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NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting AGENDA ITEM NO: ………13……………… Date of Meeting: ……………27th November 2015…….. TITLE OF REPORT:

CCG Corporate Performance Report

AUTHOR:

Melissa Laskey - AD Commissioning Mike Robinson - AD Integrated Governance & Policy Lynda Helsby - AD Primary Care Victoria Preston – Senior Information Analyst

PRESENTED BY:

Dr Barry Silvert (other Board leads available to answer questions)

PURPOSE OF PAPER: (Linking to Strategic Objectives)

The purpose of the attached report is to indicate performance against all the key delivery priorities for the CCG in 2015/16 against which NHS Bolton Clinical Commissioning Group is nationally measured

RECOMMENDATION TO THE BOARD: (Please be clear if decision required, or for noting)

Members are requested to : Note the formal month end position for September 2015 (unless stated otherwise) in respect of performance against key delivery priority targets

COMMITTEES/GROUPS PREVIOUSLY CONSULTED:

Performance is reported to: CCG Clinical Executive Contract Performance Group Quality and Safety Committee

VIEW OF THE PATIENTS, CARERS OR THE PUBLIC, AND THE EXTENT OF THEIR INVOLVEMENT:

Patients’ views are not specifically sought as part of this monthly report, but it is recognised that many of these targets such as waiting times are a priority for patients. The report does include performance against the ‘Friends and Family Test’ at Bolton FT

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CCG Corporate Performance Report 1. Executive Summary

1.1 This report highlights NHS Bolton Clinical Commissioning Group’s performance

against all the key delivery priorities for the month of September 2015 (Month 6).

1.2 Appendix 1 contains the detailed reports for each set of performance indicators the CCG is measured against: - Bolton CCG Objectives - NHS Constitution Standards - Key NHS Contractual Measures - Outcome & Quality Framework Indicators - Community Services Key Performance Indicators - Quality Premium Metrics - CCG Quality Indicators

1.3 The Integration Performance Report is included at Appendix 2. This report details performance against the key BCF outcome metrics as well as progress made and key next steps for the programme.

1.4 Section 2 exception reports against all indicators.

2. Exception Reporting 2.1 Quality Premium 2015/16 2.1.1 The performance update for Quarter 2 for the Quality Premium metrics will be

brought to the January Board meeting, with details of specific actions being taken as required to ensure delivery of the targets.

2.2 Quality & Safety – Board Lead, Dr Colin Mercer

2.2.1 MRSA bacteraemia There has been 1 FT apportioned bacteraemia in September. This case was comprehensively reviewed by the FT and presented to the CCG accordingly. It was agreed on the basis of the evidence that this result was a clinical contaminant and the patient did not have a clinical infection. 2.2.2 Falls Progress is being made in relation to the benefits of the Falls Strategy implementation. Focused e-learning has been developed for all clinical staff and face to face sessions are being delivered by the falls coordinator to specific areas of

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concern. Since April 2015 150 members of front line staff have received falls training. 107 face to face and 43 through the newly developed e-learning package. Assessment criteria for the allocation of a ‘Special’, has been developed and is currently being trialled on a number of wards. This should influence the support needed for complex patients being risk assessed as a high risk of falling. The FT aim for 80% of staff identified for training to have completed the e learning package by March 2016. Falls leading to serious harm are classed as serious incidents and full RCAs are shared with the CCG which are reviewed at the serious incident review group. 2.2.3 Serious Incidents & Never Events There were 2 SIs reported in September. One of these relates to a failure to prescribe insulin to a diabetic patient with concerns regarding escalation. Another was a Never Event reported in September relating to the retention of a throat pack post nasal surgery. Investigations are underway in both cases and expected next month. An earlier reported Never Event relating to the misplacement of a nasogastric tube in a neonate has been downgraded following the investigation and consultation with the CCG and NHS England. 2.2.4 Royal College of Surgeons (RCS) Review of Theatres at Bolton FT On the 27th & 28th of July the RCS reviewed theatres at Bolton FT in response to a number of surgical never events that had occurred since April 2014. The aim was to assess the culture, processes, procedures and behaviours across themes. The findings of the report were summarised to the FT’s Quality Assurance Committee in October and the Board in November. This was also considered by the CCG’s Quality and Safety Committee in November and the FT will present both the findings and the action plan relating to the recommendations at the December Quality and Safety Committee. The review team did not consider there to be an overarching theme to the never events and that investigations had been thorough and rightly identified where improvements could be made. However, compliance with the WHO checklist and the five steps to safer surgery, the induction of locum staff, and the development and implementation of Standard Operating Procedures was reported as being variable. The review team made 15 recommendations and the FT have produced an initial action plan which will be further reviewed at the FT’s December Quality Assurance Committee.

2.3 Commissioning – Board Lead, Dr Barry Silvert

2.3.1 Reduce Non-Elective Admissions The CCG, in its 5 year plan, set a target for a reduction of 2.9% of non-elective

admissions in 2015/16 (based on 2014/15 outturn). In September 2015 there were 2,794 admissions across all providers. This represents a decrease of

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1.17% of non-elective admissions compared to September 2014 and year to date the figure is 16,947 non-elective admissions which is a reduction of 0.18% compared to the same period last year. Bolton FT repeated the Perfect Week exercise on the 23rd September, to reinforce the process improvements that need to be made to ensure flow through the hospital and to assist in reducing emergency admissions. Work is continuing on the operational roll out of the Ambulatory Care pathways with a focus on delivering elements of this early in 2016. This will also help to reduce pressure on the A&E department by pulling appropriate patients through to the Unit for assessment, treatment and discharge. This will be allied with specialist in reach to facilitate discharge directly from the Unit without the need for a full admission.

2.3.2Reduce Non-Elective Length of Stay

The target for non-elective length of stay for 2015/16 is 4.65 days. In September, the length of stay increased to 4.39 days (from 4.0 days in August). The current YTD length of stay is 4.41.

The CCG is working with Bolton FT to introduce new processes to help to

reduce length of stay, including weekly meetings to monitor individual wards and to assist with partners in unblocking any delays in transfer of care/discharges. The key lessons learned from the September iteration of the perfect week were to further embed the SAFER Bundle which assists with expediting patient flow. This has now translated into a key CQUIN proposal for 2016/17 to further embed these principles.

2.3.3Reduce Emergency Readmissions

The number of emergency readmissions in September 2015 was 521. This represents a 2.96% increase on the same period last year. The reasons for this are being investigated. The year to date position is 3,191 readmissions which is a 3.07% increase on the same period in 2014/15.

2.3.4NHS Constitution Targets

A&E 4 hour performance for September 2015 was 93.84% (against the target of 95%). Work continues with the trust to mitigate the risk of non delivery of this national target. Conference calls have been stepped up to 3 times per week, an A&E deflection scheme is being proposed with a November Pilot and the new NHS 111 service went live on the 10th November (with the impact on A&E being assessed).

NWAS achieved all of their 3 targets in September - with performance of 83.5% for Emergency Response arriving within 8 minutes (Red 1) and 75.3% within 8 minutes (Red 2) - against a target of 75% for both. The Category A 19 minute response standard also achieved with performance of 95.5% (against a target of 95%).

The 6 week diagnostic waiting time standard was achieved for September 15, for the first time since M1. The CCG will continue, however, to work closely with

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CMFT where there are known capacity issues, predominantly affecting endoscopy performance – action plans and trajectories are in place. Demand for endoscopy services is known to have increased recently as a result of public health cancer awareness campaigns.

The cancer standard for maximum 31 day wait from diagnosis to first definitive treatment was failed in September with 5 patients out of 120 having breached. The year to date position for this standard is achieving at 97.7% against a threshold of 96%. The CCG is working closely with the relevant providers to ensure actions are in place to address any current performance issues. The cancer standard for maximum 31 day wait for treatment where treatment is for surgery was failed in September with 1 patient out of 9 having breached at Salford Royal due to capacity issues. The CCG is working with SRFT to ensure capacity meets demand, along with assurance around timescales to resolution. The year to date position for this standard is 96.6% (against a threshold of 94%). The cancer standard for 62 day wait from urgent GP referral to first definitive treatment was failed in September, with 8 out of 10 patients affected due to late onward referral. The year to date position for this standard is achieving at 86.2% against a threshold of 86%. The CCG is working closely with providers to understand the reasons behind this, along with any future mitigating actions required.

2.3.5Contractual Performance

In August there were 100 patient handovers (from ambulances to A&E) where patients waited between 30 and 59 minutes and 13 patients waited more than 60 minutes (against a target of 0 for both). The Trust is continuing to work with NWAS to drive improvements in this area and until recently had started to see improvements in the handover times.

Bolton FT failed all 3 of the stroke targets in August. 70.0% of patients were admitted to a designated stroke bed within 4 hours (against a target of 80%), 76.9% of patients spent 90% of the stay in hospital on a stroke unit (against a target of 80%) and 50.0% of TIA cases were investigated and treated within 24 hours (against a target of 60%). The remedial action plan being implemented is being monitored through the Quality and Performance Group and the ODN is currently reviewing the performance of the new hyper acute stroke pathway. The CCG Executive has recently approved work to commence on exploring the potential of commissioning the TIA service from an alternative provider.

2.4 Community Services Dashboard – Board Lead, Dr Barry Silvert 2.4.1 Detailed below are the key highlights from the overarching community services

dashboard for October 2015.

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2.4.2 The update on the 3 services areas of concern previously discussed at Board (Rheumatology, Neurological Long terms Conditions and Tissue Viability) are subject to a separate Board discussion under the procurement item.

2.4.3 Community services continue to see some improvements in all areas, particularly waiting times, staff sickness and staff turnover. A significant improvement has been shown in the Falls service for waiting times - with 88% of patients seen within 4 weeks during October compared with only 50% in September.

2.4.4 Referrals to services are comparable to last year’s activity for both adult and children’s services.

2.4.5 The performance report continues to report waiting times against 4, 12 and 18 weeks rather than against service specific waiting times agreed through the service specifications. The Trust has provided assurance that the report will be further developed to reflect service specific waiting times. This includes recognition that further work is required for the recording of activity relating to urgent referrals seen on a daily basis in accordance to clinical need as this data is not routinely captured against this target.

2.4.6 Waiting times across the services at aggregate level are above target with 65.8% of routine referrals seen within 4 weeks. The CCG is working with the FT on key actions to reduce waiting times for key services as required.

2.5 Primary Care – Board Lead, Dr Stephen Liversedge 2.5.1 The next progress report for the Bolton Quality Contract (Quarter 2 2015/16)

will be brought to the January Board meeting, following review at the Primary Care Co Commissioning Committee.

3. Recommendations

3.1 The Board is asked to note the performance for September 2015 and the

actions being taken to rectify areas of performance which are below standard.

