barnet clinical commissioning group...2016/11/24 · barnet clinical commissioning group governing...

Barnet Clinical Commissioning GroupGoverning Body Performance and Quality Report

September 2016

working together with the Barnet population to improve health and well-being

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Executive summary

Referral To Treatment (RTT)Preliminary data shows that BCCG RTT compliance was achieved in September 2016. RF(L) as the main provider for BCCG achieved the RTT standard consistently. However ongoing delivery of the waiting time standards

remains a concern. In particular, with RF(L) reducing outsourcing of activity, there is a risk that their own capacity may not be sufficient. This will be monitored closely via the Task and Finish Group Meeting. The RF(L)

Contract Performance Notice (CPN) will remain open until the RAP is successfully delivered.

RNOH failed the RTT target in August 2016. A CPN was issued by NHSE Specialist commissioning team in August 2016. As a consequence, RNOH have submitted a revised RTT trajectory, which shows compliance by February

2017.

Cancer Waiting TimesBCCG did not achieve two out of eight Cancer Waiting Times (CWT) targets in September 2016. The non- compliant CWT targets were the 62 day Cancer Waiting Times and 62 day Canmcer Screening Service target.

UCLH and Camden CCG have commissioned a joint review of Cancer services due to under performance of the Cancer Waiting Times targets . The review has informed recovery actions plans for each of the non-compliant

pathways.

The RF(L) have implemented a range of improvements including ‘straight to CT’ for lung, ‘straight to Endoscopy’ at the Barnet site, hot reporting for the prostate clinic and increased theatre capacity for renal patients.

However, there is a continuing risk that that December 2016 trajectory will not be met. This situation is being closely monitored across the whole NCL area.

The revised RNOH Cancer Trajectory identifies compliance to the constitutional standards by November 2016. Progress against this plan is reviewed closely and a follow-up meeting was held on the 4th November.

Accident and Emergency and Ambulance HandoversBCCG did not meet the A&E Target in August 2016 and performance remains challenged across the NCL area. Barnet and Enfield A&E delivery board submitted plans to NHSE in October 2016, for the five mandated A&E

improvement schemes.

RF(L) is launching a recovery programme based on the principles of NHSE ‘Safer, Faster and Better’ guidance which covers the main areas of improvement recommended by NHS I. This includes implementation of the SAFER

bundle across hospitals and Discharge to Assess pathways.

DiagnosticsPreliminary data shows that BCCG achieved the standard for diagnostic waiting times in September 2016. The RF(L) continued to perform well, UCLH is progressing on implementing their RAP through the work with

McKinsey.

Central London Community Health Care NHS Trust (CLCH)Commissioners are currently considering issuing performance notices for MSK and Children’s Occupational Therapy Services delivered by CLCH. CLCH presented their plan to improve MSK waiting times at the contact

management group on the 3rd November.

Improving Access to Psychological Therapies (IAPT)BCCG performance for the access target for Q1 is below target. A Recovery Action Plan was submitted by Surrey and Borders (SABP) in October 2016, which sets out a recovery trajectory for a return to compliance by

November 2016. Plans are being considered for services to be delivered at Finchley Memorial Hospital for two days a week which will improve the access rate.

The BCCG ‘recovery rate’ for Q1 is below target in Q1. A recovery action plan submitted by SABP in October 216 sets out a return to compliance by January 2017.

Barnet, Enfield and Haringey Mental Health NHS Trust (BEHMHT)Commissioners and BEHMHT have agreed the data requirements for the deep dive into the Adult Emergency Mental Health pathway. BEHMHT data will be available during November 2017 and a task and finish group is

being established. ECIST colleagues have offered advice on applying the ECIST capacity and demand model in mental health services.

Early Intervention in Psychosis (EIP)BEHMHT failed the two week referral to treatment time for August 2016 but are currently unable to offer a NICE complaint service to workforce and capacity issues to meet the significant increase in demand. There will be

further discussions about the resources required to meet the NICE compliant element of the standard.

Access standards

7 8 9 10 11 12 13 14 15 16 17 18

Target Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16

AS01Percentage of incomplete pathways within 18 weeks for patients

on incomplete pathways *92% 90.7% 89.2% 88.7% 89.0% 90.4% 90.7% 91.7% 92.6% 93.0% 92.5% 92.2% 92.3% 92.4%


on incomplete pathways (planned trajectory)92.0% 92.0% 92.0% 92.0%

AS03Percentage of patients treated within 18 weeks of referrals -

admitted patients- 77.7% 79.1% 81.0% 78.8% 80.8% 82.5% 80.9% 82.9% 84.4% 85.3% 86.4% 83.5% 84.1%

AS04Percentage of patients treated within 18 weeks of referrals - non-

admitted patients- 92.4% 92.6% 92.7% 92.3% 92.1% 92.0% 92.4% 92.8% 93.3% 93.7% 93.5% 92.6% 93.2%

