) Data Released: Apr/14

Coverage Period: Oct/12 – Sep/13

Expected = 100 78.91%


Pressure Ulcer Prevalence (All) National average = 4.64% 3.09% 3.09%


2.2 ICHT – Maternity Exception Report


QS2 Breastfeeding initiation rate 90% 69.3% 69.3%

QS3

First booking maternity appointments completed by 12 weeks + 6 days as a percentage of total booking appointments in month excluding late referrals (women referred after 10 weeks + 6 days)

95% 85.1% 85.1%

QS4 Home births 1.4% 0.8% 0.8%


Due Date Revised


QS2 CSU to raise at CQG Rashed Khan

01/06/14 Sep-14 Open


01/06/14 Sep-14 Open


01/06/14 Sep-14 Open


2.2 ICHT – Patient Experience: Complaints


% of complaints acknowledged within 3 days of receipt

100% 100% 100%

QS1 % of complaints responded to within the agreed target

100% 85% 85%


Due Date Revised


QS1

Patient complaints: % of complaints responded to within the agreed target

CSU to continue to monitor until 100% target is achieved.

Rashed Khan

01/04/13 Mar-14 Sep-14 Open


2.2 ICHT – Patient Experience: A&E and Inpatient Friends and Family Test (FFT)


A&E FFT: Score 55 55

A&E FFT: Response Rate 15% 19.3% 18.6%

Inpatient FFT: Score 70 74

Inpatient FFT: Response Rate 15% 41% 34.9%


2.2 ICHT – Patient Experience: Maternity FFT


Maternity Q2 FFT: Score 74 76

Maternity Q2 FFT: Response Rate

15% 44.5% 23.1%


2.3 Acute Providers Maternity Dashboard 1

ICHT NWLHT EHT THH WMUH ChelWest

Target Month YTD Target Month YTD Target Month YTD Target Month YTD Target Month YTD Target Month YTD % of first booking maternity apps by 12 weeks + 6 days as % of booking apps (exc. late referrals)

95% 85.1% 85.1% 95% 96.5% 96.5% 95% 96.8% 96.8% 95% 97% 97% 95% 98.4% 98.4% 95% 93% 93%

Breastfeeding initiation rate

90% 69.3% 69.3% 90% 89% 89% 90% 90.2% 90.2% 83% 84.1% 84.1% 95% 92.3% 92.3% 90% 89.7% 89.7%

Home Births

1.4% 0.8% 0.8% 0% 0% 0.9% 0.9% 1% 2.1% 2.4% 2.4% 2.0% 1.2% 1.2%

No data

Percentage of women smoking at the time of delivery

10% 1.1% 1.1% 10% 5% 5% 10% 2.8% 2.8% 10% 7.8% 7.8% 10% 3% 3% <10% 4.6% 4.6%

Percentage of women experiencing 3rd degree tear

5% 2.3% 2.3% 5% 3.7% 3.7% 5% 4.7% 4.7% 5% 5% 4.4% 4.4% 5% 1.2% 1.2%

No data


2.3 Acute Providers Maternity Dashboard 2

ICHT NWLHT EHT THH WMUH ChelWest

Target Month YTD Target Month YTD Target Month YTD Target Month YTD Target Month YTD Target Month YTD

Percentage of women that have elective caesarean sections

13% 11.4% 11.4% 10% 10.5% 12% 4.7% 4.7% 13.5% 13.5% 12% 12.1% 12.1% 15% 14.9% 14.9%

Percentage of women that have non-elective caesarean sections

15% 11.3% 11.3% 15% 15% 15% 15% 20.9% 20.9% 17.2% 17.2% 12% 13.6% 13.6% 15% 13.9% 13.9%

