nhs nottingham city · wards. ecip (national improvement team for emergency care) are coming into...

NHS Nottingham City Clinical Commissioning Group GB 249/16 Governing Body – 27 July 2016

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NHS Nottingham City

Performance Report

July 2016


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Contents

1.1 NHS Constitution indicators ............................................................................................................................................................. 3

2. Provider Specific Reports:…………………………………………………………………………………………………………………….14

2.1 Nottingham University Hospitals - Performance ............................................................................................................................ 14

2.2 East Midlands Ambulance Trust, NHS 111 and Arriva Transport .................................................................................................. 17

2.4 Nottinghamshire Healthcare Trust - Summary Monitor Dashboard ................................................................................................ 19

2.5 Nottingham NHS Treatment Centre - Performance Dashboard ..................................................................................................... 20

2.6 City Care Partnership Performance Report ................................................................................................................................... 21

2.7 Urgent Care Centre ........................................................................................................................................................................ 23


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1.1 NHS Constitution indicators

Note: Performance figures for IAPT services are not available due to data certification issues. These issues are expected to be resolved in the next 6 weeks. The latest published data is for April 2016.


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Exceptions A&E Waiting Times

The national standard is that 95% of patients should be treated within 4 hours. Performance is measured by combining figures for A&E at Nottingham University Hospital with the Urgent Care Centre to give a representative figure for Greater Nottingham. In May 2016 NUH reported a performance figure of 75.0% and the Urgent Care Centre 95.8%. Unaudited data suggests performance at NUH fell to 71% in June The 4 hour target has been affected by a number of constraints on flow over the month which has resulted in patients waiting in the ED department each morning for admission into the acute medicine assessment areas. This significantly impacts on the waiting times to be seen within the department as ED staff are having to manage these additional patients on top of dealing with the new arrivals into the department. This has led to high volumes in the department at certain times, particularly after surges in attendances further impacting on the wait to be seen. A revised system recovery plan is in place and a new RAP has been agreed with NUH to focus on key metrics involved with flow such as achievement of the SAFER bundle across NUH wards. ECIP (national improvement team for emergency care) are coming into the system in August to conduct a diagnostic to see what other opportunities exist for re-establishing flow across the system. The Charts below show Performance, attendances and breaches at NUH from April 2015.


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Category A (Red 1 and 2) – 8 minute response time Category A calls relate to conditions that may be immediately life threatening. The national target is that 75% of cases should receive a response within 8 minutes, irrespective of location. Red 1 performance for May 2016 for the CCG was 80.2%, for EMAS it was 59.8%. Red 2 performance for the CCG was 67.8%, for EMAS it was 67.3%. The Charts below show Performance, attendances and breaches for EMAS from April 2015.

Category A 19 minute transportation time The national standard is that calls involving presenting conditions which may be immediately life threatening should receive an ambulance within 19 minutes in 95% of cases. For the CCG performance in May 2016 was 96%, for EMAS it was 87.2%. The Charts below show Performance, attendances and breaches for EMAS from April 2015


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EMAS Performance Reasons for EMAS non-performance include:

Demand

- Increased red activity (overall and via NHS 111)

Resource availability

- workforce sickness rates

Reduced Capacity

- Hours lost due to ambulance turnaround & handovers

- Impact of resource ‘drift’ across the region

Contractual response Non-performance has been formally raised by lead commissioners (Hardwick CCG) and this is managed through the contract performance groups. At a senior level this is via the Partnership Board and via the Nottinghamshire Contract Collaborative Meeting at a local level. For 16/17 CCGs have agreed to support EMAS by taking financial responsibility for any ambulance turnaround time breaches over 60 minutes. The contractual agreement for 16/17 also includes the provision of a local recovery plan and trajectory for each County.

Quarterly commissioner only meetings have now been put in place to allow commissioners across the counties to develop plans and share learning in relation to EMAS performance.

Recovery Plan Status The recovery action plan will be updated through the PMO function at EMAS and monitored through their Intensive Support Board. Any exceptions will be

pulled out and escalated to the EMAS Executive Team meetings for action which happen weekly.

Within the 16/17 contract, CCGs have agreed an improvement trajectory across the region as it is expected that EMAS will not deliver national standards in

16/17. This trajectory was delivered for April but it is expected that it will not be delivered in June which will mean the development of a remedial action plan

across the region detailing actions for delivery of the trajectory.