AS05Number of patients waiting more than a year for treatment

(Incomplete pathways)0 9 8 5 2 1 1 4 3 2 2 2 6 19

AS06Percentage of patients waiting 6 weeks or more for a diagnostic

test*1% 3.7% 4.4% 3.6% 3.7% 1.5% 0.6% 1.7% 1.3% 0.9% 0.5% 1.0% 0.5% 1.1%


test (Planned trajectory)1.0% 1.0% 1.0% 1.0%

AS08Percentage of patients admitted, discharged or transferred out

within 4 hours of arrival in the dept.*95% 97.0% 95.4% 95.1% 92.8% 93.2% 93.0% 94.1% 95.1% 94.4% 95.0% 94.5% 0.0% 94.6%


within 4 hours of arrival in the dept (Planned trajectory)93.0% 95.0% 95.0% 95.0%

Sep-16 YTD Trend Sep-16 YTD Trend Sep-16 YTD Trend


on incomplete pathways *92% AS01R 91.9% 91.7% AS01U 93.8% 93.7% AS01W 0.0% 93.6%

AS03Percentage of patients treated within 18 weeks of referrals -

admitted patients- AS03R 82.5% 82.4% AS03U 89.6% 90.0% AS03W 0.0% 78.5%

AS04Percentage of patients treated within 18 weeks of referrals - non-

admitted patients- AS04R 0.0% 92.2% AS04U 0.0% 96.1% AS04W 0.0% 91.1%

AS05Number of patients waiting more than a year for treatment

(Incomplete pathways)0 AS05R 0 15 AS05U 0 3 AS05W 0 0


test*1% AS06R 0.0% 0.3% AS06U 0.0% 5.1% AS06W 0.0% 0.4%


within 4 hours of arrival in the dept.*95% AS08R 87.9% 90.9% AS08U 86.9% 89.7% AS08W 93.4% 87.6%

* NHS Constitutional Standard

YTDIAF

Ref.Indicator Trend

The Whittington Hospital

NHS TrustIAF

Ref.Indicator Target

Royal Free London NHS

Foundation Trust

University College Hospital

London

Access Standard Narrative

Key issues Mitigating actions ProgressReferral to Treatment (RTT)

Preliminary data shows that BCCG RTT compliance was achieved in

September 2016. RF(L) has maintained compliance with the standard and

therefore met their STF trajectory. However ongoing delivery of the waiting

time standards remains a concern. In particular, with RF(L) reducing

outsourcing of activity, there is a risk that their own capacity may not be

sufficient.

RF(L) reported three 52 week wait breaches in August and UCLH also

reported three.

For RF(L) RTT Incomplete pathway clearance time increased to 10.5 in

August 2016 (recommended <10 weeks).

RTT current backlog is still above the recommended 0.5 weeks (0.8 Weeks in

August 2016).

Since August 2016 RF(L) ceased weekly RTT PTL reporting.

Implementation of the IST exclusion rule is on hold until the next phase of

SQL implementation which is planned in January 2017. There is a potential

knock on effect on the long waiters as the numbers may increase.

RNOH 18 weeks(Incomplete target) performance was below trajectory in

August 2016. September 2016 trajectory is at risk

Diagnostics

Preliminary data shows that BCCG achieved the standard for diagnostic

waiting times in September 2016. The RF(L) continued to perform well, UCLH

is progressing on implementing their RAP through the work with McKinsey.

RNOH has consistently failed the Diagnostics waiting times target.

A&E

BCCG did not achieve the A&E target in August 2016, and NCL remains

challenged. Barnet and Enfield A&E delivery board submitted plans to NHSE

in October 2016, for the 5 mandated A&E improvement schemes.

UCLH attained 90.57% in August and September’s Unvalidated A&E

Performance is at 86.9% which is below agreed STF Trajectory of 95.0%.

Referral to Treatment (RTT)

RF(L) 52 week breaches are subject to a root cause analysis (RCA)

undertaken, with escalation to the Chief Operating Officer.

CPN meeting was re-scheduled with RNOH on 10 October to include

NEL CSU attendance. Clinical Harm review of all patients waited over

26 weeks is being reviewed. This is led by the RNOH Access

Improvement Taskforce, with monthly updates to commissioners at

CQRG via the Medical Director.

RNOH now submitted a revised trajectory to NHS Specialist

Commissioning, compliance originally in September 2016 now pushed

back to February 2017.

Diagnostics

RF(L) to attend the Optimisation event organised by TCST on 16.11.16

and 17.11.16 to discuss optimisation scenarios as a way of improving

current capacity (different way of thinking).

RNOH: Meeting was held in October 2106, RNOH revised the

trajectory (compliance by November 2016) and submitted the

transformation and sustainability plan

UCLH: CCCG and UCLH commissioned a joint external review of the

Diagnostics Service via McKinsey and final outputs was provided to

CCCG and UCLH early October.

The Diagnostics RAP was signed off on 13.10.16 and will be presented

to CCCG/UCLH Boards.

There are a number of other diagnostics recovery actions specifically

relating to governance which UCLH has also commenced such as its

JAG reaccreditation, improving its Serious incident reporting,

improvement of its booking processes and re-training of staff. UCLH

has forecast return to compliance in November 2016.