Melissa Laskey - Associate Director of Commissioning 20th November 2015

Appendix 1

2 Quality Premium

3-5 Quality Report

6 Corporate Objectives

7-9 NHS Constitution Deliverables

10-13 Performance Report

Appendix 2

14-50 Integration Report

Index

£839,697

ACHIEVED* Patient Population: 279,899

* Subject to quality and budget contraints Total Quality Premium Available: £1,399,495

* please note the population figures maybe adjusted14 15 16 17 18 19 20 21 22 23 24 25 26 27

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD / Forecast Target £ Potential £ Achieved* Notes

Reducing PYLL through amenable mortality10% of

QP2325 £139,950

Latest data released Sept 15 for

01/01/14-31/12/14 (Next

publication Sept 16)

Improving antibiotic prescribing in primary and secondary care: Part a)

Reduction in the number of antibiotics prescribed in Primary care by

1% or more

17,284 15,921 16,035 15604 13721 188,556 14/15 = 226108 *.99=223846 £139,950

Improving antibiotic prescribing in primary and secondary care: Part b)

number of co-amoxiclav, cephalosporins and quinolones as a % of the

total number of selected antibiotics prescribed in primary care to be

reduced by 10%

9.70% 10.16% 8.76% 9.47% 9.82% 9.58%14/15=9.92% reduction =

8.92%

Achieving a reduction in avoidable emergency admissions 561 490 497 508 425 513 2994 vs 3014 ly15% of

QPA reduction or zero % change £209,924 £209,924 HWB - awaiting data

An increase in the level of Non Elective discharges at weekends and

Bank Holidays22.89% 28.47% 17.01% 17.85% 25.83% 19.35% 21.9%

5% of

QP

>0.5% higher than 14/15

21.5%£69,975 £69,975

Reducing NHS responsible delayed transfers of care 348 303 346 371 422 230 4,04010% of

QP

less than 14/15 figure. 4332

Bolton FT (Excludes social

care)

£139,950 £139,950

Reduction in the number of patients with A&E breaches who have

attended with a mental Health need together with a defined

improvement in coding of patients attending A&E - Data quality, valid

A&E diagnosis > 90%

97.6% 97.6% 97.7% 97.0% 97.2% 98.0% 96.0% >90% £69,975 £69,975



improvement in coding of patients attending A&E. 4 Hour wait

component MH diagnosis

84.11% 91.90% 94.11% 87.40% 92.28% 89.16% A

14/15 = 85% for MH

diagnosis< 4 hours. Figure is

92.5% for non MH



improvement in coding of patients attending A&E. 4 Hour wait

component Non MH Diagnosis

92.00% 96.50% 97.90% 95.80% 95.28% 93.10% A

Improvement in the health related quality of life for people with a long

term mental health condition0.48 vs 0.704 A

15% of

QP

A reduction in the difference

between LTC compared to

those with a mental health

LTC

£209,924 £209,924GP Patient Survey (GPPS)/

HSCIC Portal 2.16 CCGOIS

September 2016 vs Sept 2015

Reduction in the number of people with sever mental illness who are

smokers

2% of

QP

Comparison between March

15 and March 16£27,990 GP data extracted by GPES

Increase in the proportion of adults with secondary mental health

conditions who are in paid employment

8% of

QP

Comparison of the proportion

within paid employment

between Q4 14/15 and Q4

15/16

£111,960 MHMDS

IAPT Recovery following talking therapies for people of all ages 44.90% 51.47% 50.45% 53.45% 44.70% 51.10% A10% of

QP>46.73% £139,950 £139,950

Emergency readmissions within 30 days of discharge from hospital 525 557 511 562 515 521 F10% of

QP<6086 £139,950 £0

£1,399,495 £839,697

18 week RTT - Admitted (monthly) 95.4% 95.7% 95.9% 94.6% 95.3% 94.3% A 90% -10% £0

18 week RTT - Non Admitted(monthly) 97.2% 96.8% 96.8% 97.0% 96.4% 96.0% A 95% -10% £0

18 week RTT - Incomplete (monthly) 95.7% 96.2% 96.4% 95.6% 95.7% 95.6% A 92% -10% £0

A&E <4h CCG level (monthly) 92.0% 96.8% 98.3% 95.9% 95.6% 93.8% A 95% -30% £0

Cancer 14 day waits from an urgent referral for suspected cancer 93.4% 98.2% 96.8% 95.1% 96.9% 98.2% A 93% -20% £0

Amb response <8 min (monthly) 71.2% 81.6% 79.8% 79.3% 77.7% 74.9% A 75% -20% £0

Adjusted Total £839,697

* Please note that this report is draft and currently work in progress. Awaiting guidance from NHSE regarding 18week penalties impact on Quality Premium.

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BOLTON CCG QUALITY PREMIUM RESULTS 2015/16 D R A F T

£559,798

MISSED

2326 Latest data released

June 15

2348 Latest data released

Sep 15

Area Performance Indicator 2014/15 Annual Target Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Cumulative YTD Trend (Apr 14-Sept15)

Summary Hospital Mortality Indicator (SHMI) <1.1 1.072 1.072 1.072 1.068 1.068 1.068 1.068

MRSA bacteraemia 0 1 2 0 0 0 1 4

Rates of C Difficile maximum 19 for full year 4 2 2 1 2 1 12

Number of falls (all patient falls safeguard) 982 93 80 88 97 80 92 530

Moderate 0 1 2 1 1 0 5

Severe 0 0 1 2 0 2 5

Fatal 0 0 0 0 0 0 0

Percentage of Harm (Safety thermometer) GM (rolling 12 months) <5% Harm 4.74% 4.58% 4.40% 4.40% 4.62% 4.47% 4.47%

Percentage of Harm (Safety thermometer) Bolton FT (rolling 12 months) <5% Harm 3.19% 1.52% 2.69% 2.29% 2.28% 2.24% 2.24%

% of adults who receive a falls risk assessment using an assessment too approved by

the commissioner (3a)>=95% 97.60% 98.00% 98.60% 97.70% 98.60% 96.30% 97.80%

% of adults assessed as being at risk of falling that have a care plan which reflects

best practice (3c)>=95% 92.50% 92.40% 96.50% 95.70% 96.20% 93.60% 94.40%

Medication Incidents >636 FYE 90 107 77 107 99 73 553

Total Incidents 10,786 907 895 967 1228 993 1055 6045

% Total incidents with no harm (Apr13-Sept13) NPSA 50% 69.1% 71.4% 68.3% 69.5% 71.6% 71.5% 70.0%

% of all adult patients who receive a tissue viability risk assessment using an

assessment tool approved by the commissioner (5a)>=95% 98.8% 98.1% 99.2% 98.1% 98.7% 98.4% 98.5%

% of adults assessed as being at risk of developing a pressure ulcer that have a care

plan (5c)>=95% 94.3% 92.0% 97.3% 97.2% 98.6% 94.5% 95.5%

Nursing (nurses/midwifes) shifts (% Actual Vs Planned) Day need to agree tolerance 95.1 94.9 95.8 95.5 93.9 95.3 94.0

Nursing shifts (% Actual Vs Planned) Night need to agree tolerance 98.7 97.2 97.7 98.1 95.6 95.5 96.0

Care Staff shifts (% Actual Vs Planned) Day need to agree tolerance 112.6 111.8 108.9 104.0 102.9 102.5 102.6

Care Staff shifts (% Actual Vs Planned) Night need to agree tolerance 133.2 133.9 124.5 116.8 113.7 116.1 119.7

Number of SUIs 0 3 0 3 3 0 2 11

Number of never events 0 2 0 2 0 0 1 5

Falls with at least moderate harm

QUALITY REPORT

REDUCING MORTALITY

PATIENT SAFETY

HCAI - Trust only


Complaints Responded to within time period 95% 100% 100% 100% 100% 97% 93% 98%

A&E Percentage recommended 85.0% 87.0% 87.0% 86.2% 86.4% 84.3% 86.0%

A&E Response Rate 15% 21.9% 21.9% 19.6% 20.2% 19.0% 20.1% 20.5%

Inpatient Percentage recommended 97.0% 96.0% 98.0% 98.1% 95.8% 96.2% 96.9%

Inpatient Response Rate 15% 26.8% 28.0% 27.7% 29.6% 28.8% 39.1% 30.0%

Maternity Q1 Antenatal Care % recommended

No target set No Responses No Responses No Responses No Responses No Responses 89% 89% Data supressed for very low numbers

Maternity Q2 Birth %e recommended

No target set 90.0% 94.0% 91.0% 91.8% 89.0% 91.1% 91.2%

Maternity Q2 Birth Response Rate

No target set 20.7% 19.1% 21.2% 16.6% 16.6% 16.6% 18.8%

Maternity Q3Postnatal % recommended

No target set 95.1% 91.8% 93.9% 82.8% 90.7% 93.6% 90.8%

Maternity Q4 Postnatal Community % recommended

No target set 92.5% 100.0% 95.0% 94.9% 90.7% 94.3% 94.5%

Friends and family staff (Quarterly)Percentage recommended - work

No target set 63.0%

Friends and family staff (Quarterly)Percentage recommended - Care

No target set 79.0%

62% 64%

78%79%

PATIENT EXPERIENCE (Bolton FT)


Sickness Absence 3.75% 4.38% 4.31% 4.52% 4.87% 4.66% 4.40% 4.52%

Mandatory Training - Compliance 100% 92.40% 93.30% 93.90% 94.20% 93.00% 94.00% 93.50%

Appraisals Completed 80% 82.1% 79.4% 78.4% 78.9% 79.4% 82.7% 80.1%

Induction Attendance 100% 68.90% 67.93% 70.69% 70.80% 73.30% 72.20% 70.64%

Substantive staff turnover Headcount (rolling average 12 months) <=10% 9.6% 10.0% 9.7% 9.8% 9.9% 10.3% 9.9%

Surgical WHO Checklist compliance (Elective)

100% 99.0% 99.8% 99.8% 99.8% 99.0% 99.0% 99%

Surgical WHO Checklist compliance (Emergency)

100% 98.0% 98.0% Not available Not available Not available 99.0% 99.0%

Number of SUIs 0 0 0 0 0 0 0 0

Number of never events 0 0 0 0 0 0 0 0

Number of practices with 5 red indicators on the Primary Care Dashboard (Practices

with review identified)Running Total 6 6 2 2 2 2 2

Number of patients registered at a GP Practice with a diagnosis of Dementia (deined

by the QOF dementia register code cluster) >=65 years

Need to agree denominator

and tolerance2,077 2,146 2,115 2,163 2,163

CLINICAL EFFICIENCY AND EFFECTIVENESS

BEAUMONT

Primary Care

PRIMARY CARE

Better Care, Better Value

Independent Sector

Quality Impact Indicators

STAFFING

Objective Key Measures of Success (Goals)

From (2011/12)

2013/14 for

Emergency

admissions)

To 2015 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 YTD YTD Position Comments

Reduce the gap in life expectancy

between Bolton and England 2.05 years (2010)

1.85 years

(2015)

For 2010-2012 Male 1.8 Female 1.6

Reduce the gap in life expectancy

between the most and least deprived

areas in Bolton 1

m13.5 f11.5 m13

f11

For 2006-2010 Male 13.5 Female 11.3

Achievement of all key targets / NHS

Constitution Several failing All achieved 5 2 2 2 3 4

Running

total

Number of failing targets out of 17

National measures

See NHS Constitution report

4 for September, A&E 4 Hour, 31 day

cancer for first definitive,31 day cancer

for surgery and 62 day for urgent gp

referal

Bolton patients and carers would

recommend health services

(combination of A&E and Inpatient)

90% Local

target90.1% 90.7% 92% 91.6% 90.6% 90.8% 91% 90%

New measure 'percentage

recommended' rather than 'net

promoter score'

Reduce emergency admissions 33,498 32,511 2,758 2,888 2,826 2,939 2,742 2,794 16,947 -0.2%

As per year 2 of the 5 year strategic

plan

Comparative to same period for the

previous year

Shift care closer to

home El 3.3 (baseline -

strategic plan)El 3.0 15/16 3.3 3.3 3.5 3.0 3.2 2.8 3.2


plan

NE 4.9 (baseline -

strategic plan)NE 4.65 15/16 4.8 4.7 4.2 4.3 4.0 4.4 4.4


plan

Reduce emergency readmissions 6,086 3% Reduction 525 557 511 562 515 521 3,191

BOLTON CCG CORPORATE REPORT

Improve quality of

care and patient

experience of care

Reduce elective & non elective length

of stay

(Ave LOS)

Improve Health

Outcomes

3.07%


plan

Comparative to same period for the

previous year

Data rebased due to GMW no longer

submitting and a shift in code for

admission method.

