Buckinghamshire Healthcare NHS Trust Draft Data Pack 18th ...€¦ · Buckinghamshire is the 142nd most deprived. Ethnic diversity In Buckinghamshire, 13.6% belong to non-White minorities,

Buckinghamshire Healthcare NHS Trust Draft Data Pack 18th June 2013

Overview

On 6th February the Prime Minister asked Professor Sir Bruce Keogh to review the quality of the care and treatment being provided by those hospital trusts in England that have been persistent outliers on mortality statistics. The 14 trusts which fall within the scope of this review were selected on the basis that they have been outliers for the last two consecutive years on either the Summary Hospital Mortality Index or the Hospital Standardised Mortality Ratio.

These two measures are being used as a ‘smoke alarm’ for identifying potential quality problems which warrant further review. No judgement about the actual quality of care being provided to patients is being made at this stage, or should be reached by looking at these measures in isolation.

The review will follow a three stage process:

Stage 1 – Information gathering and analysis

Stage 2 – Rapid Responsive Review

Stage 3 – Risk summit

This data pack forms one of the sources within the information gathering and analysis stage.

Information and data held across the NHS and other public bodies has been gathered and analysed and will be used to develop the Key Lines of Enquiry (KLOEs) for the individual reviews of each Trust. This analysis has included examining data relating to clinical quality and outcomes as well as patient and staff views and feedback. A full list of evidence sources can be found in the Appendix.

Given the breadth and depth of information reviewed, this pack is intended to highlight only the exceptions noted within the evidence reviewed in order to inform Key Lines of Enquiry.

Slide 2

Document review Trust information submission for

review

Benchmarking analysis

Information shared by key national

bodies including the CQC

Sources of Information

Buckinghamshire Healthcare NHS Trust

Context

A brief overview of the Buckinghamshire area and Buckinghamshire Healthcare NHS Trust. This section provides a profile of the area, outlines performance of local healthcare providers and gives a brief introduction to the Trust.

Mortality

An indication of the Trust’s mortality data based on the HSMR and SHMI indicators. This section identifies the key areas within the Trust which are outliers.

Patient Experience

A summary of the Trust’s patient experience feedback from a range of sources. This section takes data from the annual patient experience surveys.

Safety and Workforce

A summary of the Trust’s safety record and workforce profile.

Clinical and Operational Effectiveness

A summary of the Trust’s clinical and operational performance based on nationally recognised key performance indicators. This section compares the Trust’s performance to other national trusts and targets and includes patient reported outcome measures (PROMs).

Leadership and Governance

An indication of the Trust's leadership and their governance procedures. This section identifies any recent changes in leadership, current top risks to quality and outcomes from external reviews.

Slide 3

Context

Slide 4

Context

Overview:

This section provides an introduction to the Trust, providing an overview, health profile and an understanding of why the Trust has been chosen for this review.

Review Areas:

To provide an overview of the Trust, the following areas have been reviewed:

• Local area and market share;

• Health profile;

• Service overview; and

• Initial mortality analysis.

Data Sources:

• Trust’s Board of Directors meeting 29th May, 2013;

• Department of Health: Transparency Website, Dec 12;

• Healthcare Evaluation Data (HED);

• NHS Choices;

• Office of National Statistics, 2011 Census data;

• Index of Multiple Deprivation, 2010;

• © Google Maps;

• Public Health Observatories – Area health profiles; and

• Background to the review and role of the national advisory group.

Summary:

Buckinghamshire Healthcare NHS Trust in the South Central of England services a population of about 500,000, which places the Trust within the higher range of the size recommended by the Royal College of Surgeons.

Buckinghamshire is one of the least deprived areas in the country as of 149 English unitary authorities, Buckinghamshire is the 142nd most deprived. 14% of Buckinghamshire’s population belong to non-White ethnic minorities. Incidents of malignant melanoma, violent crime and infant death are significantly higher than the national average in parts of Buckinghamshire.

The Trust has two acute hospital sites: Stoke Mandeville Hospital and Wycombe Hospital. In addition, the Trust provides services at five community hospitals. Buckinghamshire is not a Foundation Trust. The Trust has a total of 739 beds. It has a 74% market share of inpatient elective activity within a 5 mile radius of the Trust’s acute hospitals. However, the Trust’s market share falls to 48% within a radius of 10 miles, and 15% within a radius of 20 miles.

A review of ambulance response times shows that the South Central Ambulance Trust meets the national 8min response target, but not the 19min response target.

Finally, Buckinghamshire’s HSMR level has been above the expected level for the last 2 years and the Trust was therefore selected for this review.

Slide 5

All data and sources used are consistent across the packs for the 14 trusts included in this review.

Number of Beds and Bed Occupancy (Oct12-Dec12)

Beds

Available

Percentage

Occupied

National

Average

Total 739 87.9% 86%

General and

Acute

682 89.7% 88%

Maternity 57 66.9% 59%

Trust Status Not currently a Foundation Trust

Inpatient/Outpatient Activity (Jan12-Dec12)

Inpatient Activity Elective

47,896 (51%)

Day Case Rate:

85%

Non Elective 46,220 (49%)

Total 94,116

Outpatient Activity Total 476.074

Buckinghamshire is not currently a Foundation Trust. The Trust serves a population in South Central England of about 500,000 people and has seven hospitals, two acute hospitals (Stoke Mandeville, and Wycombe), and five community hospitals. The Trust is integrated and therefore also provides the full range of adult and child community services. The Trust has a higher bed occupancy rate than the national average, offering a large range of services, in 2012 serving 94,116 inpatients and 476,074 outpatients.

Trust Overview

Departments and Services

Accident & Emergency, Cardiology, Children’s & Adolescent

Services, Community Nursing, Dental and Medicine Specialties,

Dentistry and Orthodontics, Dermatology, Diabetic Medicine, ENT,

Endocrinology and Metabolic Medicine, Gastrointestinal and Liver

Services, General Surgery, Geriatric Medicine, Gynaecology,

Haematology, Maternity Service, Neurology, Ophthalmology, Oral

and Maxillofacial Surgery, Orthopaedics, Pain Management, Plastic

Surgery, Respiratory Medicine, Rheumatology, Therapy Services for

adults and children, Urgent Care, Urology, Vascular Surgery

Buckinghamshire Healthcare NHS Trust

Acute Hospitals Stoke Mandeville Hospital, Wycombe Hospital

Community Hospitals Amersham Hospital, Buckingham Community

Hospital, Chalfont and Gerrards Cross Community

Hospital, Marlow Community Hospital, Thame

Community Hospital,

Slide 6

Source: Department of Health: Transparency Website

Source: Healthcare Evaluation Data (HED)

Source: NHS Choices

Source: NHS Choices

Finance Information

Apr 2012– Feb 2013 Income £321m

Apr 2012– Feb 2013 Expenditure £295m

2012–2013 EBITDA £26m

2012–2013 Net surplus (deficit) £0m

2013-2014 Budgeted Income £335m

2013-2014 Budgeted Expenditure £300m

2013-2014 Budgeted EBITDA £35m

2013-2014 Budgeted Net surplus (deficit) £5m

Source: Buckinghamshire Healthcare NHS Trust, papers for public board meeting, 29.05.2013, and papers for public board meeting, 27.03.2013

A map of Stoke Mandeville Hospital is included in the Appendix

0

200

400

600

800

1000

1200

Num

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of

Outp

atient

Spells

(T

housands)

Trusts

Outpatient Activity by Trust

Trusts Covered by Review National Outpatient Activity Curve

0

50

100

150

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250

300

Num

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of In

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Inpatient Activity by Trust

Trusts Covered by Review National Inpatient Activity Curve

Trust Overview continued...

Buckinghamshire 94,116

Buckinghamshire 476,074

Top 10 Inpatient Main Specialties as a

% of Total Inpatient Activity

General Medicine 18%

Paediatrics 12%

Gynaecology 11%

General Surgery 9%

Urology 7%

Trauma and Orthopaedics 6%

Ophthalmology 5%

Clinical Oncology 5%

Midwifery 5%

Plastic Surgery 4%

Bottom 10 Inpatient Main Specialties

and Spells

Haematology 9

Rehabilitation 25

Allied Health Professional Episode 38

General Medical Practice 154

Nursing Episode 239

Palliative Medicine 348

Medical Oncology 407

Respiratory Medicine 536

Rheumatology 652

Neurology 906

Top 10 Outpatient Main Specialties as

a % of Total Outpatient Activity

Nursing Episode 30%

Ophthalmology 12%

Trauma and Orthopaedics 7%

General Medicine 7%

Dermatology 6%

Gynaecology 5%

General Surgery 5%

Clinical Haemotology 4%

Plastic Surgery 4%

Paediatrics 3%

The graphs show the relative size of Buckinghamshire against national trusts in terms of inpatient and outpatient activity.

Buckinghamshire is a medium sized trust for inpatient activity, relative to both the 14 trusts selected for this review and the rest of England. However, the Trust is in the upper quartile of all those nationally for outpatient activity.

General Medicine and Paediatrics are the largest inpatient specialties while Nursing Episodes and Ophthalmology are the largest for outpatients.

Slide 7 Source: Healthcare Evaluation Data (HED); Jan 12-Dec 12

Buckinghamshire, in South East England, is one of the least deprived areas in the country. The age distribution in Buckinghamshire is largely similar to that of England as a whole; however, Buckinghamshire has significantly fewer women and men in their 20’s. Incidents of malignant melanoma and infant death are particular health concerns in parts of Buckinghamshire compared to the country as a whole. 14% of Buckinghamshire’s population belong to non-White minorities.

Buckinghamshire Area Overview

20% 15% 10% 5% 0% 5% 10% 15% 20%

FACT BOX

Population 500,000

The Royal College of Surgeons recommend that the

"...catchment population size...for an acute general hospital

providing the full range of facilities, specialist staff and

expertise for both elective and emergency medical and

surgical care would be 450,000 - 500,000."

IMD Of 149 English unitary authorities,

Buckinghamshire is the 142nd most

deprived.

Ethnic diversity In Buckinghamshire, 13.6% belong to

non-White minorities, including 4.2%

Pakistani.

Rural or Urban Buckinghamshire is a rural-urban region.

Incidence of

malignant

melanoma

In parts of Buckinghamshire, and

particularly in Aylesbury Vale, incidents of

malignant melanomas are significantly

more common that in the country as a

whole.

Road injuries

and death

In parts of Buckinghamshire, and

particularly in South Bucks, road injuries

and death are significantly more common

than in the country as a whole.

Slide 8

Source: Buckinghamshire Healthcare NHS Trust; Index of Multiple Deprivation 2010; ONS Census 2011

0-9

10-19

20-29

30-39

40-49

50-59

60-69

70-79

80+

Buckinghamshire Area Demographics

Female/BUC Female/ENG Male/BUC Male/ENG

Buckinghamshire Area Geographic Overview

The wheel on the left shows the elective market share of Buckinghamshire Healthcare NHS Trust. From the wheel it can be seen that Buckinghamshire has a 74% market share of inpatient activity within a 5 mile radius of the Trust.

As the size of the radius is increased, the market share falls to 48% within 10 miles and 15% within 20 miles.

The wheel shows that the main competitors in the local area are Oxford University Hospitals NHS Trust, Heatherwood and Wexham Park Hospitals NHS Foundation Trust, and Milton Keynes Hospital NHS Foundation Trust.

The map on the right shows the location of the main sites belonging to Buckinghamshire Healthcare Trust located in the South Central of England. As shown on the map, Buckinghamshire is a rural-urban area and located in proximity to London as well as to some major roads.

Slide 9

Source: Healthcare Evaluation Data (HED), Dec 11 – Nov 12

Source: © Google Maps

Market share analysis indicates from which GP practices the referrals that are being provided for by the Trust originate. High mortality may affect public confidence in a Trust, resulting in a reduced market share as patients may be referred to alternative providers.

Buckinghamshire Market Share analysis continued...

The wheel on the right shows the non-elective market share of Buckinghamshire Healthcare NHS Trust. From the wheel it can be seen that Buckinghamshire has an 85% market share of inpatient activity within a 5 mile radius of the Trust.

As the size of the radius is increased, the market share falls to 40% within 10 miles and 13% within 20 miles.

The wheel shows that the main competitors in the local area are Oxford University Hospitals NHS Trust, Heatherwood and Wrexham Park Hospitals NHS Foundation Trust, West Hertfordshire Hospitals NHS Trust and Milton Keynes Hospital NHS Foundation Trust.

Slide 10

Source: Healthcare Evaluation Data (HED), Dec 11 – Nov 12

Buckinghamshire’s Health Profile

Health Profiles, depicted on this slide and the following, are designed to help local government and health services identify problems in their areas, and decide how to tackle these issues. They provide a snapshot of the overall health of the local population, and highlight potential differences against regional and national averages.

The graph shows the level of deprivation in Aylesbury Vale, Chiltern and Wycombe compared nationally.

The tables below outline Aylesbury Vale, Chiltern and Wycombe’s health profile information in comparison with the rest of England.

1. All three areas are performing above the national average on almost all indicators within the community indicators. Only Wycombe is performing below the national average for violent crime.

1

Slide 11

Deprivation by unitary authority area

Source: Public Health Observatories – area health profiles

Aylesbury Vale, Chiltern & Wycombe


2. Aylesbury Vale, Chiltern and Wycombe are above the national average on all indicators relating to children and young people’s health.

3. For adults’ health and lifestyle, all indicators are within the expected range. However, it should be noted that all areas are below the national average for higher risk drinking and in Chiltern there are a fewer number of physically active adults than the national average. However, as noted above, these are still within the expected levels.

Slide 12


2

3


4. In Aylesbury Vale the rate of malignant melanoma is significantly higher than the national average. Also, Chiltern is slightly outside of the national average. Other disease and poor health indicators suggest all areas are above the national average but show that hip fracture in over 65s are more common in Aylesbury Vale than the national average. Once again, the rate is not significantly different from the national average.

Slide 13


4


5. Excess winter deaths are below average in Aylesbury Vale, Chiltern and Wycombe. They are all below the national average but there is no significant difference compared to the national average. The life expectancy and cause of death indicators also highlight a high number of infant deaths in Aylesbury Vale compared to the national average.