A&E

BCCG submitted Barnet and Enfield Winter plans which address the

key issues by introducing new models and or commissioning.

UCLH: The A&E RAP was signed off on 27.10.2016 and will be

presented to the UCLH Board and CCCG Governing body in November

2016.

Referral to Treatment (RTT)

NELCSU recommends BCCG re-commences the RTT Task and

Finish group until the waiting list reached to a sustainable level.

NELCSU to attend follow up RNOH CPN meeting on 04.11.16 to

check progress on the actions.

Diagnostics

UCLH has informed the lead commissioner that the Endoscopy

backlog has been cleared and modality compliance was achieved

in Jul-16. UCLH MRI backlog as at 29 September was 610 patients

waiting over six weeks, a reduction on previous weeks. The last of

the clinical reviews were completed in August and there remains

no evidence of clinical harm.

RNOH: NHSE and NELCSU to continue to monitor performance

and notice step change in September/October 2016

A&E

RF(L): Daily Escalation calls starting 01.12.16.

UCLH: UCLH progresses with implementation of the A&E recovery

actions derived from the jointly commissioned external review by

McKinsey now that this has been signed off.

Cancer Access standards

7 8 9 10 11 12 13 14 15 16 17 18


CA01 All Cancers - two week wait 93% 95.4% 93.6% 93.9% 89.2% 91.2% 91.8% 91.7% 91.0% 92.7% 94.5% 93.7% 93.1% 92.7%

CA02Two week wait for breast symptoms

(where cancer not initially suspected)93% 96.5% 89.9% 90.6% 78.8% 79.7% 88.3% 91.1% 92.1% 94.0% 93.8% 91.4% 94.3% 92.5%

CA03Percentage of patients receiving first definitive treatment within 31

days of a cancer diagnosis.96% 98.4% 100% 98.8% 100.0% 99.1% 98.1% 97.6% 99.1% 97.8% 99.2% 98.3% 99.1% 98.5%

CA04 31 Day standard for subsequent cancer treatments -surgery 94% 100% 92.9% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100.0%

CA0531 Day standard for subsequent cancer treatments -

anti cancer drug regimens98% 100% 100% 100% 100% 97.7% 100% 100% 100% 100% 100% 97.7% 100% 99.5%

CA06 31 Day standard for subsequent cancer treatments - radiotherapy 94% 100% 100% 100% 100% 100% 94.6% 100.0% 97.6% 100% 100% 100% 100% 99.5%

CA07 All cancer 62 day urgent referral to first treatment wait (Actual)* 85% 63.6% 78.8% 80.9% 70.0% 62.0% 81.5% 85.1% 85.7% 83.9% 77.8% 77.4% 79.0% 81.8%

CA08All cancer 62 day urgent referral to first treatment wait (Planned

trajectory)85.0% 86.2% 85.7% 85.0%

CA0962 day wait for first treatment following referral from an NHS cancer

screening service90% 100% 100% 83.3% 75.0% 90.0% 100% 91.7% 100% 90.0% 100% 100% 66.7% 96.2%

CA1062 day wait for first treatment for cancer following a consultant's

decision to upgrade the patients priority- 100.0% 81.8% 80.0% 100.0% 85.7% 88.9% 100.0% 87.5% 100.0% 100.0% 100.0% 90.0% 97.3%

Sep-16 YTD Trend Sep-16 YTD Trend Sep-16 YTD Trend

CA01 All Cancers - two week wait 93% CA01R 94.1% 93.7% CA01U 89.9% 87.4% CA01W 96.6% 97.2%

CA02Two week wait for breast symptoms

(where cancer not initially suspected)93% CA02R 94.7% 94.0% CA02U 95.1% 61.8% CA02W 100.0% 98.4%

CA03Percentage of patients receiving first definitive treatment within 31

days of a cancer diagnosis.96% CA03R 96.5% 96.8% CA03U 98.8% 93.3% CA03W 100.0% 100.0%

CA04 31 Day standard for subsequent cancer treatments -surgery 94% CA04R 100.0% 98.5% CA04U 100.0% 93.4% CA04W 100.0% 100.0%

CA0531 Day standard for subsequent cancer treatments -

anti cancer drug regimens98% CA05R 100.0% 100.0% CA05U 97.8% 99.9% CA05W 100.0% 100.0%

CA06 31 Day standard for subsequent cancer treatments - radiotherapy 94% CA06R 100.0% 100.0% CA06U 100.0% 99.2% CA06W 0.0% 0.0%

CA07 All cancer 62 day urgent referral to first treatment wait (Actual)* 85% CA07R 78.0% 79.6% CA07U 73.2% 69.7% CA07W 74.6% 89.0%

CA0962 day wait for first treatment following referral from an NHS cancer

screening service90% CA09R 90.9% 95.6% CA09U 66.7% 78.9% CA09W 100.0% 100.0%

CA1062 day wait for first treatment for cancer following a consultant's

decision to upgrade the patients priority- CA10R 87.2% 86.5% CA10U 68.2% 78.7% CA10W 0.0% 33.3%

CA01U

* NHS Constitutional Standard

IndicatorIAF

Ref.YTD Sparkline

The Whittington Hospital

NHS TrustIAF

Ref.Indicator Target

Royal Free London NHS

Foundation Trust

University College Hospital

London

Access Standards (Cancer) Narrative

Key issues Mitigating actions Progress

BCCG did not achieve two out of eight Cancer Waiting Times

(CWT) targets in September 2016. The non- compliant CWT

targets were the 62 day Cancer Waiting Times target and the

62 day NHS Cancer Screening standard. The main providers

who are contributing to the under performance are RF(L),

UCLH and RNOH.