Post Partum Haemorrhage 2 litres and above

2.4% 0.2% 0.2% 2.4% 0.6% 0.6% 2.4% 0.5% 0.5% 0.2% 2.4% 1.2% 1.2% 2.4% 2.9% 2.9%

No data

FFT Maternity Q2: Score

74 76 65 76 67 76 67 76 59 76 48 76

FFT Maternity Q2: Response Rate

44.5% 23.1% 21.3% 23.1% 21.3% 23.1% 34.9% 23.1% 5% 23.1% 32% 23.1%


2.4 Hounslow and Richmond Community Healthcare (HRCH) – Safety: Pressure Ulcers


Pressure Ulcer Grade 2 19 19



Pressure Ulcer Prevalence (All) National average = 4.64% 5.10% 5.10%


2.4 West London Mental Health Trust (WLMHT - All boroughs) – Safety: Incidents by Severity


Number of incidents: No harm

190 190

Number of incidents: Low harm

14 14

Number of incidents: Moderate harm

8 8

Number of incidents: violence and aggression

54 54


2.4 WLMHT - Safety: Pressure Ulcers


Pressure Ulcer Prevalence (All) National average = 4.64%

36.36%

NB 20 june This has

subsequently been

confirmed as a

reporting error

36.36%


Section 3– Out of Hospital Services Performance


3.1 GP Out of Hours (OOH) Service

Key messages

• NQR indicators10b,12a and 12d for Hounslow CCG are no longer populated as they cannot be measured. • Care UK have yet to provide data for Brent CCG. This is being chased up with the provider. • Where data has been provided, the majority of indicators have demonstrated improvement. Some indicators have seen a slight dip in

performance, but they remain within the performance thresholds.

NWL GP OOHs Data- March 2014 Ealing CCG – Harmoni Hounslow CCG – Harmoni Brent CCG – Care UK Central/ West London & H&F – LCW

Final Dispositions/Outcome (Adastra) Volume % of Total Volume % of Total Volume Volume % of Total

GP visit 248 18.18% 194 19.04% 333 10.1%

PCC/UCC 451 33.06% 342 33.56% 855 25.9%

GP/nurse advice 581 42.60% 432 42.39% 1943 58.9%

A&E / Admitted to Hospital 47 3.45% 25 2.45% N/A N/A

999 10 0.73% 4 0.39% 74 2.3%

Community Nursing 8 0.59% 3 0.29% N/A N/A

Call Handler only (Message only)

19 1.39% 19 1.86% N/A N/A

Other referral 0 0.00% 0 0.00% N/A N/A

Total 1364 100.00% 1019 100.00% 3298 100%

Walk In Pts. 4 0.29% 0 0.00% 93 2.8%


3.1 GP Out of Hours (OOH) Service (2)

National Quality Requirements Target Ealing CCG Hounslow CCG Brent CCG Central/ West London & H&F CCG

9b % calls triaged within 20 minutes (urgent) 100% 97.92% 95.85% 97.52%

9c % calls triaged within 60 minutes (routine) 100% 92.01% 86.74% 97.57%

10b % walk-ins triage complete within 20 minutes 100% 100.00% N/A 100.00%

10c % walk-ins triage complete within 60 minutes 100% 100.00% 100.00% 98.85%

11 GP cons available at all times & places 100% 100.00% 100.00% 100.00%

12a % emergencies consulted within 1 hour 100% 100.00% N/A% 100.00%

12b % urgents consulted within 2 hours 100% 100.00% 100.00% 100.00%

12c % routines consulted within 6 hours 100% 99.60% 100.00% 99.87%

12d % emergencies visited within 1 hour 100% 100.00% N/A% 100% 100.00%

12e % urgents visited within 2 hours 100% 98.61% 96.92% 100% 98.25%

12f % routines visited within 6 hours 100% 98.28% 100.00% 100% 100.00%%

13 Patient communication - special needs met 100% 100.00% 100.00% 100.00%


3.2 NHS 111 Pilot Services

06- Apr

Call standards BEHH* Hillingdon CLWH** Eng.

% Calls answered in 60

secs 85.3% 87.6% 91.2% 88.7%

% Calls abandoned in

30 secs 2.6% 2.6% 1.9% 2.6%

% Calls triaged 88.9% 73.4% 100% 87.5%

% Calls where a call

back was offered* 6.2% 4.0% 11.3% 10.2%

% Call backs within 10

minutes*** 61.4% 54.9% 43.6% 47.0%

Dispositions BEHH Hillingdon CLWH Eng.

Led to ambulance

dispatches 7.5% 10.9% 12.0% 10.9%

Recommended to attend

A&E 9.6% 6.8% 6.5% 7.4%


primary/community care 65.0% 66.1% 66.7% 62.4%


other services 1.7% 1.6% 1.4% 4.4%

Did not recommend to

attend other service 16.3% 14.7% 13.4% 14.9%

13- Apr

BEHH Hillingdon CLWH Eng.