Slide 14


5

Performance of Local Healthcare Providers

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

Isle of Wight NHS Trust

South Western

Ambulance Service NHS Foundation

Trust

West Midlands

Ambulance Service NHS

Trust

South Central Ambulance Service NHS Foundation

Trust

South East Coast


Trust

East of England


Trust

London Ambulance Service NHS

Trust

North West Ambulance Service NHS

Trust

Great Western


Trust

North East Ambulance Service NHS

Trust

Yorkshire Ambulance Service NHS

Trust

East Midlands Ambulance Service NHS

Trust

Proportion of calls responded to within 8 minutes

Ambulance Trust England

84%

86%

88%

90%

92%

94%

96%

98%

100%

Isle of Wight NHS Trust

West Midlands


Trust

London Ambulance Service NHS

Trust

South East Coast


Trust

Yorkshire Ambulance Service NHS

Trust

South Western


Trust

Great Western


Trust

North East Ambulance Service NHS

Trust

North West Ambulance Service NHS

Trust

South Central Ambulance Service NHS Foundation

Trust

East of England


Trust

East Midlands Ambulance Service NHS

Trust

Proportion of calls responded to within 19 minutes

Ambulance Trusts England Slide 15

To give an informed view of the Trust’s performance it is important to consider the service levels of non-acute local providers. For example, slow ambulance response times may increase the risk of mortality. The graphs on the right represent some key performance indicators for England’s Ambulance services. The South Central Ambulance Trust meets the 8min response target. However, the Ambulance Trust fails to meet the 19min response target.

Source: Department of Health: Transparency Website Dec 12

Based on the Summary Hospital level Mortality Indicator (SHMI) and Hospital Standardised Mortality Ratio (HSMR), 14 trusts were selected for this review. The table includes information on which trusts were selected. An explanation of each of these indicators is provided in the Mortality section. Where it does not include the SHMI for a trust, it is because the trust was selected due to a high HSMR as opposed to its SHMI. Initially, five hospital trusts were announced as falling within the scope of this investigation based on the fact that they had been outliers on SHMI for the last two years (SHMI data has only been published for the last two years). Subsequent to reviews of these five trusts being announced, Professor Sir Bruce Keogh took the decision that those hospital trusts that had also been outliers for the last two consecutive years on HSMR should also fall within the scope of his review. The rationale for this was that it had been HSMR that had provided the trigger for the Healthcare Commission’s initial investigation into the quality of care provided at Mid Staffordshire Hospitals NHS Foundation Trust. Buckinghamshire has been above the expected level for HSMR over the last 2 years and was therefore selected for this review.

Why was Buckinghamshire chosen for this review?

Banding 1 – ‘higher than expected’

Trust SHMI 2011 SHMI 2012 HSMR

FY 11

HSMR

FY 12

Within

Expected?

Basildon and Thurrock University Hospitals NHS

Foundation Trust 1 1 98 102 Within expected

Blackpool Teaching Hospitals NHS Foundation Trust 1 1 112 114 Above expected

Buckinghamshire Healthcare NHS Trust 112 110 Above expected

Burton Hospitals NHS Foundation Trust 112 112 Above expected

Colchester Hospital University NHS Foundation Trust 1 1 107 102 Within expected

East Lancashire Hospitals NHS Trust 1 1 108 103 Within expected

George Eliot Hospital NHS Trust 117 120 Above expected

Medway NHS Foundation Trust 115 112 Above expected

North Cumbria University Hospitals NHS Trust 118 118 Above expected

Northern Lincolnshire And Goole Hospitals NHS

Foundation Trust 116 118 Above expected

Sherwood Forest Hospitals NHS Foundation Trust 114 113 Above expected

Tameside Hospital NHS Foundation Trust 1 1 101 102 Within expected

The Dudley Group Of Hospitals NHS Foundation Trust 116 111 Above expected

United Lincolnshire Hospitals NHS Trust 113 111 Above expected

Source: Background to the review and role of the national advisory group Financial years 2010-11, 2011-12

Slide 16

Why was Buckinghamshire chosen for this review?

HSMR Time Series HSMR Funnel Chart

SHMI Funnel Chart SHMI Time Series

Buckinghamshire

Selected trusts Outside Range Selected trusts w/in Range

The way that levels of observed deaths that are higher than expected deaths can be understood is by using HSMR and SHMI. Both compare the number of observed deaths to the number of expected deaths. This is different to avoidable deaths. An HSMR and SHMI of 100 means that there is exactly the same number of deaths as expected. This is very unlikely so there is a range within which the variance between observed and expected deaths is statistically insignificant. On the Poisson distribution, appearing above and below the dotted red and green lines (95% confidence intervals), respectively, means that there is a statistically significant variance for the trust in question.

The funnel charts for 2010/11 and 2011/12, the period when the trusts were selected for review, show that Buckinghamshire’s SHMI and HSMR are statistically above the expected range. This is supported by the time series for both SHMI and HSMR as they are above the expected level for the majority of the period.

Buckinghamshire


Slide 17 Source: Healthcare Evaluation Data (HED); Apr 10-Mar12

Mortality

Slide 18

Mortality

Overview:

This section focuses upon recent mortality data to provide an indication of the current position. All 14 trusts in the review have been analysed using consistent methodology.

The measures identified are being used as a ‘smoke alarm’ for highlighting potential quality issues. No judgement about the actual quality of care being provided to patients is being made at this stage, nor should it be reached by looking at these measures in isolation.

Review areas

To undertake a detailed analysis of the trust’s mortality, it is necessary to look at the following areas:

• Differences between the HSMR and SHMI;

• Elective and non-elective mortality;

• Specialty and Diagnostic groups; and

• Alerts and investigations.

Data sources

• Healthcare Evaluation Data (HED);

• Health & Social Care Information Centre – SHMI and contextual indicators;

• Dr Foster – HSMR; and

• Care Quality Commission – alerts, correspondence and findings.

Summary:

The Trust has an overall HSMR of 117 for the period January 2012 to December 2012, meaning that the number of actual deaths is higher than the expected level. This is statistically above the expected range.

Deeper analysis of this demonstrates that non-elective admissions are the primary contributing factor to this figure, with an HSMR of 117, also above the expected range. Elective admissions are within the expected range, with an HSMR of 90.

Currently, Buckinghamshire has a SHMI of 114, which is statistically above the expected range.

Similar to HSMR, non-elective admissions are seen to be contributing primarily to the overall Trust SHMI, both with a figure of 114, which is above the expected range. Elective admissions are within the expected range.

Buckinghamshire was selected on the basis of its HSMR, but its SHMI has been statistically higher than expected for 4 of the last 12 months. Its HSMR has been higher than expected for 3-4 years.

Mortality concerns appear to be focused within respiratory medicine/elderly care, strongly associated with a mortality outlier alert for patients admitted with pneumonia. The Trust raised issues around clinical coding as well as process actions around the emergency care pathway for patients with pneumonia.

Buckinghamshire report above average activity associated with palliative care.

Slide 19 All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.

Mortality Overview

Slide 20

Mo

rta

lity

Outcome 1 (R17) Respecting and involving e who use services

Overall HSMR

Overall SHMI*

Weekend or weekday mortality outliers

Elective mortality (SHMI and HSMR)

Non-elective mortality (SHMI and HSMR)

Palliative care coding issues

Emergency specialty groups much worse than expected 30-day mortality following specific surgery / admissions

Emergency specialty groups worse than expected Mortality among patients with diabetes

Diagnosis group alerts to CQC

Diagnosis group alerts followed up by CQC

The following overview provides a summary of the Trust’s key mortality areas:

Source: Healthcare Evaluation Data (HED). Dec 11 – Nov 12 Health & Social Care Information Centre – SHMI and contextual indicators, Dr Foster – HSMR, Care Quality Commission – alerts, correspondence and findings

Outside expected range

Within expected range

*The detailed following analysis on SHMI is based upon a narrower set of confidence intervals compared to the Random effects model, which the HSCIC use to report whether the SHMI is within, below or above the expected range and was the range used to select the 14 trusts for this review. The narrower range is used here to increase the sensitivity to the data and serves to give an earlier warning for the purposes of this review.

Outside expected range of the HSCIC for Mar 11 – Sep 12


Outside expected range based on Poisson distribution for Dec 11 – Nov 12

SHMI*

HSMR Definition

What is the Hospital Standardised Mortality Ratio? The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures whether the mortality rate at a hospital is higher or lower than you would expect. Like all statistical indicators, HSMR is not perfect. If a hospital has a high HSMR, it cannot be said for certain that this reflects failings in the care provided by the hospital. However, it can be a warning sign that things are going wrong. How does HSMR work? The HSMR is a ratio of the observed number of in-hospital deaths at the end of a continuous inpatient spell to the expected number of in-hospital deaths (multiplied by 100) for 56 specific CCS groups; in a specified patient group. The expected deaths are calculated from logistical regression models taking into account and adjusting for a case-mix of: age band, sex, deprivation, interaction between age band and co-morbidities, month of admission, admission method, source of admission, the presence of palliative care, number of previous emergency admissions and financial year of discharge. How should HSMR be interpreted? Care is needed in interpreting these results. Although a score of 100 indicates that the observed number of deaths matched the expected number in order to identify if variation from this is significant confidence intervals are calculated. A Poisson distribution model is used to calculate 95% and 99.9% confidence intervals and only when these have been crossed is performance classed as higher or lower than expected.

Slide 21

SHMI Definition

What is the Summary Hospital-level Mortality Indicator? The Summary Hospital-level Mortality Indicator (SHMI) is a high level hospital mortality indicator that is published by the Department of Health on a quarterly basis. The SHMI follows a similar principle to the general standardised mortality ratio; a measure based upon a nationally expected value. SHMI can be used as a potential smoke alarm for potential deviations away from regular practice. How does SHMI work? 1. Deaths up to 30 days post acute trust discharge are considered in the mortality indicator, utilising ONS data 2. The SHMI is the ratio of the Observed number of deaths in a Trust vs. Expected number of deaths over a period of time 3. The Indicator will utilise 5 factors to adjust mortality rates by

a. The primary admitting diagnosis; b. The type of admission; c. A calculation of co-morbid complexity (Charlson Index of co-morbidities); d. Age; and e. Sex.

4. All inpatient mortalities that occur within a Hospital are considered in the indicator How should SHMI be interpreted? Due to the complexities of hospital care and the high variation in the statistical models used all deviations from the expected range are highlighted using a Random Effects funnel plot.

Slide 22

Some key differences between SHMI and HSMR

Slide 23

Indicator HSMR SHMI

Are all hospital deaths included? No, around 80% of in hospital deaths are

included, which varies significantly

dependent upon the services provided by

each hospital

Yes all deaths are included

When a patient dies how many times is this

counted?

If a patient is transferred between hospitals

within 2 days the death is counted multiple

times

1 death is counted once, and if the patient is

transferred the death is attached to the last

acute/secondary care provider

Does the use of the palliative care code

reduce the relative impact of a death on the

indicator?

Yes No

Does the indicator consider where deaths

occur?

Only considers in-hospital deaths Considers in-hospital deaths but also those

up to 30 days post discharge anywhere too.

Is this applied to all health care providers? Yes No, does not apply to specialist hospitals

SHMI overview

Slide 24

Month-on-month time series

Year-on-year time series

The Trust’s SHMI level for the 12 months from Dec11 to Nov12 is 114, which means, as shown below, it is statistically above the expected range and so classified as an outlier, based on the 95% confidence interval of the Poisson distribution. The time series show a general trend of decreasing SHMI month-on-month, and an initial decrease leading to a stable trend year-on-year.

SHMI funnel chart –12 months

Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012

Buckinghamshire


SHMI Statistics This slide demonstrates the

number of mortalities in and out of hospital for Buckinghamshire.

As SHMI includes mortalities that occur within the hospital and outside of it for up to 30 days following discharge, it is imperative to understand the percentage of deaths which happen inside the hospital compared to outside. This may contribute to differences in HSMR and SHMI outcomes.

The data shows that 78.0% of SHMI deaths occur in hospital at Buckinghamshire, which is higher than the national average of 73.3% and is the second highest of all of the trusts selected for review.

60%

65%

70%

75%

80%

85%

90%

Percentage of patient deaths in hospital

Trusts selected for review All Trusts

Buckinghamshire 78.0%

Slide 25

Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012

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ical O

nco

log

y

Neu

rolo

gy

Rh

eum

ato

log

y

Pa

edia

trics

Gy

na

ecolo

gy

Gy

na

ecolo

gica

l on

colo

gy

Mid

wife E

piso

de

Clin

ical o

nco

log

y

Interv

entio

na

l Ra

dio

log

y

Treatment Specialties

Mortality - SHMI Tree

Mortality trees provide a breakdown of SHMI into elective and non-elective admissions. The SHMI score for non-elective admissions has a greater impact on the overall indicator due to a higher number of expected deaths. The tree shows that Buckinghamshire has a SHMI of 114 which is above the expected range. The number of observed deaths are highlighted as being above the expected level in Palliative Medicine for elective and non – elective admissions, and in Critical Care Medicine, General Medicine for non-elective admissions. These are potential areas for review.

Slide 26

Higher than expected (above the 95th confidence interval)


Lower than expected (below the 95th confidence interval)

Overall Trust

Elective

SHMI 114

SHMI 113


SHMI 114

Diagnosis (100 ; 1 )

SHMI Observed deaths that are higher than the expected

Key

Elective (113; 4)

SHMI sub-tree of specialties

The SHMI sub-tree highlights the specialties for non-elective admissions with a statistically higher SHMI than expected and highlights the diagnostic groups with at least four more observed deaths than expected. When identifying areas to review, it is important to consider the number of deaths as well as the SHMI. General medicine has the highest number of greater than expected deaths. Acute and unspecified renal failure (22) and pneumonia (45) are seen as the main diagnostic groups contributing to this.

Slide 27

Diagnostic Groups

Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012 The diagnostic groups with 1 to 3 more observed deaths than the expected are listed in the Appendix.