Locally, there is a county level performance trajectory that will be monitored through the partnership board and local CCMs.

The trajectories are minimum levels and failure to achieve any of them will result in General Condition 9 Contract Management being enacted, which will

result in either a Remedial Action Plan or an Immediate Action Plan. We are aiming to see national performance standards at least by a regional level by

the end of the year and would certainly be looking for them next contractual year.


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CCG Assurance

Nottingham City CCG will seek assurance against delivery through the lead contracting arrangements for EMAS on a regional level and, at a local level, will

monitor performance in the South Nottinghamshire area through the local delivery plan and collaborative commissioning arrangements. System Resilience

group (SRG) will also have sight of performance data in order to understand pressures across the urgent care system and develop solutions. Demand

pressures through 111 are raised through the 111 contractual processes for resolution as necessary. Commissioners locally continue to review relevant

data and, in conjunction with the provider, develop and identify areas of service improvement.

Locally, an Ambulance Turnaround group has been set up in order to review ATT performance which contributes to EMAS performance through lost hours

on the road. There are currently trials in place for a dedicated ambulance turnaround bay in order to support quicker turnaround. So far, this has proved

successful but will need to be made sustainable.

Hardwick Commissioners are leading the procurement of a strategic review of EMAS that will focus on demand, capacity and cost at a regional and STP

level. This will highlight current gaps in service, detail areas of improvements for EMAS and opportunities for investment that yield a positive ROI.

EMAS will also receive turnaround support and have appointed a turnaround director to focus on recovery of performance in year.


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Cancer Two Week Waits The national standard is that 93% of patients with suspected cancer who are referred by their GP are seen by a consultant within 14 days of referral. Performance in the month improved slightly from 92.5% in April 2016 to 92.8% in May 2016, mostly due to performance issues at Nottingham University Hospitals. NUH claim to have sufficient capacity and that performance issue is due to patient choice. NUH and CCG are looking at measures that would allow the waiting time clock to be paused if patient is on holiday. A Recovery Action Plan is in place which targets tumour sites with most breaches (breast, upper and lower GI). Performance at NUH met target in May 2016. The charts below are for Nottingham City patients from April 2015.


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Two week wait for breast symptoms (where cancer was not initially suspected) The national standard is that 93% of patients with suspected cancer who are referred by their GP are seen by a consultant within 14 days of referral. All Nottingham City patients in the month were seen at NUH. Five breaches were recorded and the breach reason for each was that the patient could not attend the offered appointment. Work is continuing with practices that have the highest number of breaches to ensure that patients realise their referrals are urgent. The CCG is also exploring a process whereby referrals for patients on holiday within 2 week window are held by CAS until patient returns. The charts below are for Nottingham City patients from April 2015.


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Cancer – 62 days from urgent referral to treatment The national standard is that 85% of patients who are diagnosed with cancer following an urgent GP referral receive their first treatment within 62 days of that referral. Nottingham City patients are usually treated at Nottingham University Hospitals or the Treatment Centre. In May 2016, performance fell to 77.2% with 13 breaches recorded for the 57 patients treated. 53 patients received their first treatment at Nottingham University Hospitals with 13 patients receiving their first treatment after 62 days. The breakdown of reasons for the 13 breaches is as follows: 6 - Due to complex medical needs 4 - Due to patient initiated delays 3 - Due to capacity issues Four patients received their first treatment at the Treatment Centre, all within 62 days. NUH is seeking additional MRI capacity from Ramsey and The Park and is considering a mobile scanner. Risk areas are Lung, Upper GI and Lower GI. Remedial Action Plan is to be enhanced to include MRI capacity and 1 stop lung cancer diagnostic clinic.


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Cancer – 62 days to treatment – screening The national standard is that 90% of patients who are diagnosed with cancer following referral from a cancer screening service receive their first treatment within 62 days of that referral. Nottingham City patients are usually treated at Nottingham University Hospitals. In May 2016 performance fell to 80% with one breach recorded out of five patients treated. This delay was due to a patient delaying an initial diagnostic procedure.


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Early Intervention in psychosis The national standard is that 50% of people experiencing a first episode of psychosis are treated with a NICE recommended package of care within two weeks of referral. This indicator was monitored in 2015/16 and has now become a national target.

