Report to the Sutton Clinical Commissioning Group

Governing Body

Date of Meeting: 11th January 2017

Agenda No: 14 ENCLOSURE: 13

Title of Document: Performance and Quality Report

Purpose of Report:

For Discussion

Report Authors:

Mary Hopper, Director of Quality

Helen Bailey, Director of Delivery

Clare Wilson, Deputy COO

Lead Director:

Mary Hopper, Director of Quality

Helen Bailey, Director of Delivery

Executive Summary: This report is to inform and provide assurance to the Governing Body about the

performance, quality and safety of service provision commissioned by NHS Sutton

CCG. Performance is generally reported up to Month 7 (October 2016) unless

otherwise stated.

This report is in the process of being reviewed and updated to provide a more

integrated view of performance and quality across Sutton CCG (section 1) and at

each of the main providers from whom Sutton CCG commissions services (sections

2-9). The aim is to provide an overview by CCG and provider of:

Quality

Performance (both in terms of standards and performance of the contract) and

finance

The final section of each performance and quality report will provide a deep dive into

an area of quality or performance. In the case of this report the deep dive relates to

the CQC Inspection at St. George’s.

Key issues to note are:

Performance against referral to treatment time Referral to Treatment (RTT) target achieved at aggregate level for every month of 2016/17

Sutton CCG has met eight of the eight CWT Standards for October 2016/17

Diagnostic test waiting time standard achieved in Month 7

A&E 4 hour wait pressures at St George’s in Month 7

London Ambulance Service did not meet response time standards at London level, however improving performance in Sutton

Healthcare Acquired Infection rates are within thresholds for C. Difficile Improving Access to Psychological Therapies was not achieved in October

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2016 (the second month of failure in the financial year), however recovery standards were met for the first time

Dementia diagnosis rate was at 67% in October 2016, and exceeded the National trajectory of 66.7%

GP Out of Hours service is achieving all performance standards up to October 2016 (Appendix 3)

Issues that have been discussed at the regular quality meetings with providers are outlined to highlight the level of challenge and scrutiny that occurs through these discussions with information on how any themes or trends are being identified and associated actions taken.

Key issues discussed with other local providers are also outlined along with information on how any concerns are being addressed. The report also covers safeguarding and updates on other quality risks.

Key sections for particular note (paragraph/page), areas of concern etc.: Focus is on the issues highlighted above.

Recommendation: The Governing Body is asked to:

REVIEW the Performance and Quality Report.

Committees which have previously discussed/agreed the report: Quality Committee (content presented). Executive Committee – 4th January 2017

Financial Implications: None noted.

Equality Impact Assessment: The CCG is committed to monitoring the compliance with the Equality duty of the providers from whom we commission services. This is done through the quality and contracting process.

Information Privacy Issues: The information contained in this report is in the public domain.

Communication Plan: This report will be published on the CCG public website as a report to the Governing Body.

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1. Sutton CCG

This section reports all providers for Sutton patients

Quality Performance standards

Key agenda items discussed at the Quality committee

External speakers from St George’s outpatients department provided

assurance on improvements that have been put in place to improve patient

safety and experience in this area.

A presentation was received from CCG Clinical leads on Cancer. The

presentation provided the Quality Committee with an opportunity to fully

understand the breadth of work being undertaken. The team have agreed to

provide a summary document of key issues at regular intervals going forward

to enable the Quality Committee and Governing Body to keep up to date on

this key area.

Lead commissioning manager presented on Kinesis, the interface service

between hospital consultants and GPs. The Quality Committee were keen to

understand that this process has mechanisms within it that ensured patient

safety. This assurance was given but work is now underway with the Trust to

look for further ways to strengthen this.

Standard Target met

in month?

Achieving YTD

performance?

No. months below

target 2016-17

Referral to

Treatment (RTT)

Y Y 0

Cancer waits Y Y 3 (June – Aug)

Diagnostic waits Y Y 2 (June, July)

52 week breaches Y Y 0

IAPT: Access N Y 2 (Sep, Oct)

IAPT Recovery N N All (Apr – Aug)

Dementia

diagnosis rate

Y N 6 (Apr – Sep)

MRSA One

assigned to

Epsom & St.