118.2

\

Palliative Medicine (218; 76)

Non-elective (114; 222) Overall (114; 226)



SHMI Observed deaths that are higher than the expected

Key

\ \

General Medicine (119; 159) Critical Care Medicine (259; 62)

Acute cerebrovascular disease (684; 9)

Acute myocardial infarction (944; 7)

Pneumonia (except that caused by tuberculosis or sexually transmitted disease) (226; 7)

Septicemia (except in labor) (295; 6)

Acute and unspecified renal failure (149; 22)

Acute bronchitis (121; 4)



Cancer of bladder (324; 6)

Cancer of breast (234; 5)

Cancer of bronchus; lung (119; 5)

Congestive heart failure; nonhypertensive (134; 12)

Gastrointestinal hemorrhage (139; 5)

Liver disease; alcohol-related (179; 6)


Secondary malignancies (115; 5)

Urinary tract infections (136; 14)

Cancer of bronchus; lung (170; 7)

Cancer of colon (217; 5)

Cancer of head and neck (439; 4)

Cancer of prostate (192; 5)


HSCIC SHMI overview

Slide 28

The Health and Social Care Information Centre (HSCIC) publish the SHMI quarterly. This official statistic covers a rolling 12 month reporting period using a model based on a 3-year dataset refreshed quarterly. The earliest publication was in October 2011, for the period from April 2010 to March 2011. The HSCIC produce two sets of upper and lower limits. One set uses 99.8% control limits from an exact Poisson distribution based on the number of expected deaths. The other set uses a Random effects model applying a 10% trim for over-dispersion, based on the standardised Pearson residual for each provider excluding the top and bottom 10% of scores. This latter set is broader than the Poisson and is the one against which the HSCIC report whether the SHMI is within, below or above the expected range. The SHMI for Buckinghamshire was 115 in the year to Sept-12 (England baseline = 100) and has been above the expected range in the latest two periods (but within the expected range prior to that). The Trust was selected on the basis of its HSMR, but its SHMI has been significantly higher than expected since June-12. It’s HSMR has been higher than expected for three years. Buckinghamshire have a fairly low percentage of out of hospital deaths, so the SHMI may be as expected when the HSMR is high.

Source: Health & Social Care Information Centre – SHMI

SHMI published by HSCIC, Buckingham shire

112 112 111 111 112 113 115

80

85

90

95

100

105

110

115

120

Mar-11 Jun-11 Sep-11 Dec-11 Mar-12 Jun-12 Sep-12

Rolling 12 months ending

Lower limit Upper limit SHMI

HSMR overview

Slide 29

Month-on-month time series

Year-on-year time series

The Trust’s HSMR for the 12 months from Jan 12 to Dec 12 is 117, which means, as shown below, it is above the expected range and so is classified as an outlier. The time series show no real trend for HSMR year-on-year and month-on-month time series shows no real trend. Further to this, the month-on-month time series fluctuates between extremes of 103 and 135, and the year-on-year time series shows a large increase of 87 to 113 from 2008 to 2009 but a relatively stable trend following this.

HSMR funnel plot –12 months

Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012

Buckinghamshire


HSMR Statistics

The table to the right shows Buckinghamshire’s HSMR broken down by admission type. The breakdown illustrates the overall HSMR is 117 which is above the expected range. The table identifies that elective admissions have an HSMR within the expected range. Both week and weekend non-elective admissions have an HSMR higher than expected. The high non-elective admissions contribute to the weekend and week admissions HSMR being above the expected range.

Slide 30

HSMR Weekend Week All

Elective 0 95 90

Non-elective 130 113 117

All 130 112 117

Key – colour by alert level:

Red – Higher than expected (above the 95% confidence interval)

Blue – Within expected range

Green – Lower than expected (below the 95th confidence interval)


HSMR CCS Diagnostic Group Overview

The darker colour boxes have the highest HSMR while the size of the boxes represent the number of observed deaths that are higher than the expected deaths. The larger and darker boxes within the tree plot will highlight potential areas for further review.

From this tree plot it is clear that the following areas have the greatest number of above expected deaths:

• Pneumonia (HSMR of 128, and 53 observed deaths that are higher than the expected);

• Acute cerebrovascular disease(122; 30);

• Acute and unspecified renal failure (138; 21);

• Congestive heart failure; nonhypertensive (121; 12) and

• Secondary malignancies (126; 12)

Slide 31


Mortality - HSMR Tree

The tree shows that the HSMR for Buckinghamshire is 117 which is above the expected range. When breaking this down by admission type, it is clear that it is driven by non elective admissions, which are at the same level. Elective admissions are within the expected range. Within non-elective admissions Critical Care Medicine, General Medicine and Palliative Medicine have the highest number of observed deaths above the expected level and so each have an HSMR above the expected level.

Slide 32


HSMR Observed deaths that are higher than the expected

Key

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Gen

eral S

urg

ery

Uro

log

y

Va

scula

r Su

rgery

Tra

um

a &

Orth

op

aed

ics

Ea

r, No

se an

d T

hro

at (E

NT

)

Op

hth

alm

olo

gy

Pla

stic Su

rgery

Bu

rns C

are

Accid

ent &

Em

ergen

cy (A

&E

)

Pa

in M

an

ag

emen

t

Critica

l Ca

re Med

icine (2

68

; 49

)

Pa

edia

tric Derm

ato

log

y

Pa

edia

tric Dia

betic M

edicin

e

Co

mm

un

ity P

aed

iatrics

Gen

eral M

edicin

e (124

; 142

)

Ga

stroen

terolo

gy

En

do

crino

log

y

Clin

ical H

aem

ato

log

y

Dia

betic M

edicin

e

Reh

ab

ilitatio

n

Pa

lliativ

e Med

icine (14

9; 3

1)

Ca

rdio

log

y

Sp

ina

l Inju

ries

Stro

ke M

edicin

e

Derm

ato

log

y

Th

ora

cic Med

icine

Med

ical O

nco

log

y

Neu

rolo

gy

Well B

ab

ies

Geria

tric Med

icine

Ob

stetrics

Gy

na

ecolo

gy

Gy

na

ecolo

gica

l On

colo

gy

Clin

ical O

nco

log

y

Interv

entio

na

l Ra

dio

log

y

Non Elective

- - - - - - - - - - - - - - - - - - - - - -

Gen

eral S

urg

ery

Uro

log

y

Tra

um

a &

Orth

op

aed

ics

Ea

r, No

se an

d T

hro

at (E

NT

)

Op

hth

alm

olo

gy

Pla

stic Su

rgery

Critica

l Ca

re Med

icine

Gen

eral M

edicin

e

Ga

stroen

terolo

gy

Clin

ical H

aem

ato

log

y

Reh

ab

ilitatio

n

Pa

lliativ

e Med

icine

Ca

rdio

log

y

Sp

ina

l Inju

ries

Derm

ato

log

y

Th

ora

cic Med

icine

Med

ical O

nco

log

y

Pa

edia

trics

Gy

na

ecolo

gy

Gy

na

ecolo

gica

l On

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gy

Clin

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nco

log

y

Interv

entio

na

l Ra

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log

y





Overall Trust

Elective

HSMR 117

HSMR 90


HSMR 117

HSMR sub-tree of specialties

The HSMR sub-tree indicates the specialties with a statistically higher HSMR than expected and with diagnostic groups with at least four more observed deaths than expected. When identifying areas to review, it is important to consider the number of deaths as well as the HSMR. The sub-tree indicates that General Medicine has the highest number of above expected deaths. These are spread over several diagnostic groups with pneumonia (42), acute cerebrovascualr disease (17), and acute and unspecified renal failure (15) having the highest number of above expected deaths.

Slide 33


Diagnostic Groups




118.2

General Medicine (124; 142)

Non-elective (117; 184)

Overall (117; 184)

Critical Care Medicine (268; 49)


HSMR Observed deaths that are higher than the expected

Key





Septicemia (except in labor) (395; 6)

Acute and unspecified renal failure (137; 15)


Aspiration pneumonitis; food/vomitus (131; 5)

Congestive heart failure; nonhypertensive (141; 13)

Gastrointestinal hemorrhage (186; 8)

Liver disease; alcohol-related (167; 6)


Urinary tract infections (134; 9)


HSMR – Dr Foster

The HSMR time series for Buckinghamshire NHS Trust from Dr Foster shows an above expected HSMR since 2008/09. This measures the observed in-hospital death rate against an expected value based on all the data for that year. An HSMR (or SHMI) of 100 means that there is exactly the same number of deaths as expected. The HSMR is classified as above expected if the lower 95% confidence limit exceeds 100, which was the case in all financial years since 2008/09. Buckinghamshire’s latest SHMI published by the HSCIC, for Oct 11 to Sept 12, is slightly higher than the Dr Foster HSMR for the same period, which may be due to a number of factors. Dr Foster have made the following adjustments to show differences explained by these factors: • Adjustment for palliative care: used the SHMI observed deaths

but changed expected deaths to take account of palliative care. • Adjustment for in-hospital deaths:

• Removed out-of-hospital deaths from the observed figure, and

• Reduced expected deaths to only those in-hospital. The remaining variances are largely due to: • The scope of deaths included (SHMI covers all deaths whereas

HSMR covers clinical areas accounting for an average of around 80% of deaths), and

• The definition of spells, which includes those provider(s) the death attributes to.

Source: Dr Foster HSMRs, HSCIC SHMI

Slide 34

Com parison of m ortality m easures,

Buckingham shire

115

107

122

111

80

90

100

110

120

130

SHMI SHMI

adjusted for

palliative care

SHMI in

hospital

deaths only

HSMR

Time series of HSMR,

Buckinghamshire

110113

118

112

95

100

105

110

115

120

125

130

2008/09 2009/10 2010/11 2011/12

HSMR 95% Confidence intervalI

Coding

Average Diagnosis Coding Depth

Slide 35

Diagnosis coding depth has an impact on the expected number of deaths. A higher than average diagnosis coding depth is more likely to collect co-morbidity which will influence the expected mortality calculation. The diagnosis coding depth of elective patients at Buckinghamshire was performing below the national average and the average of the 14 trusts. However, more recently, the Trust has risen above the national average and is currently just above the national average. For non-elective patients, Buckinghamshire’s average coding depth has been consistently below the national average in the time period shown.


0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3

2008/09 2009/10 2010/11 2011/12 2012/13

Elective

National Average Diagnosis Coding Depth

14 Trusts' Average Diagnosis Coding Depth

Buckinghamshire

0

1

2

3

4

5

6

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3

2008/09 2009/10 2010/11 2011/12 2012/13

Non-elective

National Average Diagnosis Coding Depth

14 Trusts' Average Diagnosis Coding Depth

Buckinghamshire

Palliative care

Accurate coding of palliative care is important for contextualising SHMI and HSMR. HSMR takes into account that a patient is receiving palliative care, but SHMI does not. Buckinghamshire ranks 17 out of 142 Acute trusts for use of palliative care codes on admissions and 9 out of 142 for the percentage of deaths with palliative care codes (Apr 13 SHMI contextual indicators). Although the majority of palliative care is reported through diagnoses, Buckinghamshire also use the palliative treatment specialty, with around 11 palliative care inpatient beds in Florence Nightingale Hospice and Stoke Mandeville. Analysis of palliative care coding suggested that Buckinghamshire’s SHMI would reduce by around 3% if the treatment specialty use were accounted for in the model (report by HSCIC, Feb 13). However, the report found that the benefit of adjusting for the palliative care treatment specialty was diminished by lack of consistent coding between trusts.

Source: Health & Social Care Information Centre – SHMI contextual indicators

Percentage of admissions with palliative

care coding

-

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

Oct-11 Jan-12 Apr-12 Jul-12 Oct-12 Jan-13 Apr-13

SHMI publicationBuckinghamshire National

Percentage of deaths with palliative care

coding

-

5

10

15

20

25

30

35

Oct-11 Jan-12 Apr-12 Jul-12 Oct-12 Jan-13 Apr-13


Slide 36

u

u

Care Quality Commission findings

Emergency specialty groups much worse than expected

Sep 11 to Aug 12 0

Emergency specialty groups worse than expected

Sep 11 to Aug 12 1

Respiratory medicine

Diagnosis group alerts (2007 to date)

Alerts to CQC 7

Alerts followed up by CQC 4

Recent diagnosis group alerts pursued by CQC

Pneumonia (Aug 11)

Any related patient groups alerting more than once since 2007

Pneumonia

Acute bronchitis

Other upper respiratory disease

The Care Quality Commission (CQC) review mortality alerts for each Trust on an ongoing basis. These alerts, which indicate observed deaths significantly above expected for specialties or diagnoses, come from different sources based on either HSMR or SHMI. Where these appear unexplained, CQC correspond with the Trust to agree any appropriate action. For Buckinghamshire, the common theme that has arisen across the patient groups alerting since 2007 is Respiratory medicine, with reference also to Elderly Care. No common themes arise from responses to the CQC from the Trust. Mortality concerns appear to be focused within respiratory medicine/elderly care, strongly associated with the mortality outlier alert for patients admitted to hospital with pneumonia. The Trust raised issues around clinical coding as well as process actions around the emergency care pathway for patients with pneumonia.

Source: Care Quality Commission – alerts, correspondence and findings

Slide 37

SMRs for Diagnostic and Procedure groups – Dr Foster

The standardised mortality ratio (SMR) is used to calculate the mortality rate for diagnosis and procedure groups. This is available for the 56 diagnosis groups that are included in the HSMR and the 96 procedure groups that are part of the Real Time Monitoring system. SMRs are not yet remodelled for the year but are projected, rebased estimates. SMRs are classified as above expected if their lower 95% confidence limit exceeds 100 (excluding those with fewer than four more observed deaths than expected). From Apr 12 to Mar 13, there were five diagnosis groups and no procedure groups with above expected SMRs in Buckinghamshire, which may highlight potential areas for review. One of these diagnosis groups, Pneumonia, had above expected mortality for weekend admissions but not for weekday ones. CUSUM alerts show how many early warning flags arose within the diagnosis and procedure groups during the year. These are based on cumulative sum statistical process control charts with 99% thresholds that trigger alerts once breached. The same groups may alert multiple times. During the year, Buckinghamshire had a CUSUM alert for pneumonia. It also had four alerts for other diagnostic groups and one for a procedure group that did not have a high SMR.