In May the number of Incomplete Pathways has fallen by 10 to 54 and of the completed Pathways, 100% had been waiting 12 weeks or more (which has not always been the case in past months). When looking at the shape of the waiting list over the 4 reported months the high demand for the service in Jan & Feb (those waiting 8 weeks or less in Feb) is now working its way through to the 12+ weeks waiters, with the new demand (0-8 weeks in May) being comparatively low. The externally commissioned EIP review has been delayed further. The issues with the report have been escalated to Directors at Mental Health Strategies who are conducting the review. It is hoped the issues will be resolved by the end of the week and the report can be discussed at the Contract Strategic Clinical Board in July as planned.


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2. Provider Specific Reports:

2.1 Nottingham University Hospitals - Performance

Target Commentary Actions being taken to improve performance

Total Time in A&E Performance in May 2016 fell to 75.0%

See actions on page 4.

Cancer – 62 day Urgent Referral to Treatment

Performance fell to 78.8% in May 2016. 33 Accountable breaches were recorded. 27% of accountable reaches were due to late tertiary referrals. Most other delays were due to clinical or complexity issues

A recovery Action Plan is in place which targets main breach reasons and tumour sites with most breaches (Diagnostics, Endoscopy in particular, Lung, Upper and Lower GI). NUH particularly focusing on endoscopy waits with increased capacity in the private sector being utilised. NUH is seeking additional MRI capacity from Ramsey and The Park and is considering a mobile scanner. Risk areas are Lung, Upper GI and Lower GI. Remedial Action Plan is to be enhanced to include MRI capacity and 1 stop lung cancer diagnostic clinic.

Cancer – screening 62 day wait

Performance fell to 87.2% in May 2016. Four breaches were recorded.

Two breaches were attributed to late tertiary referrals, one was due to patient initiated delays and one was due to capacity issues in lower GI surgery


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A&E Performance – Peer Group The graph below shows performance for NUH,peer trusts and England for A&E performance. The latest national monthly performance figures are for May 2016.


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2.2 East Midlands Ambulance Trust, NHS 111 and Arriva Transport


East Midlands Ambulance Service – Breaches

Target was missed in all three performance categories.

See comments pages 5-6

Arriva - Arrival Times at Point of Care

Performance in May 2016 remained below target

Non-performance of arrival and departure times is related to the timeliness and complexity of bookings. This is exacerbated by increased activity through increasing supported discharge patients who often require transport and an increase in renal patients requiring dialysis. During peak times, Arriva have provided additional commissioned transport crews to support achievement of targets, implemented in the afternoon to hit peak discharge times. On a daily basis, Arriva are now escalating any issues relating to capacity to deliver via the urgent care midday call. This ensures issues are flagged in a timely manner and commissioners can respond accordingly. In relation to specific issues around patients requiring renal dialysis, Nottingham City has commissioned a renal co-ordinator to support the co-ordination of patient transport for this cohort.

Arriva - Departure Times from Point of Care

Performance in both indicators remained below target


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Performance is managed through the collaborative contract arrangements, managed by GEM CSU.

NHS111 - % Calls answered

85.2% of calls were answered within 60 seconds in May 2016

Dispositions to A&E and ambulance dispatch are dependent upon the need of the patient presenting and is driven by the clinical decision support system (NHS Pathways) used by 111 to determine the appropriate outcome. These areas have been recognised by DHU and additional staff training has been identified to ensure that call handlers are applying the Pathway criteria appropriately. Locally, Nottinghamshire hold a call review meeting as part of the clinical governance arrangements to review selected 111 calls to identify areas of improvement. Under the urgent care vanguard, work is taking place to implement direct bookings from 111 to services including ED to support appropriate referrals. The NHS 111 % of calls answered within 60 seconds target was not met due to increases in demand without the appropriate capacity. DHU also reference an increase in staff absence due to annual leave. Staff are currently unable to take leave at peak times –DHU are currently investigating ways of managing staff leave that reduces this impact i.e. leave arrangements following employment dates vs. financial year. The issue of attrition of staff due to the re-tendering of the contract was also raised in May 2016. Although on a monthly basis, 95% performance is not consistently being achieved, we are seeing a steady increase in performance from March 2016 and it is expected that 95% performance is achieved in July. 111 performance is managed through monthly collaborative contract meetings and a weekly exception report is prepared by DHU highlighting, on a daily basis, the reasons for non-performance and mitigating actions. Future learning is also noted and implemented to reduce occurrences. Locally, Nottingham is investigating early transfer of 111 nurse queue calls to out of hours provider to reduce pressure on 111 system when busy.