Helier Trust

Clostridium

Difficile

Y - Two new Y - 23 cf. 26

planned YTD

1

In month 7 (October) Sutton CCG failed to deliver performance above target for

Improving Access to Psychological Therapies. Both the access and recovery

targets were not achieved, however in the case of access this is not a long

term trend with achievement being missed in only two months of the financial

year. The recovery rate target continues to be an ongoing area where

performance requires improvement.

Dementia diagnosis rates performed above target for the first time in the

financial year in October 2016.

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1 Source – NHSE Operating Plan Tool

In a number of cases there has been some months were performance has

been below target however overall in year Sutton CCGs is still performing

above target.

Performance against all reported Referral to Treatment (RTT) and cancer

measures month on month is available in Appendix 1. All measures are

reported as green in October 2016. This is an improved position on September

when 62 day screening was below target for the third month and 31 day

definitive treatment underperformed for the first time in the financial year.

Finance Activity

Sutton CCG’s overall month 7 adjusted position for all acute activity is an over

performance of £706k against plan, displaying an adverse variance increase

from previous month by £85k. The adjusted forecast outturn reflects £742k

over performance.

The top drivers of overperformance across all contracts are:

Emergency Admissions (£889k) - driven by over performance at ESTH

(£582k), SGH (£142k) and RMH (£78k).

Critical Care (£849k) - driven by over performance at ESTH (£228k), SGH

(£241k), RMH (£111k).

There has been growth in most areas of secondary care when 2015-16 is compared to 2016-17. In the case of first outpatients, A&E attendances and non-elective admissions, these increased levels of activity are higher than plan. Elective admissions however have increasing at a lower rate than the planned growth.

Change 2015-16 to

2016-17

Comparison to plan1

Referrals +1.5%

First Outpatient Attendances

+2.3% +0.9%

Follow Up Outpatient Attendances

- 0.2% -8.3%

A&E Attendances +3.4% +5.5%

Elective Admissions +5.2% +3.0%

Non-Elective Admissions +6.0% +8.0%

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2. Epsom and St. Helier

2.1. Quality

Risk: Ventous Thrombosis Emboli Performance

Action: A recent drop in performance has now improved to 94% against a target of 95% due to increased

focus at ward level.

Risk: Infection Control

Action: CDifficile is running at 20 against a trajectory of 17. The new team is focusing efforts on high risk

wards. Overall the Hand Hygiene Audit result for Epsom site is 60% and at the St Helier site 56%. The

Infection prevention and control team is reviewing training in auditing. Robust implementation of monthly

audits is now properly owned by ward and departmental staff and there is commitment from staff to actively

challenge and approach colleagues not washing or gelling their hands properly. This coupled with

interventional training in infection control practice by the team in wards and departments is yielding

accurate and meaningful hand hygiene data. Areas with low compliance are now challenged through the

monthly performance meetings. There have been no new reported MRSA this month however there have

been four during the year to date.

Risk: Dementia Screening and Assessment stands at 59.6% and 53% against target of 90%.

Action: Dementia screening continues to prove to be a challenge; increased focus on this at ward level is

now in place to enhance performance.

Risk: Friend and Family Test A&E

Action: The response rate for the Friends and Family Test is above target for the quarter, with a dip

compared with the previous month. Healthcare Communications (HC) has been asked for information to

help understand the cause of the dip. Work is being undertaken with HC to ensure a sustained and stable

response rate continues.

Risk: Workforce turnover, sickness and vacancy have also risen in the last two months

Action: This rise is thought to be use to increased pressure and workload on staff, the Trust is undertaking

a detailed analysis to understand the underlying issues so they can respond appropriately. Assurance has

been provided that safe staffing has been maintained during this time. The Clinical quality review group

continues to receive updates in progress on the CQC inspection, good progress has been made there are

no current concerns.