Source: Dr Foster HSMR, SMRs, CUSUM alerts

Slide 38

Apr 2012 to Mar 2013 Diagnosis groups Procedure groups

SMRs above expected 5 0

CUSUM alerts 5 1

Diagnosis groups with SMRs above expected SMR Obs – Exp

deaths

Acute and unspecified renal failure

Acute myocardial infarction

Congestive heart failure, nonhypertensive

Pneumonia

Secondary malignancies

132

150

132

121

144

16

11

18

37

18

Mortality – other alerts

VLAD charts with a negative SHMI trend

(year to Jun-12)

No. dips to the

lower control limit

• Cancer of bronchus/lung

• Pneumonia

2

2

Variable Life Adjusted Display (VLAD) charts are produced by the Health and Social Care Information Centre to visualise the cumulative number of “statistical lives gained” over a period. A downward trend indicates a run of more deaths than expected compared to the national baseline and one with a sustained downward trend and multiple dips to the lower control limit may warrant further investigation. Buckinghamshire had such VLAD charts for two diagnosis groups in the year to June 2012: Cancer of bronchus/lung and Pneumonia (see table). Buckinghamshire had a high proportion of deaths higher than expected for Pneumonia (38 deaths, 18% more than expected) in the HSCIC’s SHMI to September 2012. The Trust was selected on the basis of its HSMR, but its SHMI has been higher than expected for 6 months or so. Its HSMR has been higher than expected for 3-4 years. Buckinghamshire has a fairly low percentage of out of hospital deaths, so the SHMI may be as expected when the HSMR is high. Dr Foster’s 2012 HSMR found Buckinghamshire above expected mortality for weekend admissions but not for weekday ones. This is different from the findings of HED (Jan 12– Dec 12) which sees both as being above the expected range. As shown by the graphs, Buckinghamshire serves one of the least deprived patient populations nationally, reflected in the percentage of both spells and deaths in the lowest quintile. This tends to reduce expected deaths in the HSMR, although it is not taken account of in the SHMI (methodologists concluded that it did not add sufficient value to the model, but they show it as context).

Source: Health & Social Care Information Centre – SHMI and contextual indicators, Dr Foster – HSMR.

Percentage of spells by deprivation quintile,

SHMI April 2013

-

5

10

15

20

25

30

35

40

45

1 Most

deprived

2 3 4 5 Least

deprived


Percentage of deaths by deprivation quintile,

SHMI April 2013

-

10

20

30

40

50

60

1 Most

deprived

2 3 4 5 Least

deprived


Slide 39

Patient Experience Slide 40

Patient Experience

Overview:

The following section provides an insight into the Trust’s patient experience.

Review Areas:

To undertake a detailed analysis of the Trust’s Patient Experience it is necessary to review the following areas:

• Patient Experience, and

• Complaints.

Data Sources:

• Patient Experience Survey; and

• Cancer Patient Experience Survey.

Summary:

Of the 9 measures reviewed within Patient Experience and Complaints the Trust was rated ‘red’ on two measures: The inpatient survey and a report from the complaints ombudsman.

On the inpatient survey, the Trust was below the national average overall, with poor scores on delays allocating patients to a ward, poor information given to discharged patients, poor communication on medication side effects, poor cleanliness, poor hospital food and noise at night from other patients.

A separate report by the Ombudsman rates the Trust as C-rated for satisfactory remedies of complaints and risk of non-compliance. This is the lowest category rating. The Trust has a high number of nurse complaints, and is above average for ‘inadequate personal remedy’.

Slide 41 All data and sources used are consistent across the packs for the 14 trusts included in this review.

Patient Experience

Inpatient PEAT : environment

Cancer survey PEAT : food

PEAT : privacy and dignity Friends and family test

Patient voice comments

Complaints about clinical aspects

Ombudsman’s rating

Pa

tie

nt

Ex

pe

rie

nc

e

This page shows the Patient Experience measures which are considered to be the most pertinent for this review. Further analysis, where relevant, is detailed in the following pages.

Slide 42



Not applicable

Overall

Clarity of doctors’ responses to important questions

Language used by doctors in front of patients

Clarity of nurses’ responses to important questions

Language used by nurses in front of patients

Ac

ce

ss

an

d

Wa

itin

g Overall

Alteration of admission date by hospital

Length of time spent on waiting list

Length of time to be allocated a bed on a ward

Sa

fe,

Hig

h

Qu

ali

ty,

Co

or

din

ate

d

Ca

re

Overall

Consistency of staff communication

Delay of patient discharge

Information provided on post-discharge danger signals

Overall

Patient involvement in decision-making

Overall

Patient noise levels at night

Staff noise levels at night

Hospital/ward cleanliness

Inpatient Experience Survey

Slide 43

Be

tte

r

Info

rm

ati

on

, M

or

e C

ho

ice

Staff communication on purpose of medication provided

Staff communication on medication side-effects

Hospital food

Degree of privacy provided

Level of respect shown by staff

Overall staff effort to ease pain

Below expected range Within expected range Above expected range

Cle

an

, C

om

for

tab

le,

Fr

ien

dly

Pla

ce

to

B

e

Bu

ild

ing

Clo

se

r

Re

lati

on

sh

ips

Buckinghamshire performs above average on survey questions relating to gaining admission to the hospital on the planned date, but below average on a range of questions, including those relating to the length of time required to be allocated a bed on a ward, information provided on post-discharge danger signals and medication side-effects, and hospital cleanliness.

Source: Patient Experience Survey 2012/13

50

55

60

65

70

75

80

85

90

95

Buckinghamshire

Source :Patient Experience Survey, Cancer patient experience survey

Trusts in

this review

National

results curve

England

average

Patient experience and patient voice

Inpatient

The national inpatient survey 2012 measures a wide range of aspects of patient experience. A composite ‘overall measure’ is calculated for use in the Outcomes Framework. This measure uses a pre-defined selection of 20 survey questions to rate the Trust on aspects including access to services, co-ordination of care, information & choice, relationship with staff and the quality of the clinical environment .

• England Average: 76.5

• Buckinghamshire: 73.9 (two standard deviations below average)

Cancer Survey

• Of 58 Questions, 14 were in the ‘top 20%’ whilst 2 were in the ‘bottom 20%’.

Patient Voice

• The quality risk profiles compiled by the Care Quality Commission collate comments from individuals and various sources. In the two years to 31st January 2013, there were 47 comments on Buckinghamshire, of which 30 were positive.

Slide 44

Overall patient experience score: Inpatients 2012

Complaints Handling

• Data returns to the Health and Social Care Information Centre showed 553 written complaints in 2011-12. The number of complaints is not always a good indicator, because stronger trusts encourage comments from patients. However, central returns are categorised by subject matter against a list of 25 headings. For this Trust, 46% of complaints related to clinical treatment, in line with the national average of 47%.

• A separate report by the Ombudsman rates the Trust as C-rated for satisfactory remedies and low-risk of non-compliance. This is the lowest category. The Trust has a high number of nurse complaints, and above average for ‘inadequate personal remedy’.

PEAT results

• Scores from patient environment action teams report a number of ratings of ‘acceptable’ for environment at Stoke Mandeville and Wycombe. Recent results are rated ‘good’.

Safety and workforce Slide 45

Safety and Workforce

Overview:

The following section provides an insight into the Trust’s workforce profile and safety record. This section outlines whether the Trust is adequately staffed and is safely operated.

Review Areas:

To undertake a detailed analysis of the Trust’s Safety and Workforce it is necessary to review the following areas:

• General Safety;

• Staffing;

• Staff Survey;

• Litigation and Coroner; and

• Analysis of patient safety incident reporting.

Data Sources:

• Acute Trust Quality Dashboard, Oct 2011 – Mar 2012;

• Safety Thermometer, Apr – Mar 2013;

• Litigation Authority Reports;

• GMC Evidence to Review 2013;

• National Staff Survey 2011, 2012;

• 2011/12 Organisational Readiness Self-Assessment (ORSA);

• National Training Survey, 2012; and

• NHS Hospital & Community Health Service (HCHS), monthly workforce statistics.

Summary:

Buckinghamshire is ‘red rated’ in one of the safety indicators: Rule 43 coroner reports.

The Trust recorded 932 incidents reported as either moderate, severe or death between April 2011 and March 2012. Since 2009, five ‘never events’ have occurred at Buckinghamshire, classified as that because they are incidents that are so serious they should never happen.

Throughout the last 12 months, the new pressure ulcer rate at Buckinghamshire has been below the national average. However, the Trust has a higher total pressure ulcer rate than the national average and has been above the national average in seven out of the last eight months.

Buckinghamshire is a net contributor to the Clinical Negligence Scheme for Trusts. Contributions to the scheme have exceeded payouts to litigants in each of the last 3 years, and in total by £10.7m. There were 2 items flagged in the Rule 43 Coroner’s reports.

Buckinghamshire is ‘red rated’ in 12 of the workforce indicators. It notably has sickness absence rates for medical, nursing and other staff above the national mean rate and has a higher staff leaving rate and lower staff joining rate than the median within the region. For training of its doctors, it has a lower score on ‘undermining’ than the national average. In addition, it is being monitored by the GMC’s ‘response to concerns’ process.


Safety



Sp

ec

ific

s

afe

ty

Me

as

ur

es

MRSA

C diff

This page shows the safety measures which are considered to be the most pertinent for this review. Further analysis, where relevant, is detailed in the following pages.

x Medication error Pressure ulcers

Slide 47

Outcome 1 (R17) Respecting and involving people who use services

Clinical negligence scheme payments

Rule 43 coroner reports

Lit

iga

tio

n a

nd

C

or

on

er

“Harm” for all four Safety Thermometer Indicators

Ge

ne

ra

l

Reporting of patient safety incidents

Number of harm incidents reported as ‘moderate, severe or death’ from April ‘11 to March ’12 932

Number of ‘never events’ (2009-2012) 5

Slide 48

Safety Analysis

Rate of reported patient safety incidents per 100 admissions (April –

September 2012)

Buckinghamshire Median rate for medium acutes

6.7 6.7

The Trust has reported at the median level for patient safety incidents in similar trusts. Buckinghamshire has a rate of 6.7 for its patient safety incident reporting per 100 admissions. Source: Incidents occurring between 1 April 2012 to 30 September

2012 and reported to the National Reporting and Learning System

Slide 49

Safety Incident Breakdown

Since 2009, five ‘never events’ have occurred at Buckinghamshire, classified as that because they are incidents that are so serious they should never happen. The patient safety incidents reported are broken down into five levels of harm below, ranging from ‘no harm’ to ‘death’. 54% of incidents which have been reported at Buckinghamshire have been classed as ‘no harm’, with 30% ‘low’, 14% ‘moderate’, 1% ‘severe’ and seven occurrences classified as ‘death’. When broken down by category, the most regular occurrences of patient incident at Buckinghamshire are in ‘patient accident’ and ‘treatment, procedure’.

Source: Freedom of information request, BBC - http://www.bbc.co.uk/news/health-22466496

Never Events Breakdown (2009-2012)

Surgical Error 2

Other 1

Wrong site surgery 1

Unexpected Death of Inpatient 1

Total 5

Source: National Patient Safety Agency (NPSA) Apr 11 – Mar 12 A definition of serious harm is given in the Appendix.

Source: National Patient Safety Agency (NPSA) . Apr 11 – Mar 12

Breakdown of patient incidents by degree of harm

Breakdown of patient incidents by incident type

3185

1753

851

74 7 0

500

1000

1500

2000

2500

3000

3500

No Harm Low Moderate Severe Death

1853

1455

596

446

333

297

256

236

172

143

83

0 500 1000 1500 2000

Patient accident

Treatment, procedure

Medication

Implementation of care and …

Access, admission, transfer, …

All others categories

Infrastructure

Clinical assessment

Documentation

Medical device / equipment

Consent, communication, …

Pressure ulcers

This slide outlines the total number of pressure ulcers and the number of new pressure ulcers broken down by category for the last 12 months. Due to the effects of seasonality on hospital acquired pressure ulcer rates, the national rate has been included which allows a comparison that takes this in to account. This provides a comparison against the national rate as well as the 14 trusts selected for the review.

Throughout the last 12 months, the new pressure ulcer rate at Buckinghamshire has been below the national average. However, the Trust has a higher total pressure ulcer rate than the national average and has been above the national average in seven out of the last eight months. This may highlight an area for review.

An understanding of specific case mix should be reviewed in parallel to understand any root causes.

Source: Safety Thermometer Apr 12 to Mar 13 Slide 50

New pressure ulcer analysis

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Number of records submitted 48 29 0 1891 1758 1648 1589 1390 1553 1372 1321 1343

Trust new pressure ulcers 0 0 0 33 25 10 16 20 16 13 23 16

Trust new pressure ulcer rate 0.0% 0.0% 0.0% 1.7% 1.4% 0.6% 1.0% 1.4% 1.0% 0.9% 1.7% 1.2%

Selected 14 Trusts new pressure

ulcer rate 1.4% 1.5% 1.4% 1.5% 1.5% 0.9% 1.0% 1.1% 0.9% 1.1% 1.0% 1.2%

National new presseure ulcer rate 1.7% 1.7% 1.5% 1.5% 1.4% 1.3% 1.2% 1.2% 1.2% 1.3% 1.3% 1.3%

Total pressure ulcer prevalence percentage

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Number of records submitted 48 29 0 1891 1758 1648 1589 1390 1553 1372 1321 1343

Trust total pressure ulcers 1 1 0 112 128 48 94 77 83 90 96 72

Trust total pressure ulcer rate 2.1% 3.4% 0.0% 5.9% 7.3% 2.9% 5.9% 5.5% 5.3% 6.6% 7.3% 5.4%

Selected 14 Trusts total pressure

ulcer rate 6.4% 6.2% 6.5% 7.0% 6.3% 5.5% 5.4% 5.9% 5.8% 6.0% 5.7% 6.2%

National total pressure ulcer rate 6.8% 6.7% 6.6% 6.1% 6.0% 5.5% 5.4% 5.3% 5.2% 5.4% 5.6% 5.3%

2.1%

3.4%

0.0%

5.9%

7.3%

2.9%

5.9% 5.5%

5.3% 6.6%

7.3%

5.4%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

-

20

40

60

80

100

120

140

Total pressure ulcers prevalence

Category 2 Category 3 Category 4 Rate

0.0% 0.0% 0.0%

1.7%

1.4%

0.6%

1.0%

1.4%

1.0% 0.9%

1.7%

1.2%

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%

1.6%

1.8%

2.0%

-

5

10

15

20

25

30

35

New pressure ulcers prevalence

Category 2 Category 3 Category 4 Rate

Litigation and Coroner

Clinical negligence payments

Clinical negligence scheme analysis: Buckinghamshire is a net contributor to the Clinical Negligence Scheme for Trusts. Contributions to the scheme have exceeded payouts to litigants in each of the last 3 years, and in total by £10.7m.