Best Value:

NHS Constitution Indicators - September 15

Indicator Target Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 YTDForecast

Achieve/FailExceptions Trend (Apr13-Sept15)

Admitted patients to start treatment within a maximum of

18 weeks from referral 90% 95.4% 95.7% 95.9% 94.6% 95.3% 94.3% 95.2% A

Aggregated target achieved, Cardiology failed at total Provider level (50%). Bolton

FT failed Orthopaedics (83.2%). Other breaches for September are Gen Surgery at

South Man (33%); Orthopaedics at Salford (83%); Ophthalmology at Central Man

(75%); Plastics at Christie (67%) and South Man (84%); Cardiology at South Man

(36.4%);Thoracic Medicine at South Man (50%); Gynae at Central Man (75%) and

Other Specs at Central Man (63.3%).

Non-admitted patients to start treatment within a

maximum of 18 weeks from referral95% 97.2% 96.8% 96.8% 97.0% 96.4% 96.0% 96.7% A

Aggregated target achieved, specialties failed for all Providers are Orthopaedics

Cardiothoracic, Gastro Cardiology and Other Specs. Bolton FT failed

Orthopaedics(92.6%) and Ophthalmology (90.7%); Other breaches for September are

Urology at Pennine (50%), Salford (83%) and South Manchester (50%); Orthopaedics

at Central Man (85.7%) and Salford (83%); ENT at Lancs Teaching (80%);

Cardiothoracic at South Man (66.7%); Gastro at Pennine (0% - 1 patient who has

breached), Salford (89%) and South Man (0% - 1 patient who has

breached)Cardiology at Salford (80%), South Man (80%) and WWL

(83%);Dermatology at Salford (82.4%); Thoracic at South Man (89%); Rheumatology

at WWL (89%); Gynae at Central Man (75%) and Other Specs at Central Man (86%)

and Salford (80.6%).

Patients on incomplete non emergency pathways (yet to

start treatment) 92% 95.7% 96.2% 96.4% 95.6% 95.7% 95.6% 95.9% A

Aggregated target achieved, specialty failed for all Providers are Ophthalmology

(90.7%) and Cardiology (91.8%). Bolton FT failed Ophthalmology (90.4%). Other

breaches for September are General Surgery at Salford (89.5%), Stockport (50%) and

South Man (85.7%); Urology at Central Man (87.5%); Orthopaedics at The Alexandra

BMI (66.7%), Pennine (87.5%), RLBG (66.7%), Salford (91%), Stockport (50%) and

Robert Jones (50%); ENT at Central Man (91%), Pennine (75%) and South Man (83%);

Plastics at St Helen's and Knowsley (85.7%); Cardiology at Lancs Teaching (87.5%)

and South Man (83%);Rheumatology at Central Man (75%); Gynae at Central Man

(91.3%) and Liverpool Women's (66.7%) and Other Specs at Central Man (89%) and

Sheffield Children's (75%).

Patients waiting for a diagnostic test should have been

waiting less than 6 weeks from referral 1% 1.00% 1.04% 1.59% 1.13% 1.05% 0.93% 1.12% A

Patients should be admitted, transferred or discharged

within 4 hours of their arrival at an A&E department -

Bolton FT

95% 92.00% 96.80% 98.30% 95.90% 95.60% 93.84% 95.00% A 605 patients waited more than 4 hours (Denominator 9,215) Breached by 144 patients

Referral to Treatment waiting times for non urgent consultant led

treatment - All Providers

Diagnostic test waiting times All providers

A & E waits - Bolton FT




Maximum two-week wait for first outpatient appointment

for patients referred urgently with suspected cancer by a

GP

93% 93.4% 98.2% 96.8% 95.1% 96.9% 98.2% 96.4% A

Maximum two week wait for first out patient appointment

for patients referred urgently with breast symptoms

(where cancer was not initially suspected)

93% 98.1% 100.0% 99.2% 97.5% 99.2% 98.3% 98.7% A

Maximum one month (31 day) wait from diagnosis to first

definitive treatment for all cancers 96% 97.7% 98.9% 97.3% 97.5% 99.1% 95.8% 97.7% A 5 breaches out of 120, late transfers and capacity issues

Maximum 31 day wait for subsequent treatment where

that treatment is surgery 94% 100.0% 100.0% 94.4% 100.0% 92.3% 88.9% 96.6% A

1 patient out of 9 breached. Elective capacity inadequate (patient unable to be

scheduled for treatment within target time)

Maximum 31 day wait for subsequent treatment where the

treatment is an anti-cancer drug regimen98% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% A


treatment is a course of radiotherapy 94% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% A

Maximum two month (62 day) wait from urgent GP referral

to first definitive treatment for cancer 85% 90.5% 80.6% 85.5% 92.1% 84.6% 82.8% 86.2% A Ten breaches of which 2 are complex patients the remaining 8 are for late referrals.

Maximum 62 day wait from referral from an NHS

screening service to first definitive treatment for all

cancers

90% 75.0% 100.0% 80.0% 100.0% 100.0% 100.0% 94.3% A

Maximum 62 day wait for first definitive treatment

following a consultants decision to upgrade the priority of

the patients (all cancers)

None set 100.0% 100.0% 87.5% 50.0% 100.0% 72.7% 96.1% A 3 breaches out of 11, all late referrals

Cancer patients - 2 week wait -All Providers

Cancer patients - 31 day wait -All Providers

Cancer waits - 62 days - All Providers




Category A calls resulting in an emergency response

arriving within 8 minutes (Red 1) 75% 71.20% 81.60% 79.80% 79.30% 77.70% 78.40% 78.00% A

Category A calls resulting in an emergency response

arriving within 8 minutes (Red 2)75% 72.10% 79.40% 78.20% 76.00% 75.40% 74.90% 76.00% A Target failed for NWAS, however Bolton achieved with 75.3%.

Category A calls resulting in an ambulance arriving at the

scene within 19 minutes 95% 93.30% 96.40% 95.90% 94.60% 95.10% 94.60% 95.00% A Target failed for NWAS, however Bolton achieved with 95.5%.

Category A ambulance calls NWAS

NHS Bolton Key Contract Performance Dashboard - September 2015.

Commissioner Performance Dashboard



Admitted patients to start treatment within a maximum of 18 weeks

from referral 90% 95.4% 95.7% 95.9% 94.6% 95.3% 94.3% 95.2% A

Aggregated target achieved, Cardiology failed at total Provider level (50%). Bolton FT failed

Orthopaedics (83.2%). Other breaches for September are Gen Surgery at South Man (33%);

Orthopaedics at Salford (83%); Ophthalmology at Central Man (75%); Plastics at Christie (67%) and

South Man (84%); Cardiology at South Man (36.4%);Thoracic Medicine at South Man (50%); Gynae

at Central Man (75%) and Other Specs at Central Man (63.3%).

Non-admitted patients to start treatment within a maximum of 18

weeks from referral95% 97.2% 96.8% 96.8% 97.0% 96.4% 96.0% 96.7% A

Aggregated target achieved, specialties failed for all Providers are Orthopaedics Cardiothoracic,

Gastro Cardiology and Other Specs. Bolton FT failed Orthopaedics(92.6%) and Ophthalmology

(90.7%); Other breaches for September are Urology at Pennine (50%), Salford (83%) and South

Manchester (50%); Orthopaedics at Central Man (85.7%) and Salford (83%); ENT at Lancs Teaching

(80%); Cardiothoracic at South Man (66.7%); Gastro at Pennine (0% - 1 patient who has breached),

Salford (89%) and South Man (0% - 1 patient who has breached)Cardiology at Salford (80%), South

Man (80%) and WWL (83%);Dermatology at Salford (82.4%); Thoracic at South Man (89%);

Rheumatology at WWL (89%); Gynae at Central Man (75%) and Other Specs at Central Man (86%)

and Salford (80.6%).

Patients on incomplete non emergency pathways (yet to start

treatment) 92% 95.7% 96.2% 96.4% 95.6% 95.7% 95.6% 95.9% A

Aggregated target achieved, specialty failed for all Providers are Ophthalmology (90.7%) and

Cardiology (91.8%). Bolton FT failed Ophthalmology (90.4%). Other breaches for September are

General Surgery at Salford (89.5%), Stockport (50%) and South Man (85.7%); Urology at Central

Man (87.5%); Orthopaedics at The Alexandra BMI (66.7%), Pennine (87.5%), RLBG (66.7%), Salford

(91%), Stockport (50%) and Robert Jones (50%); ENT at Central Man (91%), Pennine (75%) and

South Man (83%); Plastics at St Helen's and Knowsley (85.7%); Cardiology at Lancs Teaching

(87.5%) and South Man (83%);Rheumatology at Central Man (75%); Gynae at Central Man (91.3%)

and Liverpool Women's (66.7%) and Other Specs at Central Man (89%) and Sheffield Children's

(75%).

Number of patients waiting more than 52 weeks - (Bolton FT only)

Incomplete0 0 0 0 0 0 0 0 A

Number of patients who are not offered another binding date within

28 days0 1 1 0 0 0 0 2 F

Patients waiting for a diagnostic test should have been waiting less

than 6 weeks from referral 1% 1.00% 1.04% 1.59% 1.13% 1.05% 0.93% 1.12% A

Patients should be admitted, transferred or discharged within 4

hours of their arrival at an A&E department - Bolton FT95% 92.00% 96.80% 98.30% 95.90% 95.60% 93.84% 95.0% A 605 patients waited more than 4 hours (Denominator 9,215) Breached by 144 patients

Referral to Treatment waiting times for non urgent consultant led treatment - All

Providers

Diagnostic test waiting times All providers

A & E waits - Bolton FT

Number of patients who are not offered another binding date within 28 days Bolton FT




Maximum two-week wait for first outpatient appointment for

patients referred urgently with suspected cancer by a GP 93% 93.4% 98.2% 96.8% 95.1% 96.9% 98.2% 96.4% A

Maximum two week wait for first out patient appointment for

patients referred urgently with breast symptoms (where cancer

was not initially suspected)

93% 98.1% 100.0% 99.2% 97.5% 99.2% 98.3% 98.7% A

Maximum one month (31 day) wait from diagnosis to first definitive

treatment for all cancers 96% 97.7% 98.9% 97.3% 97.5% 99.1% 95.8% 97.7% A 5 breaches out of 120, late transfers and capacity issues

Maximum 31 day wait for subsequent treatment where that

treatment is surgery 94% 100.0% 100.0% 94.4% 100.0% 92.3% 88.9% 96.6% A

1 patient out of 9 breached. Elective capacity inadequate (patient unable to be scheduled for

treatment within target time)


treatment is an anti-cancer drug regimen98% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% A


treatment is a course of radiotherapy 94% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% A

Maximum two month (62 day) wait from urgent GP referral to first

definitive treatment for cancer 85% 90.5% 80.6% 85.5% 92.1% 84.6% 82.8% 86.2% A Ten breaches of which 2 are complex patients the remaining 8 are for late referrals.

Maximum 62 day wait from referral from an NHS screening service

to first definitive treatment for all cancers90% 75.0% 100.0% 80.0% 100.0% 100.0% 100.0% 94.3% A

Maximum 62 day wait for first definitive treatment following a

consultants decision to upgrade the priority of the patients (all

cancers)

none set 100.0% 100.0% 87.5% 50.0% 100.0% 72.7% 96.1% A 3 breaches out of 11, all late referrals

Cancer patients - 2 week wait -All Providers

Cancer patients - 31 day wait -All Providers

Cancer waits - 62 days - All Providers




Category A calls resulting in an emergency response arriving within

8 minutes (Red 1) 75% 71.20% 81.60% 79.80% 79.30% 77.70% 78.40% 78.00% A

Category A calls resulting in an emergency response arriving within

8 minutes (Red 2)75% 72.10% 79.40% 78.20% 76.00% 75.40% 74.90% 76.00% A Target failed for NWAS, however Bolton achieved with 75.3%.