2.2. Performance and Finance

Standard Target met in

month

Achieving YTD

performance?

No. months below target 2016-17

A&E >4 hours Y Y 4 (Apr – July)

Referral to Treatment (RTT) N N

Cancer waits Y Y 0

Diagnostic waits Y Y

52 week breaches N (1 breach) N (1 breach)

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A&E: Escalation beds have been used to achieve A&E targets in October. Some beds were closed in the 4th

week of the month due to Norovirus.

RTT: ESH cite a number of St. George’s related issues for difficulties in meeting the RTT target:

Late transfer of patients from St. George’s

Reduced capacity from consultants shared with St. Georges

Withdrawal of services at St. Georges

Additional issues are affecting a number of specialities:

Difficulties with recruitment

Loss of capacity through sickness

Some additional locum capacity has been acquired to help with backlogs (in dermatology, ENT and plastics).

Gynaecology work plans have also been changed to generate increased theatre time.

Virtual clinics have been put in place to assist with the reduction of the backlog.

Weekly update calls have been put in place between the Trust and CCG to monitor and manage progress.

3. St. George’s

3.1. Quality

See section 10 of this report for detail on quality at St. Georges.

3.2. Performance and Finance

A&E Waiting Times: St. George’s achieved 93.21% an improvement in performance of 1.01 percentage

points from the previous month and exceeds the M7 Sustainability and Transformation fund trajectory of

92.97%. Issues include:

High attendances

Reduced bed capacity

Staff

High number of trauma calls

Acuity levels peaked in week one and four, the Trust brought in specialities staff in the department for in-

reach support. The Trust met the standard for the final week of the month.

Financially, Sutton CCG is over plan by £689k (9%) year to date.

Standard Target met

in month

Achieving YTD

performance?

No. months below target 2016-17

A&E >4 hours N N 7 (Apr – Oct)

Referral to Treatment (RTT) Not currently

reporting

N 2 (Apr – May)

Cancer waits Y N 3 (Apr – June)

Diagnostic waits Y N

52 week breaches Not currently

reporting

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4. South West London and St. Georges Mental Health Trust (SWL&SG)

4.1. Quality

The Care Quality Commission has returned to the Trust and has now rated SWL&SG as good. The inspector

who returned in September was impressed by the improvements that were evident in the Trust Supervision,

administration and medicine management processes. 8 out of 10 core services were rated good which has

resulted in good as overall.

Safeguarding training –the CCG continues to be concerned around levels of adult safeguarding training

including PREVENT, Prevent is part of the Government counter-terrorism strategy. It's designed to tackle the

problem of terrorism at its roots, preventing people from supporting terrorism or becoming terrorists

themselves. This has been raised with the trust and action plans are being sought.

4.2. Performance and Finance

Patients entering treatment: The number of patients entering treatment in the IAPT service had a lower

than trajectory access rate in October 2016 at 14.2% (but this picked up again in November to 16.7%), year

to date performance is exceeding the National 15% trajectory.

IAPT recovery rates: The 50% target was met for the first time in October (however this has dropped

again to 45.1% in November). An improvement plan is in place for recovery and the CCG continues to

monitor this closely.

Further discussions continue to take place around the Autistic Spectrum Disorder (ASD)/Attention Deficit

Hyperactivity Disorder (ADHD) pathways; together South West London commissioners have made a non-

recurrent offer to the Trust to remedy the situation in the short term and build a sustainable future service.

CAMHs (Children Adolescence Mental Health): For Month 5, average waiting times for access to

CAMHS Tier 3 is 5.1 weeks with 100% of referrals seen within 8 weeks. Waiting times for ASD/ADHD

assessment have slipped from M4, with a M5 average wait time for assessment of 17 weeks (from 15.7

weeks in M4) with 70.6% of referrals seen within 12 weeks (NICE recommendation).