Slide 51

2009/10 2010/11 2011/12

Payouts (£000s) 3,791 2,087 2,751

Contributions (£000s) 5,684 6,613 7,041

Excess of Payouts over

Contributions (£000s)

1,893 4,526 4,290

Source :Litigation Authority Reports

Coroners rule 43 reports flagged 2 separate items, to consider the following: i) a review of the Trust's intubation training, procedures

and equipment in obstetric theatres ii) reviewing communication channels between medical

disciplines and the arrangements for handover of patients.

Workforce W

or

kfo

rc

e I

nd

ica

tor

s

Outcome 1 (R17) Respecting and involving e who u se services

WTE nurses per bed day

Spells per WTE staff

Vacancies –medical

Vacancies - Non-medical

Consultant appraisal rates

Agency spend



Sta

ff S

ur

ve

ys

an

d

De

an

er

y

x

Sickness absence- Overall

Sickness absence- Medical

Sickness absence -Nursing staff Sickness absence - Other staff Staff leaving rates Staff joining rates

Response Rate from National Staff Survey 2012 Staff Engagement from NSS 2012 Training Doctors – “undermining” indicator GMC monitoring under “response to concerns process”

This page shows the workforce measures which are considered to be the most pertinent for this review. Further analysis, where relevant, is detailed in the following pages.

Slide 52

Overall Rate of Patient Safety Concerns Care of patients / service users is my organisation’s top priority I would recommend my organisation as a place to work If a friend or relative needed treatment: I would be happy with the standard of care provided by this organisation

Medical Staff to Consultant Ratio

Nurse Staff to Qualified Staff Ratio

Non-clinical Staff to Total Staff Ratio Consultant Productivity (FTE/Bed Days) Nurse Hours per Patient Bed Day

2.83 2.39 0.29 459 40.35

Ca

rd

iolo

gy

Overall satisfaction

Clinical supervision

Workload

Handover

Adequate experience

Educational supervision

Feedback

Induction

Undermining

Access to educational resource

Local teaching

Study leave

Regional teaching

General Medical Council (GMC) National Training Scheme Survey 2012

The below summarises the output from the General Medical Council National Training Scheme 2012 Survey Results. Given the volume of data only specialties with red outliers are noted below (where those specialties also have green outliers, they are included).

Slide 53 Red outlier Within expected range Green outlier

De

rm

ato

log

y



Workload

Handover

Adequate experience


Feedback

Induction

Undermining


Local teaching

Study leave

Regional teaching

Em

er

ge

nc

y M

ed

icin

e



Workload

Handover

Adequate experience


Feedback

Induction

Undermining


Local teaching

Study leave

Regional teaching

General Medical Council (GMC) National Training Scheme Survey 2012 continued…

The GMC Survey results continue as follows.


En

do

cr

ino

log

y a

nd

dia

be

tes

m

ell

itu

s



Workload

Handover

Adequate experience


Feedback

Induction

Undermining


Local teaching

Study leave

Regional teaching

Ge

ria

tric

me

dic

ine



Workload

Handover

Adequate experience


Feedback

Induction

Undermining


Local teaching

Study leave

Regional teaching


Re

ha

bil

ita

tio

n m

ed

icin

e Overall satisfaction


Workload

Handover

Adequate experience


Feedback

Induction

Undermining


Local teaching

Study leave

Regional teaching



Tr

au

ma

an

d o

rth

op

ae

dic

s

ur

ge

ry



Workload

Handover

Adequate experience


Feedback

Induction

Undermining


Local teaching

Study leave

Regional teaching




The Trust also had green outliers for the following:

• Haematology – overall satisfaction;

• Plastic surgery – handover and access to educational resources;

• Respiratory medicine – overall satisfaction and adequate experience; and

• Rheumatology – workload and access to educational resources.

0%

20%

40%

60%

80%

100%

Consultant appraisal rate, 2011/12

Trusts covered by review All other trusts Buckinghamshire

Workforce Analysis

Slide 57 Source: NHS Hospital & Community Health Service (HCHS) monthly workforce statistics

Source: Health and Social Care Information Centre (HSCIC)

Source: Acute Trust Quality Dashboard, Methods Insight

WTE nurses per bed day December 2012

Buckinghamshire National Average

2.15 1.96

Agency Staff (2011/12)

Buckinghamshire

Expenditure

Percentage of

Total Staff Costs

Median within

Region

£7.7m 3.7% 3.8%

Staff Turnover (Sep 11 – Sep 12)

Buckinghamshire South Central SHA

Median

Joining Rate 9.6% 10.7%

Leaving Rate 8.8% 8.1%

0

5

10

15

20

25

30

35

40

45

50

Spells

per

WT

E

Spells per WTE for Acute Trusts

Trusts covered by review All Trusts

Buckinghamshire 20

Number of FTEs (Dec 11-Nov 12 average) 4,779

The Trust has a patient spell per whole time equivalent rate of 20, which is the lowest of all the trusts in this review and below average capacity in relation to nationally. The consultant appraisal rate of Buckinghamshire is 55.9% which is the second lowest of the trusts under review. Buckinghamshire’s staff leaving rate is 8.8% which is higher than the regional median average of 8.1%. The joining rate of 9.6% is lower than the regional average.

The data shows that the agency staff cost, as a percentage of total staff costs, is just below the median within the region.

Buckinghamshire

Source: 2011/12 Organisational Readiness Self-Assessment (ORSA)

Data based on the appraisal year from April 2011 to March 2012

Workforce Analysis continued…

Slide 58

Sickness Absence Rates (2011-2012)

Buckinghamshire South Central

SHA Average

National Average

All Staff 3.82% 3.75% 4.12%

Sickness Absence Rates by Staff Category (Dec 12)


Medical Staff 1.6% 1.3%

Nursing Staff 5.1% 4.8%

Other Staff 4.9% 4.7%

Source: Health and Social Care Information Centre (HSCIC)

Source: Acute Trust Quality Dashboard, Methods Insight

Buckinghamshire’s total sickness absence rate is higher than the South Central Strategic Health Authority average but below the national average. Despite being below the national average at an overall level, for each of the more granular categories investigated (medical, nursing, and other staff), Buckinghamshire’s rate was higher than the national average absence rate.

Buckinghamshire has a medical staff to consultant ratio above the average for all English trusts, although its nurse staff to qualified staff and non-clinical staff to total staff ratios are both below their respective national averages. The Trust’s registered nurse hours to patient day ratio is also below the national mean.

The Trust’s consultant productivity rate is below the national average.

Staff Ratios


Medical Staff to Consultant Ratio 2.83 2.59

Nurse Staff to Qualified Staff Ratio 2.39 2.50

Non-Clinical Staff to Total Staff

Ratio

0.29 0.34

Registered Nurse Hours to Patient

Day Ratio *

40.35 85.69

Source: Electronic Staff Record (ESR) April 13 *Patient Bed Days Data: Healthcare Evaluation Data (Nov 12 – Jan 13,) Nurse FTE Data: Jan 13 - Mar 13 Average

Staff Productivity


Consultant Productivity

(Spells/FTE)

459 492

Source: Electronic Staff Record (ESR) April 13 Workforce indicator calculations are listed in the Appendix.

Source: The Health and Social Care Information Centre Non-Medical Workforce Census (Sept 2009), Vacancies Survey March 2010

Workforce Analysis continued…

Slide 59

Buckinghamshire’s response rate to the staff survey is higher than the average and has risen in 2012. The staff engagement score is in the lowest 1/5th when compared with trusts of a similar type, although it improved in 2012. Buckinghamshire is significantly below the national average on all three organisational questions although all have improved in 2012.

National Staff Survey results

Buckingham-

shire

2011

Average for all

trusts

2011

Buckingham-

shire

2012

Average for all

trusts

2012

Response rate 50% 50% 52% 50%

Overall staff engagement 3.56 3.62 3.59 3.69

Care of patients/service

users in my organisation’s

top priority

49%

69% 54%

63%

I would recommend my

organisation a place to work 39%

52% 44%

55%

If a friend or relative needed

treatment, I would be happy

with the standard of care

provided by this organisation

51%

62% 53%

60%

Source: GMC evidence to Review 2013

Source: 2011/12 Organisational Readiness Self-Assessment (ORSA)

Data based on the appraisal year from April 2011 to March 2012

Source: National Staff Survey 2011, 2012

Deanery

The trust has been subject to enhanced monitoring since 2008, as a result of patient safety concerns. Doctors in training were removed by the Deanery from one site at the trust and a number of visits have taken place to investigate the concerns. Whilst the Deanery considers many of the concerns resolved, the trust is still being monitored under the response to concerns process.

National Training Scheme (NTS) Outliers – Programme Groups by Trust/Board between 2010-12

F2s in Emergency Medicine recorded the most below outliers between 2011 and 2012 (there were no outliers for 2010). F2s in Surgery recorded the most above outliers in the same period. The indicators Induction, Adequate Experience and Overall Satisfaction were all above outliers in 2011 and 2012 among Foundation Year 2s in surgery.

NTS 2012 Patient Safety Comments

6 doctors in training commented, representing 2.20% of respondents. This was less than half the national average of 4.7%. Their concerns, which were raised in relation to specific training posts, and may apply to a single or multiple departments, related to:

• Poor senior cover, including at night; • A lack of continuity of care and appropriate team leadership; • Poor stocks of fluids in Paediatrics Emergency Medicine; and • Ward designed for fast patient turnover, but has problems coping with longer term patients.

Source: GMC evidence to Review 2013

Slide 60

Deanery Reports

Monitored under the response to concerns process?

Yes, Buckinghamshire Healthcare NHS Trust has been monitored through the response to concerns process since November 2008, when it was identified that clearer mechanisms needed to be in place for monitoring patient safety at Stoke Mandeville and Wycombe Hospitals. A lack of middle grade Anaesthetics doctors created supervision issues, the location of Intensive Therapy Unit (ITU) was too far away from operating theatres and doctors in training were working unsupervised remotely in Ophthalmic block.

A Deanery visit in June 2012 to Amersham and Stoke Mandeville Hospitals indicated that Dermatology doctors in training were undertaking clinics without supervision. They reported excessive workloads, and excessive use of locum doctors which was having a detrimental effect on training.

Deanery Action

Stoke Mandeville and Wycombe Hospitals:

Seven conditions were set during a deanery visit to the Anaesthetics programme, and action plans were set and agreed. A School of Anaesthetics report sent in 29 January 2010 provided an update of conditions and an action plan; improvement was apparent and the Deanery confirmed that all requirements had been met.

2010 survey indicated no negative outliers for the programme, with a positive outlier for handover. Clinical supervision scores for anaesthetics across the Deanery were highest at another hospital in Trust. Deanery rated the programme as ‘satisfactory’ and reported no further issues.

2011 survey results indicated a number of below outliers and the Dean reported a number of issues with supervision in ITU at High Wycombe due to reduction in consultant numbers due to retirement and leave. The GMC supported the Deanery on a visit 2 March 2012, which confirmed the issues. The Deanery stopped placing new doctors in training in ITU at High Wycombe from August 2012, and remaining doctors in training were moved by November 2012.

The Deanery confirmed that issues around trainee accommodation, accurate recording of hours/rota compliance, and lack of consultants on the neonatal ward round have been fully resolved and the Deanery considers the issues to be 'closed‘.

Oxford Deanery reported concerns in the Buckinghamshire Healthcare NHS Trust in its 2011 annual report, and further concerns were raised in 2012. Issues relating to supervision and understaffing were reported in both years. Concerns in Trauma and Orthopaedic Surgery were also raised in both years - a 2011 survey negative outlier for clinical supervision was identified in F2- Trauma and Orthopaedic Surgery, a concern around patient safety (caused by the lack of leadership) among F1 doctors in training in Trauma and Orthopaedics was raised in 2012.

Slide 61

Deanery Reports continued…

Deanery Action continued….

Amersham and Stoke Mandeville Hospitals:

The Deanery is working with the Trust to ensure additional Dermatology consultants are appointed. Short term plans include training locum and SAS doctors to provide supervision. Plans are now in place to appoint additional consultants, and the Deanery is closely monitoring supervision in the meantime.

A follow up visit took place on 21/11/12, which confirmed improvement around level of supervision, but there were remaining issues with the levels of education.

The Deanery has set a number of requirements for the Trust and the department, and will be carrying out a Deanery-wide review of the specialty.

The Deanery will closely monitor the Trust action plans and supervision arrangements. It has been asked to report to the GMC in April 2013.

GMC Action

Deanery Reports and Trust action plans closely monitored.

To continue to support and feed back to the Deanery in a coordinated way, and involve our Response to Concerns Assessment Team if improvement is not forthcoming.

Undermining

For doctors undertaking training at Buckinghamshire, the trust has a score on the National Training Survey on undermining of 92.7 which is below the national average of 94. It is in the bottom 1/6 of the distribution across all training organisations

Slide 62

Clinical and operational effectiveness

Slide 63


Overview:

The following section provides an insight in to the Trust’s clinical and operational performance based on nationally recognised key performance indicators.

Review Areas:

To undertake a detailed analysis of the Trust’s clinical and operational performance it is necessary to review the following areas:

• Clinical Effectiveness;

• Operational Effectiveness; and

• Patient Reported Outcome Measures (PROMs) for the review areas.