RF(L): Behind trajectory on the 62 day pathway and also

failed to achieve the 31 day to first treatment standard in

September. Merger of 2 Infoflex (cancer reporting systems)

took place from 8 October . This will ultimately result in

better reporting but brings short term risks in reporting.

UCLH: Failed the 2ww, 31 day 1st treatment, 62 day GP

urgent referral and 62 day screening targets in August.

RNOH failed 3 out of 4 Cancer Waiting Times target. The STF

trajectory has failed consistently.

NCL Cancer Improvement Plan developed to support system

response to performance issues. Key components include

development and implementation of more straight-to-test

pathways at more sites, implementing the national optimal

pathway for lung cancer, reducing 2 week wait median

waits, seamless and timely inter-Trust transfers and a review

of the Breast cancer service across NCL. Barnet CCG is

leading the work on system oversight and improvements.

RF(L): Regular escalation meetings are held among RF(L),

BCCG and NHSE to provide support on Cancer agenda.

Continue to monitor PTL and regularly review

implementation of RAP actions.

RNOH: Contract Performance Notice issued to RNOH by

NHSE Specialised Commissioning 12 Aug 2016 for CWT (&

RTT). CPN meeting held in October 2016 and sustainability

and recovery plan submitted to NHSE.

RNOH submitted revised Cancer trajectory, compliance is

now by November 2016

UCLH: Both UCLH and CCCG commissioned a joint external

review carried out by McKinsey. Outputs linked into the

UCLH’s Cancer RAPs which were signed off on 13.10.16.

NCL Sector Wide System Leadership Forum to discuss and

review issues affecting NCL and NCEL as a Cancer System.

Governance set out and priority areas identified including

Inter-Trust Transfers (ITT).

RF(L): BCCG to continue to monitor the Cancer Waiting times

(31 day target) position, if this is consistent then raise it at

the appropriate forum, however it is expected that the under

performance is a consequence of the info flex system

merger which has affected cancer data.

RNOH: NELCSU to attend the follow up CPN meeting on

04.11.16.

UCLH: Urgent implementation of signed off Cancer RAPs

following the completion of the joint external review by

McKinsey

Mental Health standards

7 8 9 10 11 12 13 14 15 16 17 18


MH01 IAPT Access Roll-out (HSCIC published data) * 1.25% 1.2% 1.30% 0.82% 0.88% 0.94% 1.18% 1.36% 1.13% 1.17% 1.03% 0.00% 0.00% 1.22%

MH02 IAPT Recovery rate (HSCIC published data) 50% 41.4% 37.8% 38.2% 46.2% 47.1% 44.7% 40.5% 46.1% 41.5% 44.4% 0.0% 0.0% 42.7%

MH03The proportion of people that wait 6 weeks or less from referral to

entering a course of IAPT treatment against the number of people who

finish a course of treatment in the reporting period.

75% 80.6% 80.0% 83.3% 85.7% 91.9% 95.0% 91.3% 96.8% 97.5% 95.8% 0.0% 0.0% 95.8%

MH04The proportion of people that wait 18 weeks or less from referral to

entering a course of IAPT treatment against the number of people who

finish a course of treatment in the reporting period.

95% 90.3% 90.0% 97.2% 96.4% 97.3% 100.0% 95.7% 99.2% 99.7% 98.9% 0.0% 0.0% 98.8%

MH05 Estimated diagnosis rate for people with dementia (65 years+) 66.7% 76.8% 77.3% 76.6% 77.5% 77.4% 77.6% 75.6% 75.9% 76.3% 77.6% 77.9% 77.4% 76.4%

MH06

Proportion of patients on a CPA who were followed up within

seven days after discharge from psychiatric inpatient care

(quarterly)

0.0% 0.0% 100.0% 0.0% 0.0% 99.1% 0.0% 0.0% 99.1% 0.0% 0.0% 0.0%

MH07 Outpatient Did Not Attend rate - CAMHS * 10% 9.0% 9.0% 10.0% 10.0% 10.0% 10.0% 11.0% 10.0% 10.0% 11.0% 12.0% 0.0%

MH08 Outpatient Did Not Attend rate - Adult ** 10% 12.0% 11.0% 11.0% 10.0% 9.0% 10.0% 9.0% 9.0% 10.0% 10.0% 7.0% 0.0%