Child and Adolescent Mental Health Services: The provider is currently meeting all but one of its access

targets in Sutton. This being the percentage of children referred to the ASD/ADHD service that are seen

within 12 weeks (79%)

Other standards have been achieved (see appendix 2), with the following exceptions:

RTT: Incomplete Pathway: Percentage of patients on an incomplete pathway that have been

waiting less than 18 weeks.

Following a workshop in August, South West London CCGs and South West London & St George’s

Mental Health Trust have put in a bid for non-recurrent monies to invest in the CAMHS

neurodevelopment (ND) service in order to clear waiting lists. The bid is in response to a recent

communication from NHS England stating that there was an additional £25m available for 2016-17.

Standard Target met

in month?

Achieving YTD

performance?

No. months below

target 2016-17

IAPT: Access N Y 2 (Sep, Oct)

IAPT Recovery N N All (Apr – Aug)

IAPT recovery rate Y (50.5%) N 6 (Apr – Sept)

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CCGs have also been discussing back up options to provide additional investment in the

neurodevelopment service to ensure it is sustainable in the longer term. This area is still

underperforming and a report has been requested.

Access to services Community Mental Health Teams (CMHT) 2: Percentage of patients that

were assessed within 7 calendar days of referral. (Urgent Referrals)

Access to services – Older People CMHTs 2: Percentage of patients that were assessed within

seven calendar days of referral. (Urgent Referrals)

Both indicators show an underperformance at month 7. As numbers are small this can lead to a

significant change in the percentage

Communication with Primary Care at point of Discharge: All service users to have a discharge

summary sent to the GP within 24 hours of discharge (IP and Day case only). Work is being

undertaken using electronic methods to ensure delivery.

5. Sutton Community Health Services

5.1. Quality

A senior meeting has taken place as activity levels and staffing issues in some key services has become a

source of concern within the CCG. The Chief Operating Officer has requested a recovery plan from The

Royal Marsden by mid-February.

Risk: Staffing

Action: Key senior staff have recently retires further assurance is being sought on mitigation to replace

these experienced nurses.

Risk: MSK

Action: CCG have appointed a MSK programme manager to ensure the MSK service develops at pace

and new pathways are implemented.

Risk: LAC (Looked after Children) Health assessments

Action: Further assurance has been sought on LAC nurse capacity to ensure health assessments are

carried out effectively.

Work continues to improve performance data. Clinical Quality Review Group (CQRG) in December will

include all these items for further assurance and discussion.

5.2. Performance and Finance

Further detail has been requested however performance KPIs are now up to date with accurate monitoring

in place from December 2016 and there was full attendance at the last Contract Review Meeting by the

RMH team. The new Business Intelligence team is in place as is the quality lead for this contract. The CCG

is assured of greater focus moving forward.

6. 111 & Out of Hours

The GP Out of Hours service, provided by SELDOC, has performed well in 2016-17, achieving all national

quality requirements up to October 2016.

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7. London Ambulance Service

Target London

Sutton

only

Ambulance Red 1 (8 minute response) 75% 69.4% 77.1%

Ambulance Red 2 (8 minute response) 75% 66.3% 66.3%

Cat A 8 minute response 75% 66.4% 72.8%

London Ambulance Service (LAS) have not met two (Red 1 and Red 2) of the three standards London-wide

for response times since May 2014 and have an improvement plan in place.

Local response times in Sutton are improving towards the action plan trajectory. The Cat A (19-minute

target) is on plan at 97.0% (target 95%) in October. Commissioners across London continue to monitor

progress against the agreed action plan.

8. Learning Disability

Winterbourne View Concordat: Assuring transformation of care for NHS funded patients

The CCG and the Local Authority must be able to assure people with learning disability and those on the

Autistic Spectrum Disorder (ASD) spectrum, their families and carers, the wider public and the Department

of Health that our commitments to the Winterbourne View Concordat action plan are delivered.

The NHS England’s objective is to ensure that CCGs work with Local Authorities to ensure that vulnerable

people, particularly those with learning disabilities and autism, receive safe, appropriate, high quality care.

The presumption should always be that services are local and that people remain in their communities.