87.1% 87.6% 93.6% 93.8%

2.0% 2.7% 1.2% 1.7%

86.0% 73.8% 100% 86.4%

6.0% 3.5% 11.4% 8.3%

55.7% 47.4% 47.7% 53.4%

20- Apr


89.9% 91.0% 95.6% 94.2%

1.6% 2.0% 0.9% 1.3%

80.8% 77.0% 100% 88.8%

3.7% 3.4% 9.9% 9.2%

83.1% 75.9% 59.2% 53.0%

27- Apr


93.1% 92.6% 96.3% 95.6%

0.7% 1.1% 1.0% 1.1%

89.2% 76.3% 100% 89.0%

5.8% 5.5% 9.7% 9.5%

52.4% 57.6% 51.8% 52.3%


9.7% 10.4% 13.8% 10.8%

7.9% 6.7% 7.8% 7.5%

62.9% 66.8% 63.8% 63.3%

1.2% 1.6% 1.1% 3.3%

18.3% 14.5% 13.5% 15.1%


10.3% 9.0% 10.4% 9.0%

8.7% 8.1% 7.3% 6.6%

63.9% 68.0% 68.6% 65.8%

2.2% 2.1% 1.9% 4.9%

14.9%

12.8% 11.8% 13.8%


11.0% 10.7% 11.6% 10.2%

8.2% 9.8% 7.8% 7.3%

66.9% 65.4% 65.9% 64.2%

1.1% 1.7% 1.6% 4.4%

12.8% 12.4% 13.0% 13.8%

Source: Unify 2 CLWH is an outlier for calls triaged due to a telephony issue which prevents accurate reporting of the triage rate. LCW have now migrated to a new telephony system, and it is expected that once this is fully up and running the accuracy of this reporting should improve.

*BEHH = Brent, Ealing, Harrow, Hounslow

** CLWH = Central London, West London, Hammersmith & Fulham *** It is expected that call backs are an Exception

Key messages

▪ As the data below shows, April was a challenging month for the BEHH and Hillingdon services run by Care UK. Staff sickness levels were high, particularly in the first half of the month, and this impacted on the service particularly over weekends, bringing down the weekly averages. There was also a serious Adastra system failure in the first weekend of April which increased call lengths by 5-6 minutes per call. This also happened in the first half of the Easter weekend, but has since been resolved. Care UK also had technical problems with call routing to its new overflow call centre in Milton Keynes, provided by an external agency. Again, these have now been resolved, but they impacted on performance, particularly in the first two weeks of the month. Clinical performance, however, generally remained good, with a few exceptions where call backs increased above expected levels.

▪ LCW had a strong end to the month, and performed well over the Easter weekend. They had a large number of new staff complete their training during April, which was a key factor in the performance improvement. It should be noted, however, that performance has not yet reached a level where it can consistently reach the 95% target. Clinical performance remains challenging due to a shortage of clinicians in the service; LCW are currently recruiting across all staffing groups.


3.2 NHS 111 Pilot Services (2)

February 2014

BEHH Hillingdon CLWH

Call standards No. calls % No. calls % No. calls %

Number of calls

offered 5193 N/A 6421 N/A 6496 N/A

Number of calls

answered 5181 N/A 6409 N/A 6374 N/A

Calls answered in

60 secs 5082 98.1% 6287 98.1% 5841 91.6%

Calls abandoned

in 30 secs 12 0.2% 12 0.2% 122 1.9%

Calls triaged 4191 80.9% 4613 72.0% 6346 99.6%

Calls where a call

back was offered* 312 7.4% 343 7.4% 602 9.5%

Call backs within

10 minutes** 160 51.3% 173 50.4% 335 55.6%

* Figure expressed as percentage of calls answered

** Figure expressed as percentage of calls offered a call back

Source: Daily sitreps/Unify 2

March 2014


No. calls % No. calls % No. calls %

6139 N/A 7674 N/A 7351 N/A

6109 N/A 7637 N/A 7249 N/A

5883 96.3% 7324 95.9% 6739 93.0%

30 0.5% 37 0.5% 105 1.4%

5144 84.2% 5480 71.8% 7249 100%

345 6.7% 272 5.0% 675 9.3%

215 62.3% 164 60.3% 347 51.4%

April 2014



6139 N/A 7602 N/A 6616 N/A

6037 N/A 7452 N/A 6541 N/A

5468 90.6% 6801 91.3% 6184 94.5%

102 1.7% 150 2.0% 75 1.1%

5023 83.2% 5706 76.6% 6541 100%

297 5.9% 335 5.9% 693 10.6%

189 63.6% 210 62.7% 351 50.6%

Key messages

The below table shows monthly data and achievement against the contracted standards. Three months’ data is displayed in order to track trends. ▪ Call volumes were fairly stable from March to April in NWL, with just CLWH seeing a notable decrease in volumes. ▪ The BEHH and Hillingdon services missed their call answering target in April for the first time in several months; abandonment was also up but remained well

within the target. ▪ CLWH improved and only narrowly missed the 95% call answering target in April; abandonment also improved month on month. ▪ Clinical performance improved in BEHH, though the call back rate remained above target. In Hillingdon, call backs increased compare with March.