MH09 Outpatient Did Not Attend rate - Older Adults ** 10% 3.0% 4.0% 3.0% 3.0% 3.0% 3.0% 3.0% 4.0% 3.0% 3.0% 2.0% 0.0%

MH10 Early intervention Psychosis (2 week Referral To Treatment) ** 50% 0.0% 0.0% 83.3% 40.0% 53.8% 46.2% 33.3% 70.0% 37.5% 50.0% 0.0% 100.0% 47.2%

* IAPT access targets is 15% annualised or equivalent to 3.75% Quarterly and 1.25% monthly

** Barnet only performance

IAF Ref. Indicator YTD Sparkline

Access Standards (Mental Health) Narrative

Key issues Mitigating actions ProgressImproving Access to Psychological Therapies (IAPT)

After achieving the access rate in April, performance has dropped

below the national standard. Year-to-date (month 6) BCCG is 224

first assessment & treatment sessions below target.

Quarterly data shows BCCG achieved an access rate of 3.66% against

the target of 3.75% for 16/17 Q1.

Referrals have decreased from 588 in August to 558 in September.

Analysis of referrals by GP practice show that North Barnet locality

has a lower referral rate than the other localities although there are

practices in all localities have a low referral rate.

Early Intervention Psychosis (EIP)

BEHMHT reported that EIP caseloads are high resulting in a risk to

service users accessing new assessments within 2 weeks.

There are concerns about not meeting the NICE Standards for EIP.

Child and Adolescent Mental Health Services (CAMHS)

BEHMHT: The current out of hours model for CAMHS services is no

longer fit for purpose following new guidance from the Deanery.

The CAMHS teams have variable waiting times across the boroughs.

BEHMHT has reported an additional cohort of referrals to the

Enfield CAMHS service that have or will shortly have waited over 13

weeks for an assessment.

Perinatal Mental Health

Due to lack of local provision for perinatal mental health, a business

case is being put forward to support an interim arrangement for two

sessions of perinatal psychiatrist cover for residents of Barnet and

Camden pending the NCL mental health bid for a full service.

Improving Access to Psychological Therapies (IAPT)

The initial RAP was rejected by BCCG with revised RAP submitted by

SABP on 21/10. Referrals analysis underway to look at referrals by GP

practice to target low referring practices.

Key planning meetings are taking place between the frontline

managers and commissioners to agree actions for sustainable

improvement.


BEHMHT using NHSE Workforce Calculator and considering the

resource changes required to meet the NICE compliant element of

the EIP standard.

BEHMHT providing a paper clarifying the data that should have been

reported on UNIFY, NHS Digital and in local reports


BEHMHT has been asked to investigate the circumstances of the

extended waiting times within Enfield. A report is due to be

submitted on 01.11.16.


Camden will part fund this cover arrangement which will be provided

by an experienced psychiatrist with expertise in perinatal mental

health offering consultation, joint assessment, and some direct

patient care. Estimated to be in place by October.

Improving Access to Psychological Therapies (IAPT)

Remedial Action Plan submitted by SABP on 21/10 includes trajectory

for recovery in November 2016.


Final Draft cluster 10 service specification subject to CCG governance

arrangements.


The current provision of the CAMHs out of hours service requires a

system wide review.

Commissioners and NELCSU to use the new CAMHS performance

reports to review and monitor waiting times.

Commissioners to develop a service specification with clinical

pathways and waiting time KPIs.


Service expected to be in place by October

Quality and Responsiveness Measures and Standards

7 8 9 10 11 12 13 14 15 16 17 18


QU01 Number of never events (Royal Free) 0 3 0 1 1 0 3 0 1 2 0 0 0 3

QU02 New SIRIs reported in the month (Royal Free) 0 11 5 12 6 8 12 9 13 13 7 4 6 52

QU03 Overdue SIRIs (Royal Free) - 16 13 19 16 15 21 13 15 16 13 14 13 -

QU04 Patient Falls - Royal Free (Safety Thermometer) - 1.40% 1.39% 2.32% 2.47% 1.22% 1.53% 1.43% 1.60% 1.47% 1.38% 1.77% 1.79%

QU05 New CAUTIs - Royal Free (Safety Thermometer) - 1.28% 0.88% 1.36% 0.73% 0.73% 1.25% 0.57% 0.40% 0.37% 0.88% 1.27% 0.77%

QU06 New Pressure Ulcers - Royal Free (Safety Thermometer) - 0.38% 1.01% 0.82% 0.58% 0.61% 0.84% 0.14% 1.20% 0.12% 0.25% 0.89% 0.51%

QU07 New VTEs - Royal Free (Safety Thermometer) - 1.15% 0.63% 0.27% 0.15% 0.24% 1.11% 0.71% 1.20% 0.37% 1.00% 0.63% 1.02%

QU08 Friends and Family Test Score - Recommend A&E (Royal Free) 89.7% 85.9% 85.2% 84.0% 80.3% 80.8% 77.7% 83.3% 82.9% 80.4% 82.1% 84.7% 81.7%