Data Sources:

• Clinical Audit Data Trust, CQC Data Submission;

• Healthcare Evaluation Data (HED), Jan – Dec 2012;

• Department of Health;

• Cancer Waits Database, Q3, 2012-13; and

• PROMs Dashboard.

Summary:

Buckinghamshire is at the lower end of the distribution for the percentage of diabetic patients receiving a foot risk assessment due to low scores at both Stoke Mandeville and Amersham Hospitals. A key measure of clinical effectiveness is the percentage of discharged patients who are prescribed beta blockers and Stoke Mandeville was outside the control limits and is therefore an outlier on this measure. The Trust sees 92% of A&E patients within 4 hours which is below the 95% target level. The percentage of patients seen within 4 hours generally decreases during 2012. 93.7% of patients start treatment within the 18 week target time which is above the target level. This has been a consistent trend from April 2012 to March 2013. Buckinghamshire’s crude readmission rate is among the lower readmission rates of the trusts in the review as well as nationally, at 9.2%. The Trust’s standardised readmission rate shows a level of performance that is statistically within what is expected. The Trust’s average length of stay is shorter than that of the national average, at 4.92 days. The PROMs dashboard shows that Buckinghamshire was a consistent performer overall. None of the indicators fell outside of the control limits for the 3 years shown in the dashboard.


Outcome 1 (R17) Respecting and involving people who use services




This page shows the Clinical and Operational Effectiveness measures which are considered to be the most pertinent for this review. Further analysis, where relevant, is detailed in the following pages.

Neonatal – women receiving steroids Coronary angioplasty Heart failure

Adult Critical care Peripheral vascular surgery Lung cancer

Diabetes safety/ effectiveness Carotid interventions Bowel cancer

PROMS safety/ effectiveness Acute MI Hip fracture - mortality

Joints – revision ratio Acute stroke Severe trauma

Elective Surgery

Cli

nic

al

eff

ec

tiv

en

es

s

O

pe

ra

tio

na

l E

ffe

cti

ve

ne

ss

RTT Waiting Times Cancelled Operations

Emergency readmissions PbR Coding Audit

Cancer Waits

A&E Waits

PR

OM

s

Da

sh

bo

ar

d

Hip Replacement EQ-5D

Knee Replacement EQ-5D

Varicose Vein EQ-5D

Hip Replacement OHS

Knee Replacement OKS

Groin Hernia EQ-5D

Slide 65

Not applicable

Clinical Effectiveness: National Clinical Audits

The National Clinical Audits provide a valuable source of evidence on clinical effectiveness. These two tables show the clinical audit results considered as part of this review.

Slide 66

Clinical Audit Safety Measure

Diabetes Proportion with medication

error

Proportion experiencing

severe hypoglycaemic

episode

Elective Surgery Proportion of patient reported

post-operative complications

Adult Critical Care (ICNARC

CMPD)

Proportion of night-time

discharges

Clinical Audit Effectiveness Measures

Neonatal intensive and special care

(NNAP)

Proportion of women receiving ante-

natal steroids

Diabetes Proportion foot risk assessment

Adult Critical Care Standardised hospital mortality ratio

Coronary angioplasty Proportion receiving primary PCI

within 90 mins

Peripheral vascular surgery Elective abdominal aortic aneurysm

post-op mortality

Carotid interventions Proportion having surgery within 14

days of referral

Acute Myocardial Infarction Proportion discharged on beta-blocker

Acute Stroke Proportion compliant with 12 indicators

Heart Failure Proportion referred for cardiology

follow up

Bowel cancer 90 day post-op mortality

Hip Fracture 30 day mortality

Proportion operations within 36 hrs

Elective surgery (PROMS) Mean adjusted post-operative score

Severe Trauma Proportion surviving to hospital

discharge

Hip, knee and ankle Standardised revision ratio

Lung Cancer Proportion small cell patients receiving

chemotherapy

Slide 66 Source: Clinical Audit Data Trust, CQC Data Submission.

Received a foot risk assessment during the

hospital stay 2012

0%

20%

40%

60%

80%

100%

The National Diabetes Inpatient Audit for 2012 found relatively low scores for the percentage of diabetic patients receiving a foot risk assessment at Stoke Mandeville and also at Amersham Hospital.

Each graph ranks the percentage of patients with diabetes at each hospital that reported that they received a foot risk assessment during their stay.

The red line in each graph shows where this specific hospital ranks.

Note: Caution should be taken when looking at the data for some sites in these summaries as they may be based on a small sample of inpatients with diabetes. This

means that a small variation would have a substantial impact on the indicators presented.

Received a foot risk assessment during the

hospital stay 2012

0%

20%

40%

60%

80%

100%

Clinical effectiveness: Clinical Audits

Stoke Mandeville Hospital:

Amersham Hospital:

Stoke Mandeville Hospital:

Received a foot risk assessment during the hospital stay 2012

Amersham Hospital:

Received a foot risk assessment during the hospital stay 2012

Source: http://www.hscic.gov.uk/catalogue/PUB10506/nati-diab-inp-audi-12-comp.xlsx

Slide 67

Clinical effectiveness: Clinical Audits

In the National Clinical Audit for Acute Myocardial Infarction, a key measure of effectiveness is the percentage of discharged patients who are prescribed beta blockers. Stoke Mandeville was outside the control limits and is therefore an outlier.

Slide 68

Percentage of patients prescribed beta blockers on discharge by hospital in England, plotted against total number of discharges, 2011/12

Stoke Mandeville

60%

65%

70%

75%

80%

85%

90%

95%

100%

0 200 400 600 800 1000 1200 1400 1600

Stoke Mandeville

Slide 68

Source: National Institute for Cardiovascular Outcomes Research (NICOR)

A&E wait times and RTT times may indicate the effectiveness with which demand is managed.

Buckinghamshire sees 92% of A&E patients within 4 hours which is below the 95% target level. The time series graph reflects this as there has been a generally decreasing trend from January 2012.

93.7% of patients are seen within the 18 week target time which is above the target level. In addition, the time series shows that Buckinghamshire has been consistently performing above the target rate.

Operational Effectiveness – A&E wait times and Referral to Treatment (RTT) times

Source: Healthcare Evaluation Data (HED). Jan – Dec 12

Source: Department of Health. Feb 13 Source: Department of Health. Apr 12 – Feb 13 Slide 69

Source: Healthcare Evaluation Data (HED). Jan – Dec 12

70%

75%

80%

85%

90%

95%

100%

105%

A&E Percentage of Patients Seen within 4 Hours

Trusts Covered by Review All Trusts A&E Target 95%

Buckinghamshire 92%

75%

80%

85%

90%

95%

100%

105%

Referral to Treatment (Admitted)

Trusts Covered by Review All Trusts

RTT Target 90%

87%

88%

89%

90%

91%

92%

93%

94%

95%

Buckinghamshire Referral to Treatment Performance

Referral to Treatment Rate RTT Target 90%


75%

80%

85%

90%

95%

100%

0

2

4

6

8

10

12

Att

endances (T

housands)

Buckinghamshire 4 Hour A&E Waits

Number of patients seen within 4 hours

Patients Not Seen

Seen within 4 hours (%)

Readmission rates may indicate the appropriateness of treatment offered, whilst average length of stay may indicate the efficiency of treatment.

Buckinghamshire’s crude readmission rate is among the lower readmission rates of the trusts in the review as well as nationally, at 9.2%.

The standardised readmission rate, most importantly, accounts for the trust’s case mix and shows Buckinghamshire is statistically within the expected range.

Buckinghamshire’s average length of stay is 4.92 days, which is shorter than the national mean average of 5.2 days.

Operational Effectiveness – Emergency Re-admissions and Length of Stay

Buckinghamshire

Selected trusts Outside Selected trusts w/in Range

Standardised 30-day Readmission Rate

Slide 70 Source: Healthcare Evaluation Data (HED); Jan 12 – Dec 12

0%

5%

10%

15%

20%

25%

Cru

de R

eadm

issio

n R

ate

Crude Readmission Rate by Trust



0

1

2

3

4

5

6

7

8

9

10

Spell

Dura

tio

n (

Days)

Average Length of Stay by Trust


Buckinghamshire 4.92

PROMs Dashboard

PROMs Dashboard Analysis The PROMs dashboard shows that Buckinghamshire is a consistent performer, close to the national average on all measures for all years.

Slide 71

Source: PROMs Dashboard and NHS Litigation Authority

Knee Replacement OKS

0

5

10

15

20

2009/

10

2010/

11

2011/

12

England Average

Buckinghamshire

Upper Control Limit

Lower Control Limit

Slide 71

Leadership and governance

Slide 72


Overview:

This section provides an indication of the Trust’s governance procedures.

Review Areas:

To provide this indication of the Trust’s leadership and governance procedures, the following areas have been reviewed:

• Trust Board;

• Governance and clinical structure; and

• External reviews of quality.

Data Sources:

• Board and quality subcommittee agendas, minutes and papers;

• Quality strategy;

• Reports from external agencies on quality;

• Board Assurance Framework and Trust Risk Register; and

• Organisational structures and CVs of Board members.

Summary:

The Trust Board is relatively stable with two recent changes at Board level: the Chair joined the Trust in September 2012 and the Chief Operating Officer joined the Trust in Feb 2013. The Director of Human Resources (non-voting, in post since Jan 2013) is an interim post but all the other executive positions are substantive.

The Healthcare Governance Committee is chaired by a non executive (Keith Gilchrist) and reports directly to the Trust Board. The Trust has also established a Mortality Task Force.

A review of quality governance was performed by KPMG in October 2012. This review compared the governance arrangements in the Trust against Monitor’s Quality Governance Framework. KPMG scored the Trust 3.0 (trusts must achieve a score below 4 to be authorised as a foundation trust).

Key risks identified by the Trust relate to Accident & Emergency, staffing, the National Spinal Injuries Centre, theatres and Care of Older People.

Slide 73 All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.

Monitor governance risk rating n/a CQC Outcomes

Monitor finance rating n/a

Le

ad

er

sh

ip a

nd

g

ov

er

na

nc

e

This page shows the latest rating against regulatory standards, the items rated ‘red’ or ‘amber’ below are discussed in more detail in the following pages.

Slide 74


Governance risk rating CQC Concerns Red - Likely or actual significant breach of terms of authorisation Red – Major concern Amber-red - Material concerns surrounding terms of authorisation Amber – Minor or Moderate concern Amber-green - Limited concerns surrounding terms of authorisation Green – No concerns Green - No material concerns Financial risk rating rated 1-5, where 1 represents the highest risk and 5 the lowest

Trust Board

The Trust Board is relatively stable with two recent changes at Board level: the Chair joined the Trust in September 2012 and the Chief Operating Officer joined the Trust in Feb 2013. The Director of Human Resources (non-voting, in post since Jan 2013) is an interim post but all the other executive positions are substantive. There are five executive posts: Chief Executive, Director of Finance, Chief Operating Officer, Medical Director and Chief Nurse & Director of Patient Care Standards.

Governance and clinical structures

In November 2012 the Trust undertook a wide scale reconfiguration called Better Healthcare in Buckinghamshire. This reconfiguration led to consolidation of specialist clinical services on specific sites. Each of the three clinical divisions (Integrated Medicine, Surgery and Critical Care and Specialist Services) is clinically led by a divisional chair; presently within the Trust Divisional Chairs are doctors. Divisional chairs report to the chief operating officer. Responsibility for the operational running and governance of each division is shared with an associate chief nurse and an assistant chief operating officer. The Divisional Boards also report to the Trust Management Committee where quality and organisational operational business is discussed.

There are a number of Board sub-committees, including the Healthcare Governance Committee, Audit Committee and Trust Management Committee. The Healthcare Governance Committee, the forum for discussion of clinical governance matters ,reports directly to the Trust Board. The Healthcare Governance Committee is chaired by a non executive director (Keith Gilchrist). The Healthcare Governance Committee has several sub-committees including the Risk Monitoring Group and Infection Control Committee.

The Trust has established a Mortality Task Force, chaired by the Medical Director, which has a special remit to review patient care, the patient experience and clinical coding.

The Trust committee structure and board members are shown in the Appendix.

External reviews

Details of these are given overleaf.

Slide 75


Top risks to quality

Slide 76

The table includes the top risks and significant challenges identified by the Trust.

Trust identified risks Trust response

Accident and Emergency:

Post reconfiguration the performance of the four hour A&E

access targets had dropped (93.6% for 2012/13). This has led to

a diminution in patient experience as patients are in A&E for an

unacceptable time. Also it is recognised that whilst work has

been ongoing to improve the A&E environment, until this is

complete it is not the ideal care environment for patients.

Sir Jonathan Ashridge undertook a review of the service following

which he produced a report highlighting his concerns and made

recommendations. An action plan was produced to mitigate the risk.

The report also included the need to move to one site which was

undertaken as described above.

In February of this year the new COO invited in the national

Emergency Care Intense Support Team (ECIST) to review the A&E at

Stoke Mandeville. A report has been received in April and an action

plan is being developed around the findings.

Staffing:

The Trust recognises that in 2012/13 there was a need to reduce

the number off temporary staff and it is acknowledged that this

can have an impact on quality of care.

A recent CQC inspection has raised concerns around staffing

and some supervision issues and declared these as moderate

concern although it did not have a concern around patient care.

The Trust has aimed to mitigate the risk to the quality of care relating

to bank and agency staff by reviewing aspects of their role, for

example, restricting the administration of intravenous medicines to

Trust employed staff only who have undergone the relevant training.

There is also e-rostering in place with a new bank partner to help

manage and monitor our temporary staffing and importantly there is

an escalation process in place for the use of temporary staff.

Top risks to quality

Slide 77

The table includes the top risks and significant challenges identified by the Trust.

Trust identified risks Trust response

National Spinal Injuries Centre:

In 2011 a number of clinical incidents relating to the NSIC were

highlighted to the Trust executive. These incidents had been

reported by junior doctors through a Deanery visit and had not

been reported through other mechanisms. The issues related to

some staff not working within procedures and policies of the

treatment of the acute spinal patients.