Category A calls resulting in an ambulance arriving at the scene

within 19 minutes 95% 93.30% 96.40% 95.90% 94.60% 95.10% 94.60% 95.00% A Target failed for NWAS, however Bolton achieved with 95.5%.

All handovers between ambulance and A&E must take place within

15 minutes (no of patients waiting >30 mins<59 mins) Bolton FT0 74 59 25 39 56 100 353 F Deterioration from last month

All handovers between ambulance and A&E must take place within

15 minutes (no of patients waiting >60 mins) Bolton FT0 18 16 1 21 7 13 76 F Improvement from last month

Zero tolerance MSA breaches 0 4 0 0 0 2 1 7 F 1 Bolton CCG patient

Care Programme Approach (CPA): The proportion of people under

adult mental illness specialties on CPA -Completed95% 97.80% 97.40% 96.60% 95.80% 96.00% Not available 96.70% A

Care Programme Approach (CPA): The proportion of people under

adult mental illness specialties on CPA - 7 day follow up95% 91.10% 100.00% 100.00% 100.00% 100.00% 100.00% 98.30% A

IAPT Recovery rate - (GMW, 1 point and Think Positive)

Internal data50% 44.90% 51.47% 50.45% 53.45% 44.70% 51.10% 49.54% A

IAPT Access rate - (GMW, 1 point and Think Positive)

Internal data15.0% 17.50% 13.50% 17.80% 18.00% 15.60% 15.40% 16.30% A

Number of ongoing waiters >18 weeks 0 0 0 0 0 0 0 0 A

Mixed sex accommodation breaches - Bolton FT

Mental Health - GMW

Category A ambulance calls NWAS




HCAI-Healthcare Associated Infections

MRSA-Post 48 hrs (Hospital) 0 1 2 0 0 0 1 4 F 1 Bolton patient on ward E3

CDIFF-Post 72 hrs (Hospital) 19 4 2 2 1 2 1 12 F 1 Bolton patient on ward C2

A&E Percentage Recommended tbc 85.2% 86.6% 87.5% 86.2% 86.4% 84.3% 86.0% A

A&E Response Rate 15% 21.9% 21.9% 19.6% 20.2% 19.0% 20.1% 20.5% A

Inpatient Recommended

tbc 96.9% 96.4% 98.0% 98.1% 95.8% 96.2% 96.9% A

Inpatient Response Rate

15% 26.8% 28.0% 27.7% 29.6% 28.8% 39.1% 30.0% A

Never events 0 2 0 2 0 0 1 4 F

% Stroke admissions spending 90% of time on stroke unit 80% 78.4% 77.1% 83.8% 96.3% 76.9% 76.9% 82.4% A 6 patients out of 26 breached

Stroke patients arriving in a designated stroke bed within 4 hours 80% 71.0% 65.5% 76.7% 76.5% 70.0% 70.0% 71.70% F 6 patients out of 20 breached

Transient Ischaemic Attack (TIA) cases with a higher risk of stroke

treated within 24 hours60% 50.0% 25.0% 40.0% 31.3% 37.5% 50.0% 37.1% F 5 patients out of 10 breached

Never events

Stroke - Bolton FT

Annual target

Friends and family

Bolton Health & Social Care

Integration

Monthly Report

November 2015

Section 1 – Executive Summary Overall Programme Update There are significant issues regarding delivery of the integration schemes against the BCF targets.

The evidence around the current performance of the schemes indicates that the BCF targets will

not be achieved by the end of the year which will potentially incur significant financial penalties.

Performance Summary

The following provides an overview of some of the key performance metrics:

- There was under performance against the non-elective target in the month of September,

as emergency admissions were 66 (2.4%) above the BCF Target. This brings the year to

date admissions to 563 (3.4%) above the BCF target. This is particularly concerning and

urgent work is required by providers to clarify the actions that will be taken to improve

performance.

- The A&E target remains on track to deliver, in the month of September A&E attendances

were 68 (-0.9%) below plan. Performance against the year to date target remains positive

as attendances were 425 (-0.9%) below plan.

Scheme Summary

The key highlights of the work undertaken this month across the core and enabling work streams

include:

- Integration of hospital discharge services was due to commence in November 2015 to

include a pilot on complex care wards to extend the hospital discharge service to 7 days a

week. However, Confirmation has been sought from providers as to the date this service

will commence.

- The Care Homes Service is now fully resourced and is delivering services to care home

residents across 17 care homes out of 33 within the Borough. Following a meeting with

providers clarification was agreed on the service model in respect of, Admissions

avoidance planning, the GP enhanced service and the provision of proactive care.

- Intermediate Tier Services have seen further reductions this month in Non Elective

Admissions and in A&E attendances but are still below the agreed targets

- The Intermediate Tier Home based pathway has seen an increase in referrals and work

has been in progress to ensure all GP Practices are aware of the Admissions Avoidance

team and the referral pathway.

- Work is underway following the recent bed utilisation audit to increase GP referrals to step

up beds in Darley Court.

- At Greater Manchester Public Health Network (GMPHN) The Staying Well model was

selected as a best practice example, because of its preventative, integrated and enabling

approach.

- The procurement for the Complex Lifestyles Service has now gone live on The Chest on

22nd October. The procurement is due to be completed by the end of November 2015.

3

Issues

As noted above there are significant concerns about current performance against BCF targets.

There are a number of outstanding issues that need to be resolved by providers to include:

- The INT report that each GP Practice in the borough has a named practice coordinator so

there is full roll out across the borough. However, there is no evidence of full engagement

with all GP Practices which is demonstrated by the fact the number of referrals accepted by

the service is still well below the agreed trajectory and there is clear evidence that there are

no referrals received from some practices in the borough. Adrian Crook and Helen Clarke

are to review the GP Practice coordinator role and engage with all the GP Practices in the

borough in order to make improvements.

- There is assurance from providers that recruitment to the INT’s continues to be in progress

but there are vacancies within the integrated neighbourhood teams, some of which are due

to staff leaving. Vacancies are evident in social care, Bolton Foundation Trust and GMW.

Agreement was also confirmed for funding to back fill maternity leave in August 2015 but to

date backfill of the maternity leave has not been confirmed.

- A key risk noted in the workforce update is that Staff on fixed term contracts up to 31st

March 2016 will seek other opportunities if assurance of an extension to their contract is not

provided – potentially destabilising the service. Providers were required to assure their

respective staff. Confirmation is needed to ensure this assurance has been given to all

staff affected.

- The ABC integrated Care Plan which has been agreed for use within the INT’s, the Care

Home service and GP Practices is not consistently being used. This is being actively

addressed.

- The colocation of the Intermediate Care at Home and Reablement is delayed. Discussions

have taken place to develop an interim solution to enhance the joint provision of services

and plans are being progressed along with other integration estate issues by the estates

work stream. However, there are delays in implementation of the estates plan. A request

has been made for a summary of the estates plan with timescales.

- Although the Staying Well service are demonstrating an increase in referrals. As of the 1st

November the service had not yet rolled out to include more GP Practices than the original

11 that were included in the pilot. This being addressed by the Staying Well Steering

Group.

4

Section 2 – Performance Headlines

National Indicators

Emergency admissions (Bolton CCG patients, all providers)Trend from Apr13-Sep15

Target Actual Target Actual

2,728 2,794 16,384 16,947

Permanent admissions of older people to nursing and residential care homes222 2013/14 2014/15 2015/16 Q1 2015/16 Q2 Trend (annual ) - target in red

380 377 392 394

378.0 361 361 361

Proportion of patients still at home 91 days after discharge from hospital in to reablement services2010/112011/122012/132013/14 2014/15 2015/16 Q1 2015/16 Q2 Trend (annual ) - target in red

78.5% 79.9% 79.1% 79.1%

82.1% 86% 86%

Delayed transfers of care (total delayed days)Trend from Apr13-Aug15

Plan Actual Plan Actual

308 382 1,577 2,029

Note: due to a change in national reporting,

this measure is one month behind others

Referrals to home based intermediate careTrend from Apr14-Sep15

Last year This year Last year This year

85 144 519 752

Local Indicators

A&E attendances (Bolton CCG patients, all providers)Trend from Apr13-Sep15


7,600 7,532 47,053 46,628

30 day readmissions (Bolton CCG patients, all providers)Trend from Apr13-Sep15


506 521 3,096 3,191

Non-elective average length of stay (Bolton CCG patients, all providers)Trend from Apr13-Sep15


4.65 4.39 4.65 4.41

Non-elective average length of stay (Bolton CCG patients, medical specialties at Bolton FT)Trend from Apr13-Sep15


4.19 4.19 4.09 4.14

YTD (Apr-Sep)In Month (Sep)

There was an increase in the number of permanent admissions of older

people to nursing and residential care homes when comparing Q2

2015/16 with Q1 2015/16 (roll ing 12 month totals). The Better Care Fund

target for this measure was to decrease the number of permanent

admissions to residential and nursing care homes to 361 in 2015/16.

There was a decrease in the proportion of patients stil l at home 91 days

after discharge from hospital in to reablement services in Q2 2015/16

compared with 2014/15. The Better Care Fund target for this measure

was 82.1% in 2014/15 and is 86.0% in 2015/16.

A Better Care Fund target has been set for this measure, which accounts

for an anticipated increase in the number of delayed transfers of care

due to more accurate recording. For the current year to date, the number

of delayed days is significantly above plan. DTOCs this YTD are lower

than the figure for 2014/15 (2,943).

In Month (Sep) YTD (Apr-Sep)


The Better Care Fund target is to reduce the number of emergency spells

by 3.5% in 2015/16 compared to 2014/15. In the month of September, the

number of emergency admissions was 66 (+2.4%) above target. Year to

date (Apr-Sep) the number of emergency admissions was 563 (+3.4%)

above target.

The CCG's 5 year plan target is to reduce the number of A&E attendances

by 3.2% from 2014/15 to 2015/16. In the month of September, the number

of A&E attendances was 68 (-0.9%) below plan. Year to date (Apr-Sep) the

number of A&E attendances was 425 (-0.9%) below plan.

The number of referrals to home based intermediate care is 752 for the

current year to date (Apr-Sep). This is 45% higher than the number of

referrals in the same period last year (519 referrals).


In Month (Aug) YTD (Apr-Aug)

The average non-elective length of stay (for Bolton CCG patients) in

medical specialties at Bolton FT is 4.14 days for the current year to date

(Apr-Jul). This is sl ightly higher than the average length of stay in the

same period last year (4.09 days).


In Month (Sep) YTD (Apr-Sep)The number of 30 day readmissions is higher when comparing Apr15-

Sep15 with the same period in 2014. The readmission rate for this year to

date (Apr-Aug) is 9.9%, which is slightly higher than the same period last

year (9.7%).

The CCG's 2015/16 plan target for average non-elective length of stay is

4.65 days. For the current year to date (Apr-Sep) the average non-elective

length of stay is 4.41 days. The average length of stay for the same period

in 2014/15 was 4.92 days.

5

Section 3 – Work stream Performance and Update Intermediate Tier Services Project Contribution to High level Outcomes (using agreed proxy metrics)

Sept target Sept actual Year to Date target Year to date actual

NEL reduction 60 49 358 280

A&E reduction 81 76 483 448

Intermediate Tier Services are continuing to develop and embed the Admission Avoidance and

Home Based Pathway elements of the service. In terms of referrals and caseload activity, the

teams are performing well and pathways are being built with other services across the health

economy for example NWAS, Careline and the developing Integrated Neighbourhood Teams to

support admission avoidance and maintaining patients safely at home rather than being admitted

to hospital or long term care. September saw the management structure finally being fully in place

for intermediate tier services which will facilitate further service development.