QU09Friends and Family Test Score - Recommend Inpatients (Royal

Free)95.13% 87.9% 88.8% 87.2% 87.5% 88.2% 90.5% 90.4% 91.1% 90.5% 90.9% 90.4% 89.2%

QU10A Cumulative cases of Clostridium difficile - actual 22 30 35 41

QU10P Cumulative cases of Clostridium difficile monthly ceiling plan 84 15 26 35 42

QU11 Cases of MRSA 0 0 0 1 0 0 0 0 2 0 1 1 0 4

QU12 VTE Assessments undertaken upon admission - Royal Free 95.0% 90.6% 94.0% 94.2% 95.7% 94.0% 94.0% 96.2% 96.7% 96.9% 96.6% 92.9% 91.9% -

QU13 Mixed Sex Accommodation breaches 0 5 5 5 6 5 2 2 3 4 6 9 11 30

AM01Ambulance Handover - 15 minutes (Royal Free London

Hampstead site)100% 28.6% 28.4% 26.9% 25.0% 22.8% 21.2% 22.4% 26.7% 32.2% 40.8% 38.6% 0.0% 0.0%

AM02Ambulance Handover - 30 minutes (Royal Free London

Hampstead site)100% 91.0% 90.7% 87.3% 82.9% 81.2% 78.0% 84.5% 86.6% 77.2% 86.1% 84.0% 0.0% 0.0%

AM03 Category A 8 minute response time (LAS) - Red 1 75% 70.7% 69.0% 73.8% 67.3% 64.7% 65.6% 70.0% 70.3% 72.2% 68.3% 68.7% 0.0% 69.9%

AM04 Category A 8 minute response time (LAS) - Red 2 75% 65.4% 64.4% 66.4% 60.9% 56.4% 57.9% 64.6% 65.1% 65.3% 63.6% 67.4% 0.0% 65.2%

DC01 Delayed transfers of Care - All reasons (Royal Free only) 2.5% 3.38% 3.55% 3.03% 2.97% 2.50% 2.53% 3.12% 3.37% 2.71% 2.79% 4.89% 0.00%

DC04 Delayed transfers of Care (BEH MHT only) 7.5% 12.0% 14.0% 12.0% 8.0% 9.0% 5.0% 7.0% 12.0% 11.0% 8.0% 10.0% 0.0%

* Annual C.Difficile ceiling (all providers aggregated to Barnet CCG) of 84 cases

IAF Ref. Indicator YTD Sparkline

Quality Narrative


Serious Incidents (SIs)

For September 2016, the RF(L) reported six Serious Incidences

Requiring Investigation (SIRIs).

Following the setting of an improvement trajectory, a

reduction in the number of overdue SIRI reports for the end of

September, RF(L) has reduced the number of overdue SIRIs

from 16 overdue SIs in June 2016 to 13 overdue in September

2016.

Never Events

There were no Never Events in September for RF(L).

Discharge Communciation

Significant concerns raised by Barnet GPs regarding quality of

discharge summaries. Concerns mostly relate to inadequate

information, medication or referral onto appropriate services.

BEHMHT

The Trust reported 7 serious incidents in September 2016.

There were no Never Events reported. There were eight

reports overdue. There are 57 open serious incidents opened

on STeIS.

Eight investigation reports are overdue.

12 further information requests are within the assurance

process.

CLCH

There has been a significant reduction of overdue reports and

work is ongoing to reduce this further. There were a total of

11 new serious incidents reported in September and all were

relating to pressure ulcers 3 and 4. There are 65 open serious

incidents, with 20 not yet due/ being currently investigated. 7

RCA reports were due for submission in September 2016 of

which 100% were submitted on schedule.


CQRG has requested that the RF(L) concentrates on incidents

that meet SIRI criteria to reduce backlog. The overdue status

of reports is being monitored weekly by RF(L) Executive

Committee. The Trust has a trajectory to have zero overdue

RCAs by 1 January 2017.

Never Events

All Never Events are subject to a RCA. The learning from the

quality assurance visit will be included within the next quality

report to the November Clinical Quality and Risk Committee.


A formal contract letter was sent by the CCG to RFL

confimring that the Trust were not complying with their

responsibilities set out in the NHS Standard Contract

BEHMHT

In August 93% of SIs (13 SIs) were reported within two days

of identification. Non-compliance for the incident reported

outside of the two days was due to an error in the initial

grading of the incident.

Compliance with Duty of Care part 2 for 2015/2016 was 93%.

In Q1 2016/17 Compliance with Duty of Care part 2 is 100%

CLCH

The Trust-wide SI assurance group provides an opportunity

to identify and resolve obstacles to timely investigation. The

Trust has an overarching pressure ulcer action plan and there

is a monthly pressure ulcer monitoring report that is

presented monthly at CQRG.


Following the setting of an improvement trajectory with a

reduction in the number of overdue SIRI reports for the

end of September early indications are that the Trust is on

target to meet its target of zero overdue SIRI reports by

end of January 2017.

The quality of investigations continues to improve.

UCLH continue to report improved compliance with the

Duty of Candour. UCLH are part of the ‘sign up to safety’

campaign.