NHS111 - % ambulance dispatches

11.0 % of calls had ambulances dispatched in May 2016

NHS 111 - % recommended to attend A&E

8.3% of callers were recommended to attend A&E in May 2016


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2.3 Nottinghamshire Healthcare Trust - Summary Monitor Dashboard


Early Intervention in psychosis

14.3% of patients were treated within 2 weeks in May 2016

Of the five EIP teams across Nottinghamshire, three are not achieving the target and these are the City (where demand is 25% higher than allocated resources), County South and Mansfield and Ashfield. The first draft of the external review was completed; however it has been returned by the Commissioners and the final iteration is expected mid-June. Discussions will be held between Commissioners and the Trust regarding its recommendations and the level of investment required. It is anticipated that the Trust will start achieving the standard across all five teams from Quarter 3 2016/17.


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2.4 Nottingham NHS Treatment Centre - Performance Dashboard

All performance indicators were rated as “Green” in May 2016.


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2.5 City Care Partnership Performance Report

Historically, City Care waiting standards have been monitored against median waits. In an effort to bring consistency to reporting this is being switched to percentage achievement. There will be a delay before all services are able to report in this way. Services which still report using the median wait calculation are marked with a *.


Care homes nursing team

Performance fell to 66% in May 2016

The median waiting time was within the 3 hours target at 2.5 hours and the longest wait incurred was 5 hours. 153 new assessments were carried out in May which is over 50% more than in April. Performance will be reviewed until August data and an action plan developed if no improvement.

Community Stroke Discharge and Rehab service

Performance improved to 58% in May 2016

CityCare have reported that there is a difficulty interpreting the definition of the waiting time target for when someone is identified as being appropriate for discharge from NUH and that it is currently unclear when to 'start the clock'. There service is currently looking at data reporting mechanism to support accurate reporting. An action plan is in place to report back in September.

Home Safety Equipment and Review pilot (10 days)

Performance fell to 12 days in May 2016

The performance has improved from April. 108 equipment installations were delivered in May compared to 78 in April.


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Nutrition and Dietetics Paediatrics (20 days)


The service has breached for the 2nd month running. There is work being progressed to increase take up of the food allergy pathway to encourage more generalist staff to undertake the initial work before a referral to the specialist service is made. The service has delivered 40 more contacts than in April. Performance will be reviewed for 3 months and an action plan developed if no improvement.

Adult SLT Performance improved to 22 days in May 2016

The service has identified a capacity gap of 1.1wte and has approached the CCG for consideration of additional monies. The service is also working with the commissioner to revise activity and waiting times targets.

Community MSK (PT)/ Community MSK (OT)

Performance remained at 39 days in May 2016

Demand for the service continues to grow. There is a service redesign being undertaken currently following the CCG decision not to award any additional recurrent monies to the service.

Community Neurology

Performance remained at 70% in May 2016

16 out of 23 patients were seen within the 20 days target. Due to the low numbers, the percentage achievement is affected greatly. The median waiting time is 10 days which is within target.

Continence service (Adults)


The service is delivering 32% more activity for City CCG at month 2 16-17 compared to month 2 in 15-16. The service met the target last month. The specification is being reviewed currently and CityCare are looking at the clinics and availability of appointments for the whole service to improve access and choice.

Continence service (Paediatrics)

Performance improved to 105 days in May 2016

CityCare have confirmed the non-recurrent monies required to implement the group parental education sessions which should reduce waiting times. City CCG need to request the funding through EMT before the improvements will be seen.

Neighbourhood teams

Performance fell to 82% in May 2016

The service has just missed out on the target for month 2 having achieved target in April. The median wait is 20 days. The service is not reporting a capacity issue so performance will be reviewed for the next 3 months.


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2.6 Urgent Care Centre

The Urgent Care Centre opened in October 2015. Detailed monitoring is received on a monthly basis and has been used to populate the graphs below which show the utilisation of the Urgent Care Centre against the initial targets set.


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