Admission Avoidance Multi-disciplinary Teams - in September 144 referrals were made to the

team of those 144 who were assessed and treated 76 were from the community/GP practices and

the remainder from A/E. 88 of the total referrals were as a result of a fall or decline in functional

ability without a fall. 82 were unable to be discharged following first contact and required on-going

support from the Admission Avoidance Team, the average length of time on the caseload being 4

days. A further 9 of the original referral total were stepped up into intermediate tier community bed

to avoid an admission. 32 of the referrals to the Admission Avoidance Team in September had

been discharged from hospital within the previous 30 days and required support to prevent

readmission. Patient satisfaction is high with 100% rating the service as excellent via the Friends

and Family Test and 94% reporting it was extremely likely that they would recommend the service

to others and 6% saying it was likely.

Home Based Pathway – The reablement and intermediate care at home teams are working closely

together supporting an increase in caseload activity. There were 250 new referrals in September.

An increasing number are from community and GP referrals. The joint therapy and support worker

input to the reablement service provides the opportunity for patients to reach their maximum

potential to be independent and remain at home. The average length of stay in the home pathway

was 24 days in September. The majority of patients leave the home based pathway with no on-

going statutory services. The challenge surrounds co-location of the intermediate care at home

and reablement teams and a move to shared accommodation which will enhance the joint

provision of services with a single contact number being available for the home based and

admission avoidance teams, estates and facilities are supporting progressing this with scheduled

fortnightly meetings.

Bed Based Pathway- September saw the highest number of referrals since April this year to bed

based services with 105. There has been an increase in the number of step down referrals from

the hospital, this being as high as 88% limiting the ability to step patients up into an intermediate

6

care bed from the community. The majority of referrals to intermediate care beds have been from

the orthopaedic ward closely followed by the frailty unit at Royal Bolton Hospital. There has been

a high proportion of repeat admissions to intermediate care beds and the development of the

Integrated Neighbourhood Teams should have a positive impact on this in the future with

vulnerable patients being able to be supported by proactive management. The average length of

stay in the bed based units has reduced to 23 days which is lower than the bench marked average

of 27 days. 91% reported via the Friends and Family Test that they were very satisfied with the

service and 9% quite satisfied and overall 90.3% said it was extremely likely that they would

recommend the service to others.

Key Issues and Risks: A risk is that co-location of the home based Local Authority and Health

Teams are still split, although workshops have now been scheduled fortnightly led by Estates and

Facilities. Co-location will further enhance the service provision and deliver a more effective and

efficient service. IT access will be key with staff having access to both NHS and Local Authority

systems. Current recruitment and staff overcrowding in buildings and lack of IT kit in existing

bases is a growing problem with the team expansion leading to health and safety risks and the

potential for increased staff sickness due to stress.

Integrated Neighbourhood Teams

The Integrated Neighbourhood Teams are now implemented across the borough and continue to

establish themselves within each GP Practice. Referrals to the teams are steadily increasing but

the teams are currently below the expected referral trajectory.

The diagram below demonstrates the team’s performance against the agreed trajectory up to the

end of September 2015.

7

Work is therefore in progress to consult with all the GP Practices to review the GP Practice

Coordinator role and referral pathways from other services into the integrated neighbourhood

teams.

At the end of September the team had received 612 referrals (95 in September). This is an

increase of 25% on the referrals in August.

Throughout October work was completed to:

Refresh the Privacy Impact Assessment to inform information governance work

Refresh the Equality Impact Assessment

Develop and establish the role of the Advanced Nurse Practitioners in the team

Complete a Carefirst design document to ensure correct recording on Carefirst to support

performance reporting.

Work will continue to ensure all people in receipt of the service will have the opportunity to express

their views. The outcome of this engagement work will be included in performance reports on a

quarterly basis. The performance teams in each of the provider organisations are working with the

CCG to establish robust reporting against agreed performance metrics.

A pilot will be introduced in December to implement a single patient care plan located on the GP

primary care system, which will be used by the integrated neighbourhood teams and the GP.

Shared use of this care plan will support the implementation of hospital admission deflection

pathways with NWAS.

Providers are working together in the workforce work stream to develop joint training plans to

support staff to deliver new roles.

Care Homes

Sept target Sept actual Year to Date

target

Year to date

actual

NEL reduction 4 0 23 12

A&E reduction 9 1 36 8

The team is now fully resourced enabling the full roll out to be implemented without any

impediment. Further work has been undertaken in the last month to ensure that the service is in a

fit state to deliver the agreed outcomes, these include:

- A joint implementation steering group has been established that will meet fortnightly

- Work is in progress to develop a performance dashboard for the service in line with agreed

metrics

- The roll out plan submitted was not endorsed by IDG consequently the plan has now been

refreshed and was resubmitted to the CCG on the 2nd November as a draft.

8

The service has now completed phase one and two of the roll out plan and has progressed to a

further four in phase 3, the remaining homes in phase 3 are in progress. This will equate to 17 care

homes in total.

The intention is to roll the service out to all the care and residential homes in Bolton. The target for

completion is 22nd July 2016. The roll out plan is currently on target.

Next steps

Refreshed roll out plan to be endorsed at Integration Board and JTG

Wider communication plan to be developed in accordance to the implementation plan.

Performance dashboard to be finalised in line with agreed metrics and signed off at

Integration Board and JTG

Staying Well Period

Forecast

Clients

Contacted

Actual

Clients

Contacted

%

Increase/Decrease

Forecast

Clients

Visited

Actual

Clients

Visited

%

Increase/Decrease

Apr-15 180 65 -64% 108 35 -68%

May-15 180 122 -32% 108 77 -29%

June-15 180 103 -43% 108 65 -40%

July-15 180 147 -18% 108 51 -53%

Aug-15 180 202 12% 108 86 -20%

Sept-15 180 226 26% 108 144 33%

The Staying Well service continues to demonstrate positive outcomes. There are some staffing

changes to manage over the coming months.

A staged roll out programme is being formalised. We will link with INT colleagues to capitalise on

good work already done establishing INT Coordinators in Practices across the borough. We intend

to have Staying Well Coordinators introduced to phase 3 Practices and ready to make service

offers by the end of the year.

Greater Manchester Public Health Network (GMPHN) recently conducted a scoping exercise as

part of the health and social care devolution strategy. They selected 12 of the best examples of

national and international organisations who are demonstrating innovative ways of improving

community health and wellbeing using an asset-based approach. The Staying Well service was

selected as a best practice example because of its preventative, integrated and enabling

approach.

9

During October several members of the team attended a study visit with Innovation Unit

(commissioned to conduct the scoping exercise), at Bolton Town Hall. Discussions took place

around the Staying Well Coordinator role and tools developed that support an open, collaborative

conversation between the Coordinator and client. The case study was presented at the 5th Primary

Care Summit at the AJ Bell Stadium on 5th November.

Complex Lifestyles The Complex Lifestyles tender went ‘live’ on The Chest on the 22nd October 2015 (The Chest is an electronic advertising portal which is used to manage tenders). The tender will close on the 3rd November 2015 and evaluations will be complete by the 17th November 2015 with the intention of awarding the contract for the new Complex Lifestyles Service by 1st December 2015. It is also, intended for the service to have started before Christmas 2015.

Section 4 – Enabling Work stream Summary

Performance Monitoring

Progress Update

Work on the development of the ‘local’ performance dashboard for INTs and Intermediate Tier is ongoing. A draft document relating to INT performance has been circulated to IDG for comment. Performance leads from the CCG, FT and Local Authority met to agree a schedule for provision of operational data for the board report. The majority of the metrics identified for the INT workstream will be provided by the LA via the CareFirst system (where possible). It was agreed that a data group will be set up to discuss performance data on a monthly basis. Key Risks and Issues

If a number of performance metrics require additional data manipulation to source then this will cause delay in the production of the performance metrics. Key Activities to be completed next period

A reporting schedule to be provided to the LA and FT to ensure that the new dashboard becomes

operational within the next month or two – once formalised this will feed into a monthly workstream

performance dashboard.

Communications and Engagement

A branding exercise is presently being undertaken in partnership with key stakeholders to deliver by

December 2015, in order to provide an identity for Integration in Bolton. Full roll-out of this brand will

further enable a cohesive conversation with staff, stakeholders and residents, and provide an umbrella

brand which organisations can utilise to promote integration.

10

Workforce

Progress Update

A Team from the Steering Group attended the North West Regional Workforce Demonstrator site

event on 3rd November. The team presented the INT Toolkit, the Culture Club Programme and

the Staying Well Toolkit. At the event Bolton was selected as one of only two sites out of 24 sites

presenting their work at the event, for wider roll-out across the region. The Workforce Steering Group

will be reviewing its terms of reference and membership at its meeting on 4th November. The group

will also be considering the use of the WRAPT Workforce Repository and Planning Tool for long-term

strategic workforce planning for Integrated Care Services.

Key Risk and Issues

Remain the same: Staff on fixed term contracts up to 31st March 2016 will seek other opportunities if

assurance of an extension to their contract is not provided – potentially destabilising the service.

Providers are required to assure their respective staff.

Key activities for next period

Final recruitment to outstanding posts. Further Culture Club sessions planned.

Finance and Contracting

Progress Update The agreed Pooled Budget for Integration is £30.8m for 2015/16. The forecast expenditure was

estimated at £29.0m for Month 6. The forecast underspend of £1.8m is mostly attributable to

slippages in recruitment into new schemes, i.e. INTs and Intermediate Tier; and delays in project start

date for Complex Needs. However, with £802k of the P4P element of the BCF not released into the

Pool, this gives an overall forecast underspend of £1m against the revised pooled funds of £29.994m

at Month 6.

Bolton’s Q2 BCF performance is due to be reported to NHS England on 27th November 2015. The

release of £1.79m of the BCF into the Integration Pool is linked to the non-elective admissions

reduction target, i.e., Pay for Performance (P4P) funding. This P4P funding will only be released into

the Pool on a proportionate basis based on achievement of this target as set out in the BCF plan and

in accordance with BCF Guidance.

Key Risks and Issues Bolton continues to see an increase in NEL admissions. Integration schemes are not fully

implemented due to slippages in recruitment and fragmented delivery on integrated services. In spite

of various mitigating actions being taken, there is a risk that the BCF NEL target will not be achieved

this year. If Bolton delivers 2014/15 activity levels (which the CCG is currently forecasting), this would

cost the CCG an additional £3-£3.5m in 2015/16. The BCF only provides for £1.79m of this.

Therefore, the CCG would need to find an additional £1.2m-£1.7m This increase in NEL activity based

on previous year’s outturn will require close monitoring and management.

Key Activities to be completed next period Analyse Q2 performance and determine payment for performance release into the pool.

11

Estates

Key Risks and Issues

The Local Authority are currently working on the future locations of Health Visiting services within

Childrens Centres. This will free up accommodation at Waters meeting and Crompton H.C., for

integrated neighbourhood teams two and three, however this work needs to be concluded by Bolton

Council before we can implement the teams in these two locations. This is currently outside the

control of the Estates Workstream.

Source of monies for both the capital works and on-going revenue costs are yet to be confirmed – a

potential solution has been sourced (via legacy monies) this, however, may take a number of months

before it is made available to us (requires submission of a comprehensive PID).

IM&T and IG

Progress Update Detailed requirements for a short term and medium term solution have been articulated at a high level. Docman Collaborator to share care records – there are concerns about the ease of access which requires either terminal services (RDP) or citrix access. This is not feasible given the diverse stakeholder groups and Docman are currently looking in to an easier method of accessing the stored care plan possibly through a web front end. However there are no timescales as to when this might be done or even if it is possible. MIG, the business case was rejected by the CCG Exec and further analysis work needs to be undertaken before the business case can be resubmitted for consideration. Graphnet is used by the 3 Manchester CCGs for ePaCCS and shared care plans as well as for information sharing. A meeting has been arranged to review the product set. Key Risks and Issues There is currently no practical quick to implement solution for sharing of care plans. It has been

recommended that the care plans are held within the existing GP systems and INT staff attend the

practice to update.