The Deanery informed the executive and prompt action was taken.

The ward in question was closed to new patients and a review of the

area was undertaken and actions put in place.

There was also a recent case where a patient had not received the

correct level of ventilation support again by individuals not following

procedures. There has been a robust plan around this including a

review of staff numbers and staff training in this area.

The risk now lies at a lower level on the risk register however this

continues to be monitored to ensure that changes are embedded in

the unit and have a long term impact.

Theatres:

Over the last three years there have been six never events in

theatres; two occurring in 2012/13.

In addition there were concerns that theatres had an unhealthy

culture of behaviours and leadership issues.

Each of these has been reported and investigated as a Serious Event

and a root cause analysis investigation undertaken and which was

presented to the Serious Event Review Group. In each case actions

have completed to reduce the risk of occurrence of such incidents.

The Trust invited an external team from North West London NHS

Trust to review theatres. An active performance management process

and the historical concerns continue to be closely monitored.

Care of Older People:

The Trust is aware that nationally there is a rightful focus on the

care of older people using NHS services, and the Trust takes the

care of this vulnerable group of patients very seriously.

The recent Health Overview and Scrutiny Committee reports evidence

of good practice and the Trust want to see best practice consistently

applied across the whole organisation

External reviews

The CQC April 2013 report of an inspection carried in Mar 2013 indicates the following: There is an Enforcement Action in place for Stoke Mandeville Hospital for Outcome 14 (Staff should be properly trained and supervised, and have the chance to develop and improve their skills) Improvements are required for Outcome 13 at Stoke Mandeville Hospital (There should be enough members of staff to keep people safe and meet their health and welfare needs) Improvements are required for Outcome 13 at Amersham Hospital(There should be enough members of staff to keep people safe and meet their health and welfare needs) The August 2012 CQC report of Wycombe Hospital indicated that all standards are being met. A Quality Governance Review was conducted by KPMG in October 2012. The Trust’s position was assessed and scored using Monitor’s scoring methodology as detailed in “Applying for NHS Foundation Trust Status-Guide for Applicants” (July 2010). Each area of the 10 questions was scored. The findings identified no Red areas, no Amber/Red areas, 6 Amber/Green areas and 4 Green areas. The Trust’s overall score was calculated as being 3.0. This assumes that the Trust continues to implement identified actions and that the new systems and processes recently implemented become embedded in the Trust, in particular, the new divisional structure. From the review, it was noted quality impact assessments are in place for cost improvement programmes(CIPs), but the monitoring of the impact of CIPs on quality could be better enhanced by understanding the pre-implementation performance. Postgraduate Dean’s annual visit to Buckinghamshire Healthcare NHS Trust in June 2012 reported that although the Deanery focused on two main areas of concern (Anaesthetics/ICM and Dermatology), overall, the visiting team’s impression of the Trust was very positive. Who Cares? A report into the Care of Older People in Hospital Wards by Buckinghamshire County Council Health Overview & Scrutiny Committee Task and Finish Group, dated October 2012: The report makes a number of recommendations to the BHT Board, which are considered will raise both the standard of care, and consistency of care across its wards. The report recommendations therefore apply to all wards and not just those specialising in care for older patients.

Cost Improvement Programme

There was an overall £800k shortfall in the CIP target for 2012/13. The efficiency plans for the clinical divisions for 2013/14 include: Surgery: £3,499k (31.78 WTEs) Integrated medicine: £3,960k (35.97 WTEs) Specialist services: £4,980k (45.24 WTEs)

Slide 78

Leadership and governance – other areas for further review

Appendix

Slide 79

Trust Map – Stoke Mandeville Hospital

Slide 80

Source: www.medical-architecture.com

Serious harm definition

A serious incident requiring investigation is defined as an incident that occurred in relation to NHS-funded services and care resulting in one of the following:

Unexpected or avoidable death of one or more patients, staff, visitors or members of the public;

Serious harm to one or more patients, staff, visitors or members of the public or where the outcome requires life-saving intervention, major surgical/medical intervention, permanent harm or will shorten life expectancy or result in prolonged pain or psychological harm (this includes incidents graded under the NPSA definition of severe harm);

A scenario that prevents or threatens to prevent a provider organisation's ability to continue to deliver healthcare services, for example, actual or potential loss of personal/organisational information, damage to property, reputation or the environment, or IT failure;

Allegations of abuse;

Adverse media coverage or public concern about the organisation or the wider NHS; and

One of the core set of "Never Events" as updated on an annual basis.

Slide 81

Source: UK National Screening Committee

Workforce indicator calculations

Indicator Numerator /

Denominator

Calculation Source

WTE nurses per bed day

Numerator Nurses FTE’s Acute

Quality

Dashboard Denominator Total number of Bed Days

Spells per WTE staff Numerator Total Number of Spells HED

ESR Denominator Total number of WTE’s

Medical Staff to Consultant

Ratio

Numerator FTE whose job role is ‘Consultant’ ESR

Denominator FTE in ‘Medical and Dental’ Staff Group

Nurse Staff to Qualified Staff

Ratio

Numerator FTE in ‘Nursing & Midwifery Registered’ Staff Group ESR

Denominator FTE of Additional Clinical Services – 85% of bands 2, 3 and 4

Non-clinical Staff to Total Staff

Ratio

Numerator FTE not in ‘Nursing and Midwifery Registered’, ‘Additional Clinical

Services,’ ‘Allied Health Professionals’ or ‘Medical and Dental’ staff

groups

ESR

Denominator Sum of FTE for all staff groups

Consultant Productivity

(FTE/Bed Days)

Numerator Consultant FTE’s ESR

Denominator Total Bed Days

Nurse hours per patient day

Numerator Nurse FTE’s multiplied by 1522 (calculated number of hours per year

which takes into account annual leave and sickness rates)

ESR

HED Denominator Total Bed Days

Note: ESR Data only includes substantive staff.

Slide 82

Board of Directors

Slide 83 Source: Management_structure_chart_28.02.13.pdf" - Trust submission folder 6

Overall governance structure chart

Slide 84

TRUST BOARD Monthly

ASSURANCE STATUTORY

AUDIT

Bi-monthly

HEALTHCARE GOVERNANCE

Bi-Monthly

Nominations and Remuneration Committee

As and when necessary

CHARITABLE FUNDS

Quarterly

TRUST MANAGEMENT COMMITTEE

Monthly

OPERATIONAL

Source: MASTER-Governance structures Vs 7 August 2012.ppt" - Trust submission folder 7

Integrated governance assurance committees

Slide 85

Trust Board

Healthcare Governance Committee

Audit Committee

Divisional Boards

Integrated Medicine

Surgery and Critical Care

Specialist Services

Risk Monitoring Group

Infection Control Committee

Drug and Therapeutics Committee

Footnote: this depicts risk and assurance process, not operational management

Organ &Tissue Donation

Committee

Source: MASTER-Governance structures Vs 7 August 2012.ppt" - Trust submission folder 7

No. Data Source name Type Area

49 Outline Timetable - Mortality Outlier Review Analysis Mortality

50 CQC review of Mortality data and alerts -Blackpool NHSFT Analysis Mortality

51 Peoples Voice QRP v4.7 Analysis Patient Experience

52 Mortality outlier review -PE score Analysis Patient Experience

53 CPES Review Analysis Patient Experience

54 Pat experience quick wins from dh tool Analysis Patient Experience

55 PEAT 2008-2012 for KATE Analysis Patient Experience

56 PROMs Dashboard and Data for 14 trusts Analysis Patient Experience

57 PROMS for stage 1 review Analysis Patient Experience

58 NHS written complaints, mortality outlier review Data Patient Experience

59 Summary of Monitor SHA Evidence Analysis Patient Experience

60 Suggested KLOI CQC Analysis Patient Experience

61 Various debate and discussion thread Data Patient Experience

62 People Voice Summaries Analysis Patient Experience

63 Litigation Authority Reports Analysis Patient Experience

64 PROMs Dashboard Analysis Patient Experience

65 Rule 43 reports Analysis Patient Experience

66 Data from NHS Litigation Authority Analysis Patient Experience

67 Annual Sickness rates by org Analysis Safety and Workforce

68 Evidence from staff survey Analysis Safety and Workforce

69 Monthly HCSC Workforce Oct 2012 Quarterly tables turnover Data Safety and Workforce

70 Monthly HCSC Workforce Oct 2012 Annual time series turnover Analysis Safety and Workforce

71 Mortality outlier review -education and training KLOI Analysis Safety and Workforce

72 Staff in post Analysis Safety and Workforce

73 Staff survey score in Org Analysis Safety and Workforce

74 Agency and turnover Analysis Safety and Workforce

75 GMC ANNEX -GMC summary of education Data Safety and Workforce

76 Analysis of most recent Pat safety incident data for 14 Analysis Safety and Workforce

77 Safety Thermometer for non spec Data Safety and Workforce

78 Acute Trust Quality Dashboard v1.1 Data Safety and Workforce

79 Initial Findings on NHS written complaints 2011_12 Data Safety and Workforce

80 Quality accounts First Cut Summary Data Safety and Workforce

81 Monitor SHA evidence Analysis Safety and Workforce

82 Care and compassion - analysis and evidence Analysis Safety and Workforce

83 United Linc never events Analysis Safety and Workforce

84 QRP Materials Analysis Safety and Workforce

85 QRP Guidance Data Safety and Workforce

86 QRP User Feedback Analysis Safety and Workforce

87 QRP List of 16 Outcome areas Analysis Safety and Workforce

88 Monitor Briefing on FTs Analysis Safety and Workforce

89 Acute Trust Quality Dashboard v1.1 Analysis Safety and Workforce

90 Safety Thermometer Analysis Safety and Workforce

91 Agency and Turnover - output Analysis Safety and Workforce

92 Quality Account 2011-12 Analysis Safety and Workforce

93 Annual Sickness Absence rates by org Analysis Safety and Workforce

94 Evidence from Staff Survey Analysis Safety and Workforce

95 Monthly HCHS Workforce October 2012 QTT Analysis Safety and Workforce

96 Monthly HCHS Workforce October 2012 ATT Analysis Safety and Workforce

97 Source: Freedom of information request, BBC -

http://www.bbc.co.uk/news/health-22466496 Data Safety and Workforce

Slide 86

No. Data Source name Type Area

1 3 years CDI extended Analysis Clinical and Operational Effectiveness

2 3 years MRSA Analysis Clinical and Operational Effectiveness

3 Acute Trust Quality Dashboard Analysis Clinical and Operational Effectiveness

4 NQD alerts for 14 Analysis Clinical and Operational Effectiveness

5 PbR review data Data Clinical and Operational Effectiveness

6 QRP time series Analysis Clinical and Operational Effectiveness

7 Healthcare Evaluation Data Analysis General

8 GMC Annex - GMC summary of Education Evidence - trusts with high mortality rates Data General

9 1 Buckinghamshire Healthcare Quality Accounts Data General

10 Burton Quality Account Data General

11 CHUFT Annual Report 2012 Data General

12 Quality Report 2011-12 Data General

13 Annual Report 2011-12_final Data General

14 NLG. Quality Account 2011-12 Data General

15 Annual Report 2012 Data General

16 Litigation covering email Data Governance and leadership

17 Litigation summary sheet Data Governance and leadership

18 Rule 43 reports by Trust Data Governance and leadership

19 Rule 43 reports MOJ Data Governance and leadership

20 Governance and Finance Data Governance and leadership

21 MOR Board reports Data Governance and leadership

22 Board papers Data Governance and leadership

23 CQC data submissions Data Governance and leadership

24 Evidence Chronology B&T Data Governance and leadership

25 Hospital Sites within Trust Data Governance and leadership

26 NHS LA Factsheet Analysis Governance and leadership

27 NHSLA comment on five Analysis Governance and leadership

28 Steering Group Agenda and Papers incl Governance Structure and Timetable Analysis Governance and leadership

29 List of products Data Governance and leadership

30 Provider Site details from QRP Analysis Governance and leadership

31 Annual Report 2011-12 Analysis Governance and leadership

32 SHMI Summary Analysis Mortality

33 Diabetes Mortality Outliers Analysis Mortality

34 Mortality among inpatient with diabetes Analysis Mortality

35 supplementary analysis of HES mortality data Analysis Mortality

36 VLAD summary Analysis Mortality

37 Mor Dr Foster HSMR Analysis Mortality

38 Outliers Elective Non elective split Analysis Mortality

39 Presentation to DH Analysts about Mid-staffs Analysis Mortality

40 CQC mortality outlier summaries Data Mortality

41 SHMI Materials Analysis Mortality

42 Dr Foster HSMR Analysis Mortality

43 AQuA material Analysis Mortality

44 Mortality Outlier Review Analysis Mortality

45 Original Analysis Identifying Mortality Outliers Analysis Mortality

46 Original Analysis of HSMR-2010-12 Analysis Mortality

47 High-level Methodology and Timetable Data Mortality

48 Analytical Distribution of Work_extended table Data Mortality

Data Sources

Slide 87

No. Data Source Name Type Area

98 Health and Social Care Information Centre (HSCIC) monthly workforce

statistics Data Safety and Workforce

99 National Staff Survey, 2011, 2012 Data Safety and Workforce

100 GMC evidence to review, 2013 Analysis Safety and Workforce

101 2011/12 Organisational Readiness Self-Assessment (ORSA) Data Safety and Workforce

102 National Training Survey, 2012 Data Safety and Workforce

103 National Patient Safety Agency (NPSA) Apr 11 – Mar 12 Data Safety and Workforce

Data Sources

SHMI Appendix

Admission Method Treatment Specialty Diagnostic Group SHMI

Observed Deaths that

are higher than the

expected

Elective 315 – Palliative Medicine Cancer of esophagus 1476 1

Elective 315 – Palliative Medicine Cancer of colon 3995 1

Elective 315 – Palliative Medicine Cancer of rectum and anus 1587 1

Elective 315 – Palliative Medicine Cancer of bronchus; lung 1832 1

Elective 315 – Palliative Medicine Cancer of prostate 980 3

Elective 315 – Palliative Medicine Non-Hodgkin`s lymphoma 1583 1

Elective 315 – Palliative Medicine Multiple myeloma 891 1

Elective 315 – Palliative Medicine Secondary malignancies 814 2

Elective 315 – Palliative Medicine Deficiency and other anemia 4285 2

Elective 315 – Palliative Medicine Pleurisy; pneumothorax; pulmonary collapse 671 1