Performance on call backs within 10 minutes remained stable in both Care UK services. ▪ Shortage of clinicians meant that warm transfers decreased in CLWH to under 90%. Performance on call backs within 10 minutes has also declined over the

past three months. More detailed reporting of call back breaches has now been agreed and will be reported via the Clinical Governance group.



February 2014


Dispositions No. calls % No. calls % No. calls %

Led to ambulance

dispatches 461 10.7% 592 12.5% 808 12.7%

Recommended to

attend A&E 368 8.6% 389 8.2% 489 7.7%

Recommended to

attend primary/

community care 2751 64.0% 3044 64.3% 3900 61.3%

Recommended to

attend other service 69 1.6% 62 1.3% 326 5.1%

Did not recommend

to attend other

service 650 15.1% 649 13.7% 835 13.1%

Source: Unify 2

Key messages

The below table shows monthly data on the volume and proportion of calls which were routed to different disposition types. Three months’ data is displayed in order to track trends. ▪ Both urgent disposition types reduced in the BEHH and Hillingdon services in April, with fewer ambulance dispatches and fewer referrals to A&E. Urgent

dispositions also reduced in CLWH, although LCW’s services remain an outlier in London for ambulance dispatches. This was discussed at the recent contract meeting and LCW are looking at carrying out an audit of ambulance dispatches.

▪ All services recorded an increase in referrals to primary/community care as a proportion of all calls triaged. ▪ Referrals to other services remained fairly stable in all services, with only small changes. This was also the case with recommendations not to attend another

service.

March 2014



601 10.5% 764 12.4% 1002 12.5%

506 8.8% 505 8.2% 655 8.1%

3681 64.1% 3928 64.0% 5118 63.8%

95 1.6% 92 1.5% 150 1.9%

862 15.0% 855 13.9% 1102 13.7%

April 2014



532 9.9% 579 10.3% 846 11.9%

466 8.7% 446 8.0% 535 7.5%

3450 64.5% 3717 66.4% 4706 66.1%

81 1.5% 98 1.8% 112 1.6%

820 15.3% 760 13.6% 924 13.0%



Area

March 2014 BEHH Hillingdon CLWH Croydon Wandsworth Sutton &

Merton

Kingston &

Richmond North Central

South East

London

East London

& City

Outer North

East London

Dispositions No.

calls %

No.

calls %

No.

calls %

No.

calls %

No.

calls %

No.

calls %

No.

calls %

No.

calls %

No.

calls %

No.

calls %

No.

calls %

Led to ambulance

dispatches 543 10.3% 663 11.8% 887 12.2% 443 11.8% 284 9.9% 488 10.0% 265 9.0% 2117 12.4% 1964 8.5% 719 11.0% 1757 10.5%

Recommended to

attend A&E 473 9.0% 452 8.1% 585 8.1% 316 8.4% 283 9.8% 447 9.2% 271 9.2% 1374 8.0% 1825 7.9% 625 9.6% 1385 8.2%

Recommended to

attend primary/

community care 3393 64.3% 3608 64.3% 4669 64.4% 2425 64.8% 1823 63.3% 3207 65.9% 1942 65.8% 10996 64.2% 13622 59.2% 3989 61.0% 10421 62.0%

Recommended to

attend other

service 87 1.6% 88 1.6% 118 1.6% 82 2.2% 68 2.4% 99 2.0% 51 1.7% 244 1.4% 671 2.9% 264 4.0% 859 5.1%

Did not

recommend to

attend other

service

777 14.7% 796 14.2% 992 13.7% 479 12.8% 424 14.7% 623 12.8% 421 14.3% 2384 13.9% 4927 21.4% 943 14.4% 2388 14.2%

Source: NHS England Minimum Data Set

Overview

▪ The below table shows the disposition split across all London contracts for the most recent month available. It should be noted that this is March 2014 rather than April due to the time lag between the end of the month and publication of the MDS by NHS England.


3.3 London Ambulance Service (LAS)

Description Reporting Frequency Reporting Period Threshold In Month YTD Variance Notes

Cat A Red 1 responses within 8 mins Monthly M1 75% 76.8% 76.8% Quality Premium payment based on achievement of Red 1 target.