We continue to assure the Governing Body that person-centred, community-based services are in place to

meet the needs of any local people in this vulnerable group; to limit problems arising, manage any

problems that do arise, and prevent future institutional admissions.

The assurance meeting for People with Learning Disabilities (PLD) which commenced in January 2015 has

now resulted in the contemporaneous production of a risk register together with a quarterly reporting

dashboard from the Learning Disability Health Team. Key issues identified for priority have included

improved transition planning and a set of initial actions has been formulated and agreed that will support

this.

As of December 2016, the CCG now has four patients subject to NHS England “Transforming Care”

reporting, despite having earlier in 2016 successfully stepped two down from hospital registered service

into the community. Two of these are recent CAMHS “graduates”, whilst a 3rd is an inherited case from

another borough and CCG of a patient placed in Sutton and subsequently detained under the Mental

Health Act 1983. Care and Treatment Reviews have been held on all four.

9. Care Homes

Work continues through the Joint intelligence group to identify and support homes where concerns are

raised. Two new homes have recently opened in Sutton and the Local Authority and CCG are working

closely together to ensure a safe opening. A joint policy between the CCG and Local Authority has been

created to ensure new homes have a clear understanding on the expectations required of them in Sutton.

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10. Deep dive on St. Georges CQC Inspection

What was the Trust’s Overall Rating?

What were the ratings for St Georges Tooting? How does this inspection compare to 2014?

Core Area Inspected (St Georges Tooting

Only) 2014 2016

Accident and emergency/Urgent and

emergency services Good Requires improvement

Medical care/ Medical care (including older

people’s care) Good Requires improvement

Surgery/ Good Requires improvement

Intensive/critical care/ Outstanding Good

Maternity and family planning/ Maternity

and gynaecology Good Good

Services for children & young people/ Good Requires improvement

End of life care/ Requires

improvement Requires improvement

Outpatients/Outpatients and diagnostic

imaging Good Inadequate

Overall Good Requires improvement

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What were the key findings?

• Caring staff who, whilst working under pressure, spoke with candour about their experience of working at St George’s

• A workforce who, with the right leadership and support, are focussed on improving quality and enhancing patient experience

• Disconnected governance arrangements meant that lessons were not always learnt and risks were not always effectively managed

• An ageing estate impacting on the overall quality of care and poor experience for patients

What were the areas of outstanding practice?

• Outcomes for renal patients in relation to survival rates and transplant outcomes were excellent and some of the best in the country

• The outcomes achieved by the specialist medical and surgical services provided by St George's Hospital

• The effectiveness of maternity care delivered by the St George's Hospital

• The responsiveness of the neonatal unit to parents whilst their baby was on the unit and the support provided by the outreach nurse

• The involvement of children of varying ages on the interview panel as part of the recruitment process for ED paediatric nurses

Next Steps

• Trust in Special Measures (enhanced surveillance).

• Quality Summit held on 2nd November 2016

• Programme of work to address Section 29A Warning notice (“Must Do”) areas of improvement –30th November 2016

• Development of CQC Action Plan jointly with NHSE

• CQRG2 – To monitor progress of CQC actions (CCG/NHSI joint chairs)

• Joint Single Oversight Group - SOG (SGH/NHSI/CCG/NHSE) for ongoing oversight and escalation from CQRG2

Trust Response to CQC Report

• The Trust has accepted the findings of the report and their responsibility to address the issues

• ‘’We will be realistic in our plans and determined in our delivery’’

• ‘’We will prioritise to ensure that we achieve’’

• ‘’We need, and welcome, support’’

• Trust was open about the challenges in their presentation to the inspectors

• The report largely reflects the themes that were identified

• There has been progress once inspection occurred in June 2016

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Appendix 1: CCG Performance Dashboard 2016/17 Month 7 (October 2016)

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Appendix 2: Sutton CCG Mental Health Performance 2016/17 Month 7 (October 2016)

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Appendix 3: GP Out of Hours (SELDOC) Performance

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