NHS Mail has been suggested as a means of sharing the plans across the wider H&S care

economy. It should be noted that council staff should have secure email addresses:

http://systems.hscic.gov.uk/nhsmail/secure

Key Activities to be completed next period

Define processes to set up INT members on practice systems.

Define operational processes to support use of practice systems.

http://systems.hscic.gov.uk/nhsmail/secure

12

Work with Docman on proposal for easier access to Collaborator.

Further discussion with Clinical Directors.

Wigan has implemented MIG and Salford is starting their implementation. Further

investigation is required.

Bolton Health & Social Care IM&T Innovation Workshop – A technical workshop of IT leads is

to take to place on Monday 9th November to understand what systems are currently in place

and how these could be leveraged to provide a shared view of patients in Bolton. Outputs will

be a high-level systems catalogue and next steps for systems integration including the Bolton

footprint Digital Roadmap and high-level; strategy.

13

Section 5: Case Study

Client KSC is a 46 year old woman with 14 listed medical conditions who is registered disabled

and blind and has complex and multiple support needs. She is currently receiving CHC funding

and she has spent the funds on employing two full time carers. She lives with her husband and

daughter. She is very knowledgeable about her conditions and medication used to treat the

symptoms.

KSC is very intelligent and runs her own consultancy business for advice on disability matters and

is employed by NICE on committees to develop guidelines in relation to disability and re-ablement.

KSC attends specialist appointments in London every few months since the National Hospital,

London is the centre of specialism in Ehlers Danlos Hypermobility syndrome. She attends every 6

months as an NHS patient and pays privately in between for extra visits.

She is known to the local dietician since she is sometimes PEG fed and is at risk of re-feeding

syndrome.

When the Integrated Neighbourhood Team initially visited KSC, she was very frustrated that only

two specialists seemed to take her seriously and that she has had to fight so hard for every

intervention and resolution to her problems. She was extremely distressed and downhearted and

felt that she was facing battles on her own.

KSC has subsequently received a range of interventions from the INT which was led by the

Pharmacist who was her Key Worker. The outcome of which has resulted in improvements around

her medication, the fitting of ring splints to enable dexterity and assessments for equipment and

adaptions.

KSC values the INT as a group of professionals who take her needs and concerns seriously, so

much so that she recently wrote the following in a thank you letter sent to Chris Vernon: (one of the

team managers)

“Having worked on numerous guideline committees for NICE in relation to health and social care,

as well as my work with people with long term health conditions on a national basis, the lack of co-

ordination in health and social care services is a consistently frustrating theme. However, I can

only say that if all health professionals were as responsive to the needs of their clients, as your

team have been to my needs, the work of the Guideline Committees would not be necessary. I am

so glad that I have been put in touch with your service and would like to highly commend your staff

team for their fantastic service to people with complex needs in Bolton.”

14

Appendix A – Detailed Performance Report

Better Care Fund metrics BCF1. Total emergency admissions Objective: to decrease The key measure which will be used for Better Care Fund (BCF) performance payments is emergency admissions. This is now the sole measure on which the pay for performance element of the BCF will be assessed. A target reduction of 3.5% has been set, which will be assessed by comparing the period January to December 2014 with January to December 2015 (shown in Chart 1 below). In the year January to December 2014, there were 34,385 emergency admissions. A 3.5% decrease would therefore equate to 1,203 admissions in a year. In the year to date (January to September 2015), there have been 25,418 admissions, an increase of 59 from the same period in 2014. Bolton CCG’s 5 year plan target for 2015/16 is a decrease of 2.8% from 2014/15. There was a 1.8% increase from 2013/14 to 2014/15.

Chart 1 - Emergency admissions to all acute providers (all Bolton CCG patients), including BCU admissions between April 2012 – December 2013

Please note chart 1 does not include admissions to Greater Manchester West Mental Health Foundation Trust; the data source (Monthly Activity Return) contains admissions to general and acute specialties only.

2,000

2,200

2,400

2,600

2,800

3,000

3,200

3,400

Ap

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13

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13

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v-2

01

3D

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20

13

Jan

-20

14

Feb

-20

14

Mar

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14

Ap

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14

Sep

-20

14

Oct

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14

No

v-2

01

4D

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20

14

Jan

-20

15

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-20

15

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15

Ap

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15

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-20

15

Nu

mb

er

of

adm

issi

on

s

Month

Non-elective emergency admissions to all acute providers - all Bolton CCG patientsIncludes BCU admissions between April 2012 - December 2013

BCF Target Actual number of admissions Average UCL LCL

15

Chart 2 – Emergency admissions per 100,000 population benchmarked across Greater Manchester CCGs

When compared with Greater Manchester CCGs, Bolton CCG benchmarked slightly above (+0.3%) the median rate in 2014/15. As part of the Better Care Fund submission, Health and Wellbeing Boards were also asked to identify their ambitions for improvement against wider performance metrics:

Permanent admissions of older people (aged 65 and over) to residential and nursing care homes

Proportion of older people (aged 65 and over) who were still at home 91 days after discharge from hospital in to reablement/rehabilitation services (effectiveness of the service)

Delayed discharges (total number of delayed days)

Overall satisfaction of people who use services with their care and support

Referrals to home based intermediate care BCF2. Permanent admissions of older people (aged 65 and over) to residential and nursing care homes

Objective: To decrease

In the 12 months to September 2015 there were 394 permanent admissions to residential and nursing care homes in Bolton, this equated to 842.0 admissions per 100,000 population aged over 65. In the Better Care Fund submission, Bolton was set an ambition to decrease the number of permanent admissions to nursing and residential care homes (per 100,000 population) to 805.7 in 2014/15 and to reduce further to 752.6 in 2015/16. At the same time, the number of people aged over 65 in Bolton is projected to grow by 5.7% from 2013/14 to 2014/15 and by a further 2.2% in 2015/16.

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000Tr

affo

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an

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& G

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CCG

Non-elective emergency admissions per 100,000 population Greater Manchester CCGs (2014/15)

CCG Median 75th centile 90th centile

16

Chart 3 shows the number of permanent admissions to nursing and residential care homes, per 100,000 population from 2010/11 to date, along with the BCF ambition for 2015/16. Chart 3 - Admissions to nursing and residential homes - trend over time and BCF ambitions

Chart 4 shows that Bolton had the second highest rate of admissions to residential and nursing care homes in 2013/14 when benchmarked across Greater Manchester. Chart 4 – Admissions of older people to residential and nursing care homes benchmarked across Greater Manchester

BCF3. Proportion of older people (aged 65 and over) who were still at home 91 days after discharge to reablement/ rehabilitation services (effectiveness of the service)

Objective: To increase In the second quarter of 2015/16, 87.0% of patients were still at home 91 days after discharge to reablement/rehabilitation services. Chart 5 illustrates this measure over time from 2010/11 to 2015/16, along with the levels of ambition that were included in the BCF submission. The aim is to increase the proportion of people still at home 91 days after discharge to reablement to the level seen in 2012/13 (86%).

805.4 809.9793.1

858.4

825.6

854.8842.0 837.7 829.2

842.0 842.0

805.7

752.6

600

650

700

750

800

850

900

2010/11 2011/12 2012/13 2013/14 2014/15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15

Ad

mis

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,00

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Permanent admissions of older people (aged 65 and over) to residential and nursing care homes in Bolton, per 100,000 population - rolling 12 months

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1,000

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Local Authority

Permanent admissions of older people (aged 65 and over) to residential and nursing care homes, per 100,000 population (2013/14)

Local Authority rate Median 75th centile 90th centile

17

Chart 5 – Proportion of people still at home 91 days after discharge – trend over time and BCF ambitions

Please note the data in chart 5 includes social care reablement services only. Chart 6 shows that in 2013/14 Bolton had the 4th lowest value for this measure, when compared across Greater Manchester. Chart 6 – Proportion of people still at home 91 days after discharge – benchmarked across Greater

Manchester

BCF4. Delayed transfers of care (total number of delayed days) Objective: To decrease Chart 7 shows the trend in the number of delayed days for Bolton patients. A marked increase can be seen from March 2014, which is due to a change in recording at Bolton FT. The reported number of delayed days decreased between September and December 2014, the data shows an increase in January, February and March 2015, with a fall back below the average in April, May and June 2015.

52.3%

79.7%85.9%

78.5% 79.9% 79.1%87.0%

82.1%86.0% 86.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 Q1 2015/16 Q2Ad

mis

sio

ns

pe

r 1

00

,00

0 p

op

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Proportion of older people (65 and over) who were still at home 91 days after discharge to reablement/rehabilitation services (effectiveness of the service)

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Pro

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Local Authority

Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services (2013/14)

Local Authority rate Median 75th centile 90th centile

18

In the Better Care Fund submission, Bolton’s levels of ambition for 2014/15 allowed for the anticipated growth in the number of delayed transfers of care due to improved recording. The target for January to June 2015 was 321 (as shown in the chart below). The target for the remainder of 2015/16 is 308 delayed days per month. Chart 7 – Delayed transfers of care (total delayed days)

Chart 8 shows the number of delayed days over the last 12 months, broken down by attributable organisation. Over the 12 month period September 2014 to August 2015, 81% of delayed days were attributable to NHS, 14% were attributable to social care and 5% were attributable to both NHS and social care organisations. Chart 8 – Delayed transfers of care for Bolton patients, by attributable organisation

0

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Delayed transfers of care - total delayed days for Bolton patients

Target Actual total delayed days Average UCL LCL

282

286

203

187

550

560

629

313

231

315

334

328

48

71

59

76

34

30

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Sep-14

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Aug-15

Number of delayed days

Mo

nth

Delayed transfers of care (total delayed days)

Attributable to NHS Attributable to Social Care Attributable to Both

19

Chart 9 shows how the number of delayed transfers of care in Bolton compared across Greater Manchester in 2013/14. Bolton benchmarked above the Greater Manchester median rate. Chart 9 – Delayed transfers of care benchmarked across Greater Manchester

BCF5. Overall satisfaction of people who use services with their care and support Objective: to increase As part of the BCF submission, Health and Wellbeing Boards were required to select a patient experience metric. Bolton chose “overall satisfaction of people who use services with their care and support”. This metric was chosen because it is the nearest equivalent measure to a new metric which is under development for both the NHS Outcomes Framework and the Adult Social Care Outcomes Framework, “Improving people’s experience of integrated care”. The metric is the proportion of respondents who say they are "extremely satisfied" or "very satisfied" in response to the question "Overall, how satisfied or dissatisfied are you with the care and support services you receive?”. In 2013/14 Bolton scored 65.6%, which was just above the Greater Manchester median, as illustrated in chart 10. In the BCF submission, an ambition was set to reach 66.6% in 2014/15 and 67.6% in 2015/16.