Never Events

CQRG to continue to closely monitor any further Never

Events and for evidence that organisational learning from

previous Never Events has been embedded. The CCG is

part way throuhg completing quaity visits to the 3

endoscopy suites at RFL sites following 2 never events

related to wrong site endoscopy.


The CCG has received a formal response from the Trust

and is setting up a working group led by RFL Director of

Quality and have asked the CCG to be part of this.

BEHMHT

A review of six completed SI investigations was undertaken

to identify themes and emerging trends. Each incident was

found to be very individual and although the investigation

of three serious incidents found that risk assessments

and/or RiO were not adequately updated, no other themes

were identified. The Patient Safety Team will continue to

review completed SIRI investigations to identify any

themes and trends.

CLCH

Barnet CCG is now providing the quality assuring role on

all the serious incident reports from October 1st 2016. This

role was previously being undertaken by the SIRI CWHHE

Clinical Commissioning Groups Collaborative.

Internal Key Performance Indicators

7 8 9 10 11 12 13 14 15 16 17 18


Risk Management

Number of risks on the Operational Risk Register (ORR) - 6 4 47 -

Number of ORR risks rated as 'Extreme' - 4 -

Number of ORR risks rated as 'High' - 2 2 4 -

Number of risks where the rating (composite score) has increased from last

month- 0 -

Number of risks where the rating (composite score) has decreased from last

month- 0 -

Individual Funding Requests (data published quarterly)

Number of new applications received for IFR in the quarter -

Turnaround time - Percentage of cases closed within four weeks 93%

CCG Triage: Approved - Percentage of cases closed -

CCG Triage: Declined - Percentage of cases closed -

Closed for other reasons (inappropriate referrals) -

Number of appeals received per quarter -

Continuing Health Care

Percentage of patients who passed away in preferred place of death 64.0% 68.0% 80.0% 70.0% 74.0% -

Percentage of patients in receipt of scheduled reviews completed within 3

months80% 88% 58% 90% 71% 100% -

Percentage of patients in receipt of scheduled reviews completed within 12

months80% 92% 78% 75% 66% 92% -

Percentage of appeals upheld – both Local Appeal and Independent Review

Panels (NA - No Appeals made in the month)0.0% 0% 0% 0% 0% 0% -

Percentage of completed MDT referrals carried out jointly by health and social

care professionals100% 100% 100% 100% 100% 100% -

Number of formal DToCs in a hospital setting attributed to Continuing Healthcare 0 1 2 1 0 2 5

Indicator

12m

rolling

YTD

Sparkline

207 195226

4%

0

99% 90% 92%

83%

13%

Internal indicators narrative


Percentage of patients in receipt of scheduled reviews

completed within three months and 12 months has

increased compared to last month's as data entry more

robust on database following training

The percentage of completed assessments carried out by a

multi-disciplinary team is fully compliant as per National

framework

It is anticipated that successful recruitment in June will be

reflected in improved turnaround times when the Q2 data is

reported.

Independent Funding Review

Two cases were reviewed by the IFR panel during Quarter 1.

One was approved to treat rheumatoid arthritis, whilst one

for IVF was declined.

In Quarter 1, across NCL, the IFR team achieved 89% of cases

closed within four weeks. The agreed target for the IFR team

for the five NCL CCGs combined is 93% of cases closed within

four weeks, to be reported quarterly. Barnet was slightly

below the target, with performance of 92%.

Operational Risk Register

In support of the CCG's approach to risk management, a

structured programme of training is being delivered by the

CCG's Risk and Governance Manager


Continuing Healthcare

Due to a gap in reporting risk register data is not available for

June to August. In addition, the total risks reported on the

Risk Register has changed significantly (47 in September) as a

result of all risks now being captured, with those rated as

high or extreme also reported. This has taken effect from

September and will be reported in future reports.

Lower graded risks (rated 10 or less) can be reported and

monitored at a Directorate level, and the Governing Body

can request further detail if required.

All risks are reviewed by each Directorate on a monthly

basis, and updated accordingly.

Independent Funding Review

There were no appeals in September


Continuing Healthcare

The percentage of patients who passed away in their

preferred place of death (PPoD) is continues to be higher

than the national average of 45%.

Progress against national PPoD data is monitored routinely

by the CHC team.

There were two formal DToCs in a hospital setting reported

in September. Both were due to the family exercising choice.

Internal Key Performance Indicators

7 8 9 10 11 12 13 14 15 16 17 18


Programme Management Office

PM01 Number of schemes signed off per month

PM02 Total value of schemes signed off

PM03 Percentage of schemes commenced in the month planned

PM04 Schemes on track as per project plan

PM05 Project/scheme abandonment

Workforce

WF01 Staff sickness - short term (<28 days) 2.0% 0.68% 1.02% 0.13% 0.25%

WF02 Staff sickness - long term (=>28 days) 0.5% 1.64% 0.00% 0.00% 0.95%

WF03 Staff turnover (Voluntary) 10% 1.02% 1.92% 0.98% 0.95%

WF05 Mandatory training compliance 90% 95.0% 90.0% 90.0% 90.0%

WF06 PDP compliance 90% 0.00% 0.00%

Plan Actual Var. Plan Actual Var.