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Cancer of bronchus; lung 220 1

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Non-Hodgkin`s lymphoma 2368 1

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Leukemias 740 1

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Coma; stupor; and brain damage 309 2

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Coronary atherosclerosis and other heart disease 6489 1

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Pulmonary heart disease 1299 2

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Cardiac arrest and ventricular fibrillation 111 1

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Phlebitis; thrombophlebitis and thromboembolism 7522 1

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine)

Chronic obstructive pulmonary disease and

bronchiectasis 782 1

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Asthma 3541 1

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Pleurisy; pneumothorax; pulmonary collapse 292 1

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Esophageal disorders 2480 1

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Abdominal hernia 521 2

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Diverticulosis and diverticulitis 1052 1

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Peritonitis and intestinal abscess 331 1

Slide 88

SHMI Appendix



are higher than the

expected

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Liver disease; alcohol-related 306 3

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Other liver diseases 294 1

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Pancreatic disorders (not diabetes) 1170 2

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Gastrointestinal hemorrhage 595 1

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Other gastrointestinal disorders 1239 3

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Acute and unspecified renal failure 173 2

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Urinary tract infections 497 2

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Other connective tissue disease 979 1

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Other fractures 763 1

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Intracranial injury 329 1

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Complications of surgical procedures or medical care 725 2

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Poisoning by psychotropic agents 989 1

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Poisoning by other medications and drugs 1718 2

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Poisoning by nonmedicinal substances 5305 1

Non-elective 192 - Critical Care Medicine (also known as intensive care medicine) Other injuries and conditions due to external causes 1946 1

Non-elective 300 - General medicine Tuberculosis 779 1

Non-elective 300 - General medicine Bacterial infection; unspecified site 364 1

Non-elective 300 - General medicine Cancer of esophagus 160 3

Non-elective 300 - General medicine Cancer of stomach 171 2

Non-elective 300 - General medicine Cancer of colon 205 3

Non-elective 300 - General medicine Cancer of rectum and anus 164 2

Non-elective 300 - General medicine Cancer of liver and intrahepatic bile duct 184 1

Non-elective 300 - General medicine Cancer of pancreas 123 2

Non-elective 300 - General medicine Cancer of bone and connective tissue 155 1

Non-elective 300 - General medicine Cancer of uterus 219 2

Slide 89

SHMI Appendix



are higher than the

expected

Non-elective 300 - General medicine Cancer of cervix 229 1

Non-elective 300 - General medicine Cancer of other male genital organs 488 1

Non-elective 300 - General medicine Cancer of kidney and renal pelvis 164 1

Non-elective 300 - General medicine Leukemias 172 2

Non-elective 300 - General medicine Multiple myeloma 235 1

Non-elective 300 - General medicine Malignant neoplasm without specification of site 141 2

Non-elective 300 - General medicine Neoplasms of unspecified nature or uncertain behavior 176 1

Non-elective 300 - General medicine Diabetes mellitus without complication 231 1

Non-elective 300 - General medicine Diabetes mellitus with complications 139 1

Non-elective 300 - General medicine Other CNS infection and poliomyelitis 218 1

Non-elective 300 - General medicine Other hereditary and degenerative nervous system conditions 246 2

Non-elective 300 - General medicine Epilepsy; convulsions 135 2

Non-elective 300 - General medicine Retinal detachments; defects; vascular occlusion; and retinopathy 3123 1

Non-elective 300 - General medicine

Inflammation; infection of eye (except that caused by tuberculosis or sexually

transmitted disease) 1751 1

Non-elective 300 - General medicine

Peri-; endo-; and myocarditis; cardiomyopathy (except that caused by tuberculosis

or sexually transmitted disease) 137 1

Non-elective 300 - General medicine Hypertension with complications and secondary hypertension 275 1

Non-elective 300 - General medicine Coronary atherosclerosis and other heart disease 229 2

Non-elective 300 - General medicine Other and ill-defined cerebrovascular disease 1091 3

Non-elective 300 - General medicine Peripheral and visceral atherosclerosis 141 1

Non-elective 300 - General medicine Aortic; peripheral; and visceral artery aneurysms 134 1

Non-elective 300 - General medicine Asthma 284 2

Non-elective 300 - General medicine Aspiration pneumonitis; food/vomitus 119 3

Non-elective 300 - General medicine Other lower respiratory disease 125 1

Non-elective 300 - General medicine Appendicitis and other appendiceal conditions 337 1

Non-elective 300 - General medicine Regional enteritis and ulcerative colitis 264 1 Slide 90

SHMI Appendix



are higher than the

expected

Non-elective 300 - General medicine Intestinal obstruction without hernia 144 1

Non-elective 300 - General medicine Diverticulosis and diverticulitis 202 1

Non-elective 300 - General medicine Peritonitis and intestinal abscess 790 3

Non-elective 300 - General medicine Biliary tract disease 181 2

Non-elective 300 - General medicine Other liver diseases 113 1

Non-elective 300 - General medicine Chronic renal failure 249 2

Non-elective 300 - General medicine Other diseases of kidney and ureters 413 1

Non-elective 300 - General medicine Genitourinary symptoms and ill-defined conditions 212 1

Non-elective 300 - General medicine Skin and subcutaneous tissue infections 128 2

Non-elective 300 - General medicine Chronic ulcer of skin 197 2

Non-elective 300 - General medicine Other non-traumatic joint disorders 236 1

Non-elective 300 - General medicine Spondylosis; intervertebral disc disorders; other back problems 151 1

Non-elective 300 - General medicine Pathological fracture 282 1

Non-elective 300 - General medicine Fracture of neck of femur (hip) 348 1

Non-elective 300 - General medicine Fracture of upper limb 189 1

Non-elective 300 - General medicine Other fractures 181 1

Non-elective 300 - General medicine Intracranial injury 120 1

Non-elective 300 - General medicine Crushing injury or internal injury 330 1

Non-elective 300 - General medicine Syncope 124 1

Non-elective 300 - General medicine Shock 310 1

Non-elective 315 – Palliative Medicine Abdominal pain 201 1

Non-elective 315 – Palliative Medicine Cancer of esophagus 178 2

Non-elective 315 – Palliative Medicine Cancer of stomach 246 3

Non-elective 315 – Palliative Medicine Cancer of rectum and anus 345 2

Non-elective 315 – Palliative Medicine Cancer of liver and intrahepatic bile duct 161 1 Slide 91

SHMI Appendix



are higher than the

expected

Non-elective 315 – Palliative Medicine Cancer of pancreas 132 1

Non-elective 315 – Palliative Medicine Cancer of other GI organs; peritoneum 250 1

Non-elective 315 – Palliative Medicine Cancer; other respiratory and intrathoracic 356 1

Non-elective 315 – Palliative Medicine Cancer of bone and connective tissue 168 1

Non-elective 315 – Palliative Medicine Cancer of breast 181 3

Non-elective 315 – Palliative Medicine Cancer of uterus 159 1

Non-elective 315 – Palliative Medicine Cancer of cervix 413 1

Non-elective 315 – Palliative Medicine Cancer of ovary 222 2

Non-elective 315 – Palliative Medicine Cancer of brain and nervous system 277 1

Non-elective 315 – Palliative Medicine Leukemias 243 1

Non-elective 315 – Palliative Medicine Multiple myeloma 561 1

Non-elective 315 – Palliative Medicine Cancer; other and unspecified primary 263 2

Non-elective 315 – Palliative Medicine Malignant neoplasm without specification of site 162 2

Non-elective 315 – Palliative Medicine Other hereditary and degenerative nervous system conditions 688 1

Non-elective 315 – Palliative Medicine Other nervous system disorders 1198 1

Non-elective 315 – Palliative Medicine

Peri-; endo-; and myocarditis; cardiomyopathy (except that caused by tuberculosis

or sexually transmitted disease) 7867 1

Non-elective 315 – Palliative Medicine Congestive heart failure; nonhypertensive 423 2

Non-elective 315 – Palliative Medicine Pneumonia (except that caused by tuberculosis or sexually transmitted disease) 388 3

Non-elective 315 – Palliative Medicine Acute bronchitis 347 1

Non-elective 315 – Palliative Medicine Pleurisy; pneumothorax; pulmonary collapse 425 1

Non-elective 315 – Palliative Medicine Lung disease due to external agents 319 1

Non-elective 315 – Palliative Medicine Intestinal infection 382 1

Non-elective 315 – Palliative Medicine Other disorders of stomach and duodenum 2710 1

Non-elective 315 – Palliative Medicine Intestinal obstruction without hernia 601 1

Non-elective 315 – Palliative Medicine Urinary tract infections 635 2

Slide 92

SHMI Appendix



are higher than the

expected

Non-elective 315 – Palliative Medicine Other connective tissue disease 3368 3

Non-elective 315 – Palliative Medicine 231 - Other fractures 669 1

Slide 93

HSMR Appendix

Admission Method Treatment Specialty Diagnostic Group HSMR


are higher than the

expected

Non-elective 192 - Critical care medicine Acute and unspecified renal failure 174 2

Non-elective 192 - Critical care medicine Cancer of bronchus; lung 411 1

Non-elective 192 - Critical care medicine Chronic obstructive pulmonary disease and bronchie 1153 1

Non-elective 192 - Critical care medicine Coronary atherosclerosis and other heart disease 9759 1

Non-elective 192 - Critical care medicine Gastrointestinal hemorrhage 192 1

Non-elective 192 - Critical care medicine Intracranial injury 283 1

Non-elective 192 - Critical care medicine Leukemias 709 1

Non-elective 192 - Critical care medicine Liver disease; alcohol-related 435 3

Non-elective 192 - Critical care medicine Non-Hodgkin`s lymphoma 859 1

Non-elective 192 - Critical care medicine Other fractures 715 1

Non-elective 192 - Critical care medicine Other gastrointestinal disorders 1640 2

Non-elective 192 - Critical care medicine Other liver diseases 214 1

Non-elective 192 - Critical care medicine Peritonitis and intestinal abscess 196 1

Non-elective 192 - Critical care medicine Pleurisy; pneumothorax; pulmonary collapse 531 1

Non-elective 192 - Critical care medicine Pulmonary heart disease 3005 2

Non-elective 192 - Critical care medicine Secondary malignancies 649 1

Non-elective 192 - Critical care medicine Urinary tract infections 747 2

Non-elective 300 - General medicine Acute bronchitis 127 3

Non-elective 300 - General medicine Acute myocardial infarction 154 3

Non-elective 300 - General medicine Aortic; peripheral; and visceral artery aneurysms 147 1

Non-elective 300 - General medicine Biliary tract disease 189 2

Non-elective 300 - General medicine Cancer of bladder 177 3

Non-elective 300 - General medicine Cancer of breast 190 2

Non-elective 300 - General medicine Cancer of bronchus; lung 106 1

Non-elective 300 - General medicine Cancer of esophagus 154 2

Slide 94

HSMR Appendix



are higher than the

expected

Non-elective 300 - General medicine Cancer of pancreas 138 3

Non-elective 300 - General medicine Cancer of rectum and anus 152 1

Non-elective 300 - General medicine Cancer of stomach 214 1

Non-elective 300 - General medicine Chronic obstructive pulmonary disease and bronchie 102 1

Non-elective 300 - General medicine Chronic renal failure 148 1

Non-elective 300 - General medicine Coronary atherosclerosis and other heart disease 162 1

Non-elective 300 - General medicine Fracture of neck of femur (hip) 395 1

Non-elective 300 - General medicine Intestinal obstruction without hernia 165 2

Non-elective 300 - General medicine Leukemias 169 2

Non-elective 300 - General medicine Malignant neoplasm without specification of site 151 2

Non-elective 300 - General medicine Other circulatory disease 279 2

Non-elective 300 - General medicine Other liver diseases 145 2

Non-elective 300 - General medicine Other lower respiratory disease 121 1

Non-elective 300 - General medicine Peripheral and visceral atherosclerosis 128 1

Non-elective 300 - General medicine Peritonitis and intestinal abscess 416 2

Non-elective 300 - General medicine Senility and organic mental disorders 128 2

Non-elective 300 - General medicine Syncope 161 1

Non-elective 315 - Palliative medicine Cancer of breast 129 1

Non-elective 315 - Palliative medicine Cancer of bronchus; lung 133 3

Non-elective 315 - Palliative medicine Cancer of esophagus 125 1

Non-elective 315 - Palliative medicine Cancer of ovary 143 1

Non-elective 315 - Palliative medicine Cancer of pancreas 134 1

Non-elective 315 - Palliative medicine Cancer of prostate 129 3

Non-elective 315 - Palliative medicine Cancer of rectum and anus 323 2

Non-elective 315 - Palliative medicine Cancer of stomach 188 2

Slide 95

HSMR Appendix



are higher than the

expected

Non-elective 315 - Palliative medicine Intestinal obstruction without hernia 417 1

Non-elective 315 - Palliative medicine Other fractures 208 1

Non-elective 315 - Palliative medicine Pleurisy; pneumothorax; pulmonary collapse 205 1

Non-elective 315 - Palliative medicine Pneumonia (except that caused by tuberculosis or s 182 2

Non-elective 315 - Palliative medicine Urinary tract infections 214 1

Slide 96

Higher than Expected Diagnostic Groups HSMR / SHMI Summary (Elective)

Treatment Specialty HSMR SHMI

Palliative medicine X

Slide 97

Higher than Expected Diagnostic Groups HSMR / SHMI Summary (Non-elective)

Slide 98

Treatment Specialty HSMR SHMI

Critical care medicine X X

General medicine X X

Palliative medicine X X

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Buckinghamshire Healthcare NHS Trust Draft Data Pack 18th ...€¦ · Buckinghamshire is the 142nd most deprived. Ethnic diversity In Buckinghamshire, 13.6% belong to non-White minorities,