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Local Authority

Delayed transfers of care (total delayed days) per 100,000 populationGreater Manchester Local Authorities 2014/15

Local Authority Median 75th centile 90th centile

20

Chart 10 - Overall satisfaction of people who use services with their care and support benchmarked across Greater Manchester

BCF6. Referrals to home based intermediate care

Objective: to increase For the Better Care Fund submission, Health and Wellbeing Board areas were required to select a local metric. Bolton chose to monitor referrals to home based intermediate care. The National Audit for Intermediate Care in 2012/13 identified that Bolton was an outlier with regard to the number of intermediate care beds commissioned and intermediate tier services are now being refocused on home based services. In 2012/13 the Greater Manchester average was 522 referrals per 100,000 population. This has been set as a target for Bolton to reach by 2015/16, which equates to 1,136 actual referrals. Chart 11 shows that Bolton exceeded this target in 2014/15. Chart 11 – Referrals to home based intermediate care

60.761.6

63.1

65.2 65.4 65.5 65.6

67.568.8

70.6

54

56

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core

Local Authority

Overall satisfaction of people who use services with their care and support (2013/14)

Local Authority score GM Median GM 75th centile GM 90th centile

505

798

1,288

1,504

967

1,136

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2012/13 2013/14 2014/15 2015/16 (est. based onQ1 & Q2) YTD = 752

Nu

mb

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als

Number of referrals to home based intermediate care in Bolton

Number of referrals BCF ambition

21

Greater Manchester and locally selected metrics A number of further metrics have been identified across Greater Manchester and locally within Bolton. GM1. A&E attendances Objective: To decrease Chart 12 shows the number of A&E attendances at all acute providers from April 2012, for Bolton CCG patients. The number of attendances decreased significantly from August 2013 to February 2014, however there was a particularly high number of attendances between March and July 2014. January and February 2015 had fewer attendances than the average. Bolton CCG’s target for 2015/16 was to decrease the number of A&E attendances by -3.2% from 2014/15. For the year to date 2015/16, attendances have reduced by -4.1% when compared to 2014/15 (equal to 1,980 fewer attendances). Chart 12 – A&E attendances across all providers

In 2014/15, Bolton had a lower than average number of attendances per 100,000 population, when compared across Greater Manchester.

5,000

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A&E attendances - Bolton CCG patients at all providers

Target Actual number of attendances Average UCL LCL

22

Chart 13 – A&E attendances benchmarked across Greater Manchester

GM2. 30 day emergency readmissions Objective: To decrease Chart 14 shows the number of emergency readmissions within 30 days of previous discharge (following an elective, day case or non-elective admission). When comparing 2015/16 YTD with the same period in 2014/15, there has been a +0.5% increase in the number of 30 day readmissions. Chart 14 – 30 day emergency readmissions for Bolton patients across all acute providers

To provide some context to the number of readmissions, chart 15 illustrates the crude readmissions rate (readmissions as a percentage of all discharges) by quarter, from Q1 2012/13 to Q2 2015/16.

0

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A&E attendances per 100,000 population Greater Manchester CCGs (2014/15)


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30 day readmissions - Bolton CCG patients at all providers

Target Actual 30 day readmissions Average UCL LCL

23

Chart 15 – 30 day readmission rate for Bolton patients across all acute providers

It should be noted that the number of readmissions shown in charts 14 and 15 includes patients who were discharged from one provider and readmitted in an emergency to a different provider, as well as patients admitted to the same provider twice. However, this measure does not include emergency admissions to Greater Manchester West Mental Health Foundation Trust, as admissions with no national tariff are excluded. There are also some further exclusions for this measure, full details of which can be found at the end of this report. Chart 16 shows the 30 day readmission rate across Greater Manchester CCGs in 2014/15. Bolton CCG was below the median readmission rate (9.2%). Chart 16 – 30 day readmission rate benchmarked across Greater Manchester

8.1%

7.6% 7.7%

8.0%

8.5%

8.9%8.4%

9.1%

9.9%

9.0% 9.3%

8.8%

9.6%9.4%

6%

7%

8%

9%

10%

11%

Ap

r -

Jun

20

12

Jul -

Sep

20

12

Oct

- D

ec2

01

2

Jan

- M

ar2

01

3

Ap

r -

Jun

20

13

Jul -

Sep

20

13

Oct

- D

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01

3

Jan

- M

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01

4

Ap

r -

Jun

20

14

Jul -

Sep

20

14

Oct

- D

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01

4

Jan

- M

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01

5

Ap

r -

Jun

20

15

Jul -

Sep

20

15

Re

adm

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on

rat

e

Quarter

30 day emergency readmission rate (% of discharges) - Bolton patients at all providers

% readmission rate

5%

6%

7%

8%

9%

10%

11%

Tam

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Traf

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Man

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30

day

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CCG

30 day emergency readmissions (crude % rate)Greater Manchester CCGs (2014/15)


24

GM4. Percentage of people who die in their usual place of residence Objective: To increase Chart 17 shows a rolling 12 month position for the proportion of deaths occurring in the person’s usual place of residence in Bolton. There has been a steady increase from 37.1% in the year 2010/11, with a slight fall in the last four data points. Chart 17 – Proportion of deaths in usual place of residence – Bolton CCG patients

In the year January 2014 to December 2014, 40.8% of deaths in Bolton occurred in the person’s usual place of residence. Bolton CCG ranked 6th across Greater Manchester, as illustrated in Chart 18.

Chart 18 – Proportion of deaths in usual place of residence – benchmarked across Greater Manchester

37.1%37.7% 37.9%

38.7% 38.8%

39.8%40.6% 40.5% 40.7%

42.3% 42.4%

43.9% 44.0%

41.4% 41.5%40.7% 40.7%

32%

34%

36%

38%

40%

42%

44%

46%

Apr '10to

Mar '11

Jul '10to

Jun '11

Oct '10to

Sep '11

Jan '11to

Dec '11

Apr '11to

Mar '12

Jul '11to

Jun '12

Oct '11to

Sep '12

Jan '12to

Dec '12

Apr '12to

Mar '13

Jul '12to

Jun '13

Oct '12to

Sep '13

Jan '13to

Dec '13

Apr '13to

Mar '14

Jul '13to

Jun '14

Oct '13to

Sep '14

Jan '14to

Dec '14

Apr '14to

Mar '15

Pro

po

rtio

n o

f d

eat

hs

in u

sual

pla

ce o

f re

sid

en

ce

Period

Proportion of deaths in usual place of residence (%) - Bolton CCG

Proportion of deaths in usual place of residence

25

30

35

40

45

50

Tam

esi

de

&G

los.

Traf

ford

Ce

ntr

al M

anc.

Salf

ord

Wig

an

Bo

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n

Sou

th M

anc.

Old

ham

No

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Man

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R

Bu

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Pro

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in u

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pla

ce o

f re

sid

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ce (

%)

CCG

Proportion of deaths in usual place of residenceGreater Manchester CCGs - Latest avaliable 12 months (to Mar'15)

Indicator Median 75th centile 90th centile

25

L1. Avoidable emergency admissions Objective: To decrease This is a composite measure of:

chronic ambulatory care sensitive conditions

acute conditions that should not usually require hospital admission

asthma, diabetes and epilepsy in children

children with lower respiratory tract infection. A full list of the conditions included can be found in at the end of this report. Chart 19 shows the trend in avoidable emergency admissions for Bolton patients across all hospital providers. There is a slight seasonal trend, with relatively more admissions in winter months (December 2013 to January 2014 and October 2014 to December 2014). Overall the trend is increasing; there was a 5.1% increase from 2012/13 to 2013/14 and a 7.4% increase when comparing 2013/14 to 2014/15. There has been a -0.7% reduction YTD in 2015/16 when compared to the same period in the previous year.

Chart 19 – avoidable emergency admissions to all providers

It should be noted that the types of conditions which are included in this measure could in the past have been admitted to the Bolton Community Unit, which closed in December 2013.

0

100

200

300

400

500

600

700

800

900

Ap

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01

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20

12

Sep

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12

Oct

-20

12

No

v-2

01

2D

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20

12

Jan

-20

13

Feb

-20

13

Mar

-20

13

Ap

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01

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13

Sep

-20

13

Oct

-20

13

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v-2

01

3D

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20

13

Jan

-20

14

Feb

-20

14

Mar

-20

14

Ap

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01

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4Ju

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4Ju

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20

14

Sep

-20

14

Oct

-20

14

No

v-2

01

4D

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20

14

Jan

-20

15

Feb

-20

15

Mar

-20

15

Ap

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01

5M

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5Ju

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5Ju

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01

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15

Sep

-20

15

Nu

mb

er o

f ad

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ns

Month

Avoidable emergency admissions for all Bolton CCG patients to any provider

Number of admissions Average Upper control limit Lower control limit

26

Chart 20 illustrates how Bolton compares across Greater Manchester. Data for the latest available 12 month period (October 2012 – September 2013) shows that Bolton had the second lowest rate of avoidable admissions across Greater Manchester. Chart 20 – Avoidable emergency admissions benchmarked across Greater Manchester

L2. Average length of stay (non-elective) Objective: To decrease In the year 2013/14, the average length of stay for an emergency admission across all hospital providers was 5.1 days for Bolton CCG patients. The target for 2014/15 was 4.8 days, however the average length of stay in 2014/15 was sustained at 5.1 days. Average length of stay has fallen since June 2015, for the year to date 2015/16 the average length of stay is 4.4 days. Chart 21 – Average length of stay for emergency admissions across all providers

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

Traf

ford

Bo

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Bu

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Man

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Sto

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ort

Old

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Ro

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ale

Tam

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Ind

ire

ct s

tan

dar

dis

ed

rat

e

CCG

Avoidable emergency admissions per 100,000 populationGreater Manchester Local Authorities - Oct 2012 - Sep 2013

Median 75th centile 90th centile

3.5

4.0

4.5

5.0

5.5

6.0

6.5

Ap

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12

Sep

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12

Oct

-20

12

No

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01

2D

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20

12

Jan

-20

13

Feb

-20

13

Mar

-20

13

Ap

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01

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01

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01

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13

Sep

-20

13

Oct

-20

13

No

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01

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20

13

Jan

-20

14

Feb

-20

14

Mar

-20

14

Ap

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01

4M

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01

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20

14

Sep

-20

14

Oct

-20

14

No

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20

14

Jan

-20

15

Feb

-20

15

Mar

-20

15

Ap

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01

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20

15

Sep

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15

Ave

rage

len

gth

of

stay

(d

ays)

Month

Average length of stay for emergency admissions - Bolton CCG patients at all providers

Annual target Average length of stay Average UCL LCL

27

Chart 22 illustrates how Bolton CCG benchmarks against other Greater Manchester CCGs for average non-elective length of stay. In 2014/15, Bolton CCG was above the Greater Manchester median length of stay. Chart 22 – Average length of stay for emergency admissions benchmarked across Greater Manchester

L3. Emergency admissions due to falls and fall related injuries (over 65s) Objective: To decrease Chart 23 illustrates the number of emergency admissions for Bolton patients aged 65 years and over, to any hospital provider, with a fall related injury. Overall there is an increasing trend in the number of falls admissions. Comparing 2014/15 with 2013/14, the number of admissions increased by 23%, from 730 in 2013/14 to 900 in 2014/15. There have been 12 more admissions in the year to date 2015/16 when compared with 2014/15, an increase of 2.9%. It should be noted however that the closure of the BCU in December 2013 may affect these figures, as this cohort of patients may have been treated in BCU in the past.

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

Salf

ord

Sou

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anch

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r

Cen

tral

Man

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ter

Traf

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No

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Man

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Bu

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Bo

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Tam

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de

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loss

op

30

day

re

adm

issi

on

s ra

te

CCG

Average length of stay (non-elective)Greater Manchester CCGs (2014/15)


28

Chart 23 – Emergency admissions due to falls and fall related injuries.