A Contract Query Notice has been served to the LAS

regarding Cat A performance and a recovery plan is in development

Cat A Red 2 responses within 8 mins Monthly M1 75% 70.7% 70.7%

Cat A 19 transportation within 19 mins Monthly M1 95% 96.4% 96.4%

CCG Cat A 8 mins Performance Threshold Reporting Period Months Below

72% (Red 1) Months Below

72% (Red 1 & 2) Notes

Hounslow 3 consecutive months

below 72% M11-M1 1 1

Red 1 = Immediately Life Threatening – e.g. not breathing

Red 2 = potentially life threatening – e.g. chest pain

The information shows the number of times performance by CCG has gone below 72% in the Year to Date (12 months); the colour is shown Red where this

has occurred for the last 3 consecutive months.

Key messages

The LAS achieved the Red 1 (life threatening) target during April, however failed to achieve the Red 2 target. A contract Query Notice was served on the 19th of May, a recovery plan is in development and a CCG Summit meeting is scheduled for the end of June. The core reasons provided for under performance are , unpredictably high Cat A activity, lower than expected staff recruitment and crew fatigue following the push to achieve Red 1 and Red 2 performance for 2013/14.


Section 4 - Appendices


Appendix 1: QOF Diabetes Prevalence

Data Source: Diabetes QOF Register, Weighted Population List Size as at 01/01/2013. More up-to-date information has been requested to be reported in Month 12 (May 2014) Note: Average Diabetes Indicator Exceptions % - Due to the 2012-13 Diabetes indicators not being made available until 29th October 2013 an average of the 2011-12 Diabetes Indicator exceptions has been used.


Appendix 2: Immunisation COVER data

Data Source: Quarterly Vaccine Coverage Table- Public Health England. Data is currently not available at practice level.

Cohert Immunisation Q1 12/13 Q2 12/13 Q3 12/13 Q4 12/13 Q1 13/14 Q2 13/14 Q3 13/14

12 months Number Of Children 1199 1146 1099 1163 1071 1174 1130

DTaP/IPV/Hib % 90.9% 92.8% 91.8% 90.8% 92.40% 90.50% 91.70%

MenC % 85.9% 87.0% 86.6% 87.4% 90.90% 89.10% 89.00%

PCV2 % 90.2% 91.9% 91.6% 90.5% 92.20% 90.70% 91.20%

% Hep B 50.0% 50.0% 100.0% 71.4% 100% 100% 62.5%

24 months Number Of Children 1134 1178 1098 1007 1123 1159 1172

DTaP/IPV/Hib % 93.7% 93.7% 94.4% 94.5% 95.90% 94.20% 91.8%

MenC2 % 90.7% 96.0% 94.6% 95.4% N/A N/A N/A

Hib/MenC 86.9% 90.1% 86.5% 88.4% 89.00% 89.00% 85.30%

PCV booster % 87.1% 88.2% 85.7% 87.6% 87.90% 87.10% 83.40%

% Hep B N/A 75.0% 37.5% 33.3% 28.60% 66.70% 85.70%

MMR % 86.4% 87.3% 87.2% 87.4% 88.50% 89.90% 85.80%

5 years Number Of Children 988 1103 1073 1069 1049 1122 992

DTaP/IPV % N/A 81.20% N/A N/A N/A N/A N/A

DTaP/IPV/Hib % N/A N/A N/A N/A N/A N/A N/A

DTaP/IPV/booster % 77.1% N/A 76.9% 79.2% 78.00% 71.50% 92.00%

MenC Primary % 92.3% 92.4% 91.9% 92.0% N/A N/A N/A

Hib/MenC Booster 90.0% 89.9% 89.5% 90.6% 87.60% 86.00% 87.80%

Hib Primary 91.00% 91.20% 91.6% 90.60% N/A N/A N/A

PCV booster % 85.20% 86.70% 85.5% 87.40% N/A N/A N/A

MMR 1st Dose % 92.80% 93.80% 92.4% 93.90% 92.10% 89.70% 92.40%

MMR 2nd Dose % 74.90% 80.40% 74.0% 77.20% 79.00% 74.10% 77.40%

DT/Pol Primary 92.90% 93.90% 94.0% 93.7% 92.90% 91.20% 92.00%

Documents

Summary Sheet: Governing Body...PAPER 13 1 Part: 1 Paper: 13 Summary Sheet: Governing Body Date Tuesday, 8th July, 2014 Presenter & Organisation Mary Burkett, CSU Author Performance