Finance to month 7

FI02 Surplus - Year to Date (£'000s) £642 £642 £0 G

FI03 Surplus - Full Year Forecast (£'000s) £1,100 £1,100 £0 G

FI04 1% Non Recurrent Funds (£'000s) £0 £0 £0 £4,576 £4,576 £0 G

FI05 QIPP - Year to Date (£'000s) £5,777 £5,677 £100 G

FI06 QIPP - Full Year Forecast (£'000s) £12,000 £11,661 £339 G

FI07 Running Costs (£'000s) £5,235 £5,235 £0 £8,648 £8,648 £0 G G

FI10Percentage expenditure on interim, temporary &

agency staff32.1% 49.3% 22.0% 47.0% R R

Indicator

12m

rolling

YTD

SparklineIAF

Ref.

YTD

Rating

FOT

Rating

Year to Date (YTD) Forecast Outturn (FOT)IAF

Ref

Internal indicators narrative


Programme Management Office (PMO)

The CCG has recently relaunched the PMO, including the

introduction of new documentation and governance

arrangements. This will enable the PMO to report its KPIs

from November onwards once these new processes have

become established.

Workforce

Workforce data will be split between substantive staff and

interim, temporary and contract staff in order to give the

Governing Body sufficient insight into the CCG's workforce

activity.

Operational Planning 2016/17 - activity status

IAF Ref.EM.

CodePoint of Delivery (acute care)

Source of

data *

Period

covered

Annual activity

plan 2016/17Year To Date Plan

Year To Date

ActualVariance

CO01 EM7 Total Referrals (General & Acute specialties) MAR Sep-16 155,261 77,835 76,356 -1.94%

CO02 EM8 Consultant Led First Outpatient Attendances (Specific Acute specialties) SUS Sep-16 148,128 76,095 76,311 0.28%

CO03 EM9 Consultant Led Follow-Up Outpatient Attendances (Specific Acute specialties) SUS Sep-16 281,899 141,899 127,702 -11.12%

CO04 EM10 Total Elective Admissions (Spells) (Specific Acute) [Ordinary Electives + Daycases] SUS Sep-16 36,545 19,676 18,843 -4.42%

CO05 EM10A Total Ordinary Elective Admissions (Spells) (Specific Acute specialties) SUS Sep-16 5,542 3,021 2,699 -11.93%

CO06 EM10B Total Day Case Elective Admissions (Spells) (Specific Acute specialties) SUS Sep-16 31,003 16,655 16,144 -3.17%

CO07 EM11 Total Non-Elective Admissions (Spells) (Specific Acute specialties) SUS Sep-16 30,497 14,937 14,170 -5.41%

CO08 EM12 Total A&E Attendances excluding planned follow ups SUS Sep-16 203,497 98,331 99,026 0.70%

CO09 EM13 Endoscopy Activity DM01 Sep-16 9,192 4,466 6,022 25.83%

CO10 EM14 Diagnostic Activity (excluding Endoscopy) DM01 Sep-16 143,436 72,006 69,157 -4.12%

CO11 EM16 Cancer Two Week Wait Referrals Seen Unify2 Sep-16 14,744 7,400 6,225 -18.88%

CO12 EM17 Cancer 62 Day Treatments following an Urgent GP Referral Unify2 Sep-16 715 359 332 -8.13%

CO13 EM18 Number of Completed Admitted RTT Pathways Unify2 Sep-16 26,344 13,482 15,302 11.89%

CO14 EM19 Number of Completed Non-Admitted RTT Pathways Unify2 Sep-16 95,314 48,780 50,444 3.30%

* Key to sources of data

MAR Monthly Activity Returns

SUS Secondary Use Service

DM01 Monthly Diagnostic return

Unify2 Department of Health portal

Contractual performance narrative


The Operating plan has been rebased, with adjustments to

the phasing of RTT backlog, activity levels, adjusted to known

data quality issues in 2016/17 and re-phasing of QIPP activity.

Endoscopy activity at Month 6 YTD is 34.8% above plan.

The anticipated growth built into Cancer 2ww has not been

seen yet at Month 6 YTD and is therefore under performing

at 15.9% and 62 day urgent GP referral have increased from -

23.4% to -7.5% from Month 1 to Month 6.

Continue to monitor RTT performance and backlog

reduction. Work underway to quantify impact of RTT

backlog in 2016/17.

SRG action plan in place to manage urgent care demand and

patient flows.

Endoscopy backlog clearance programme at RF(L) continues

including insourcing and outsourcing. Anticipated reduction

in over performance over the coming months in line with

move to sustainable backlog. Continue to monitor.

Continue to monitor Cancer activity in-line with

performance.

A&E avoidance: New SRG dashboard in development.

Options appraisal in progress for Discharge To Assess

model. Increased support for Care Homes.

barnet clinical commissioning group...2016/11/24 · barnet clinical commissioning group governing...

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