Chart 24 shows how Bolton CCG compares across Greater Manchester for the number of falls admissions per 1,000 population aged over 65. In the year 2014/15 Bolton had the third lowest rate of falls admissions across all Greater Manchester CCGs. Chart 24 – Emergency admissions due to falls and fall related injuries benchmarked across Greater Manchester

0

20

40

60

80

100

120

Ap

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01

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12

Sep

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12

Oct

-20

12

No

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01

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20

12

Jan

-20

13

Feb

-20

13

Mar

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13

Ap

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13

Sep

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13

Oct

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13

No

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20

13

Jan

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14

Feb

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14

Mar

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14

Ap

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Sep

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14

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No

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Jan

-20

15

Feb

-20

15

Mar

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15

Ap

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Sep

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15

Nu

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Month

Emergency admissions due to falls and fall related injuries at all providers (patients aged 65 and over)

Number of admissions Average Upper control limit Lower control limit

0

5

10

15

20

25

30

Tam

esi

de

&G

loss

op

Bu

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Bo

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0 p

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CCG

Emergency admissions due to falls and fall related injuries at all providers Patients aged 65 and over - 2014/15 - Greater Manchester CCGs


29

L4. Proportion of patients who experience harm-free care Objective: to increase Chart 25 shows the proportion of patients who experienced harm-free care at Bolton NHS FT between April 2013 and September 2015. This measure is taken from the NHS Safety Thermometer, which records the presence or absence of four harms: pressure ulcers, falls, urinary tract infections (UTIs) in patients with a catheter, new venous thromboembolisms (VTEs). The target, set nationally, is to achieve 95% harm-free care. Chart 25 also shows the monthly harm-free care achievement for all Greater Manchester Trusts combined. Chart 25 – Patients experiencing harm-free care at Bolton NHS FT

L5. Number of people aged 65 and over receiving residential care, nursing care and community based services

Chart 26 shows the number of people aged 65 and over receiving residential care, nursing care and community based services in Bolton. The numbers represent a snapshot at quarter end. The total number of people receiving the service at any point in 2014/15 was 3,402.

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

Ap

r-2

01

3

May

-20

13

Jun

-20

13

Jul-

20

13

Au

g-2

01

3

Sep

-20

13

Oct

-20

13

No

v-2

01

3

De

c-2

01

3

Jan

-20

14

Feb

-20

14

Mar

-20

14

Ap

r-2

01

4

May

-20

14

Jun

-20

14

Jul-

20

14

Au

g-2

01

4

Sep

-20

14

Oct

-20

14

No

v-2

01

4

De

c-2

01

4

Jan

-20

15

Feb

-20

15

Mar

-20

15

Ap

r-2

01

5

May

-20

15

Jun

-20

15

Jul-

20

15

Au

g-2

01

5

Sep

-20

15

% h

arm

fre

e ca

re

Month

Proportion of patients who experience harm free care at Bolton NHS FT

Bolton Foundation Trust All Greater Manchester Trusts Target

30

Chart 26 - Number of people aged 65 and over receiving residential care, nursing care and community based services

L6. Proportion of people using social care receiving direct payments Objective: to increase Chart 27 shows the proportion of people using social care receiving direct payments at year end. Chart 27 – Proportion of people using social care receiving direct payments

2,681

2,654

2,699

2,7332,723

2,741

2,600

2,620

2,640

2,660

2,680

2,700

2,720

2,740

2,760

2013/14 2014/15Q1

2014/15Q2

2014/15Q3

2014/15Q4

2015/16Q1

2015/16Q2

Nu

mb

er

of

pe

op

le

Number of people aged 65 and over receiving residential care, nursing care and community based services

28.9%

31.4%

32.2%

25%

27%

29%

31%

33%

35%

2013/14 2014/15 2015/16Q1

2015/16Q2

Pro

po

rtio

n

Proportion of people using social care receiving direct payments

31

L7. The proportion of older people aged 65 and over offered reablement services following discharge from hospital Objective: to increase The number of older people offered reablement services following discharge from hospital as a proportion of all discharges (people aged 65 and over). The full year figure for 2014/15 was 4.3%. L8. Percentage of people finishing Intermediate care or reablement who have a reduced package of care Objective: to increase Data to follow L9. Percentage of people finishing reablement or intermediate care who have no package of care Objective: to increase Data to follow L10. Health-related quality of life for carers Objective: to increase Chart 29 shows the latest available health-related quality of life scores for Bolton CCG and its statistical peers, taken from the 2013/14 GP Patient Survey. Bolton had the fifth lowest score out of the 16 statistical peer organisations. The score has been relatively consistent over the last three years: In 2011/12 Bolton scored 0.786, in 2012/13 the score was 0.792 and in 2013/14 Bolton’s score was 0.78. Chart 29 – Health-related quality of life for carers – average health status scores

0.7

8

0.73

0.74

0.75

0.76

0.77

0.78

0.79

0.8

0.81

0.82

St. H

ele

ns

Salf

ord

Bra

dfo

rd

Tam

esi

de

Bo

lto

n

Old

ham

Ro

the

rham

Wig

an

Wak

efi

eld

Bu

ry

Ro

chd

ale

San

dw

ell

Wal

sall

Co

ven

try

Kir

kle

es

Du

dle

yDir

ect

ly s

tan

dar

dis

ed

ave

rage

he

alth

sta

tus

sco

re

Local Authority

Health-related quality of life for carers (April 2013 - March 2014)

Local Authority score Median 75th centile 90th centile

32

L11. Carer reported quality of life Objective: to increase Chart 30 shows quality of life scores for carers in Bolton, as reported in the biennial carers’ survey. In 2012/13, when the survey was last carried out, Bolton had the 4th highest scores among it statistical peer organisations. Chart 30 – Carer reported quality of life

L12. People feeling supported to manage their condition

Objective: to increase

Chart 31 shows the percentage of people who answered “yes” to the following question in the GP

Patient Survey:

“In the last 6 months, have you had enough support from local services or organisations to help

you to manage your long-term health condition(s)?”

Bolton CCG had the highest proportion of patients responding positively (68.0%) when compared

across Greater Manchester CCGs. This measure has been relatively consistent over the last three

years.

6.5

7

7.5

8

8.5

9

Wal

sall

Old

ham

Co

ven

try

Kir

kle

es

Salf

ord

Wig

an

San

dw

ell

Wak

efi

eld

Tam

esi

de

Ro

chd

ale

Du

dle

y

Bra

dfo

rd

Bo

lto

n

Bu

ry

St. H

ele

ns

Ro

the

rham

Qu

alit

y o

f lif

e s

core

Local Authority

Carer reported quality of life (2012/13)

Local Authority score Median 75th centile 90th centile

33

Chart 31 – proportion of people feeling supported to manage their condition

L14. Reducing the gap in life expectancy between Bolton and the England average Objective: to decrease Life expectancy in Bolton is currently 76.5 years for men and 80.6 years for women. The gap in life expectancy between Bolton and England now stands at 2.1 years for men and 2.0 years for women. Chart 32 illustrates this gap between Bolton and England. Chart 32 – Life expectancy at birth – Bolton vs. England

60

.5%

62

.3%

62

.5%

63

.6%

63

.7%

64

.6%

64

.7%

64

.8%

65

.3%

65

.8%

67

.8%

68

.0%

50%

52%

54%

56%

58%

60%

62%

64%

66%

68%

70%N

ort

hM

anch

este

r

Ce

ntr

alM

anch

este

r

Sou

thM

anch

este

r

HM

R

Tam

esi

de

an

dG

loss

op

Sto

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ort

Traf

ford

Bu

ry

Salf

ord

Old

ham

Wig

anB

oro

ugh

Bo

lto

n

Pe

rce

nta

ge f

ee

ling

sup

po

rte

d

CCG

People feeling supported to manage their condition (aggregated data Jan-Mar '14 and Jul-Sep '14)

CCG England Greater Manchester

76.5

80.6

78.6

82.6

73

74

75

76

77

78

79

80

81

82

83

84

Male Female

Life

exp

ect

ancy

(ye

ars)

Life expectancy at birth: Bolton vs. England

Bolton England

2.1 year gap

2.0 year gap

34

L15. Reducing the gap in life expectancy across Bolton Objective: to decrease

Within Bolton there is a significant gap between the most deprived and least deprived areas. The most deprived decile in Bolton has a life expectancy of 69.2 years for men and 74.8 years for women. The least deprived decile in Bolton has a life expectancy of 81.7 years for men and 85.2 years for women. This is a gap of 12.5 years for men and 10.4 years for women, as illustrated in chart 33. Chart 33 – Life expectancy at birth – gap within Bolton

69.2 74.881.7 85.250

55

60

65

70

75

80

85

90

Male Female

Life

exp

ect

ancy

(ye

ars)

Life expectancy at birth within Bolton

Bolton averageMost deprived decile Least deprived decile

12.5 year gap

10.4

year gap

35

KPI Definitions

L1. Avoidable emergency admissions

The avoidable emergency admissions measure is a composite measure of four categories:

Chronic ACS conditions (adults), including: o COPD/ emphysema o Atrial fibrillation and flutter o Heart failure o Asthma o Angina o Epilepsy o Diabetes o Anaemia o Bronchiectasis o Hypertension

Acute conditions not normally requiring admission (adults), including: o Urinary tract infections o Pneumonia o Gastroenteritis o Cellulitis o Convulsions o Gastro-oesophageal reflux disease (GORD) o Viral intestinal infection o Tubulo-interstitial nephritis not spec as acute or chronic o Tonsillitis o Volume depletion o Cutaneous abscess, furuncle and carbuncle

Children with lower respiratory tract infections (LRTIs), including: o Bronchiolitis o Pneumonia o Influenza

Asthma, diabetes and epilepsy in under 19s

GM2. 30 day emergency readmissions

The following exclusions apply to the 30 day readmissions KPI:

Excludes spells with a primary diagnosis of cancer

Excludes spells with an obstetrics HRG

Excludes patients aged under 4

Excludes patients who self discharged from the initial admission

Excludes spells which do not have a national tariff

Where a readmission rate is shown, the following exclusions apply to the denominator:

Excludes spells which do not have a national tariff

Excludes patients aged under 4

Excludes spells where the patient died.

36

Data Sources

KPI Data Source Comments

Better Care Fund Indicators

BCF1. Emergency admissions Monthly Activity Return (MAR)

BCF2/ GM4. Permanent admissions of older people (aged 65 and over) to residential and nursing care homes

Adult Social Care Outcomes Framework (ASCOF)/ CareFirst

BCF3. Proportion of older people (aged 65 and over) who were still at home 91 days after discharge from to reablement/ rehabilitation services

Adult Social Care Outcomes Framework (ASCOF)/ CareFirst

BCF4. Delayed transfers of care (total number of delayed days)

Unify

BCF5. Overall satisfaction of people who use services with their care and support

Adult Social Care Outcomes Framework (ASCOF)

BCF6. Referrals to home based intermediate care National Audit for Intermediate Care (NAIC)

Greater Manchester Indicators

GM1. A&E attendances Patient Level SLAM/ SUS

GM2. 30 day emergency readmissions Patient Level SLAM/ SUS

GM3. See BCF2. -

GM4. Increasing the percentage of people that die in their usual place of residence.

ONS, via National End of Life Care Intelligence Network

Local Indicators

L1. Avoidable emergency admissions Patient Level SLAM/ SUS

L2. Average length of stay (non-elective) SUS

L3. Reducing the number of admissions due to falls and fall related injuries (over 65s)

Patient Level SLAM/ SUS

L4. Increasing the proportion of patients who experience harm free care

NHS Safety Thermometer

L5. Number of people aged 65 and over receiving residential care, nursing care and community based services

CareFirst

L6. Proportion of people using social care receiving direct payments

CareFirst

L7. Increasing the percentage of people receiving reablement or intermediate care at the point of discharge

TBC

L8. Increasing the percentage of people finishing Intermediate care or reablement who have a reduced package of care

Bolton Council

L9. Increasing the percentage of people finishing reablement or intermediate care who have no package of care

Bolton Council

L10. Improved health-related quality of life for carers

HSCIC/ GP Patient Survey

L11. Improved carer reported quality of life HSCIC/ Carers’ survey

L12. People feeling supported to manage their condition

HSCIC/ GP Patient Survey

L13. See BCF5. -

L14. Reducing the gap in life expectancy between Bolton and the England average

Public Health Intelligence Team

L15. Reducing the gap in life expectancy across Bolton

Public Health Intelligence Team

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