Governing Body Meeting in Public - East and North ......from HPFT as part of the CQUIN to drive up self-referrals (through radio adverts and billboard adverts etc). ENHCCG has recently

Agenda Item No: 4.2

Date of Meeting: 24th October 2013

Governing Body Meeting in Public

Paper Title: ENHCCG Performance and Quality Report October 2013

Decision Discussion Information Follow up from last meeting

Report author: Gerry Moir, Assistant Director Performance

James Gleed, Associate Director Quality Report signed off by: Alan Pond, Director of Finance

John Webster, Director of Commissioning Sheilagh Reavey, Director of Nursing and Quality

Purpose of the paper: To update the Board

Conflicts of Interest involved:

None to note

Recommendations to the Board

The Governing Body is asked to note the current performance and actions described in the paper.

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East and North Hertfordshire CCG Performance and Quality Report

EXECUTIVE SUMMARY

1. Introduction This Performance and Quality report provides an update on the performance of local NHS Trusts in relation to key national performance indicators. It includes quality and performance information from an ENHCCG commissioner view perspective and also from a provider perspective. Published information for August 2013 has been used.

2. Acronyms used in the Report ENHCCG East and North Hertfordshire Clinical Commissioning Group ENHT East and North Herts NHS Trust PAH Princess Alexandra Hospital NHS Trust BCF Barnet and Chase Farm Hospitals NHS Trust HPFT Hertfordshire Partnerships Foundation NHS Trust EEAST East of England Ambulance Service NHS Trust HCT Hertfordshire Community NHS Trust HVCCG Herts Valley Clinical Commissioning Group A&E Accident and Emergency RTT Referral to Treatment QP Quality Premium MRSA Methicillin-resistant Staphylococcus Aureus IAPT Increased Access to Psychological Therapies SI Serious Incident FFT Friends & Family Test

3. Key Concerns

The key concerns for ENHCCG in relation to performance & quality are as follows:

• Barnet and Chase Farm The trust has failed to meet the required standards for 4 hour A&E waits, diagnostic waits and mixed sex accommodation (MSA) breaches to date in 2013/14. The MSA breaches are likely to be as a result of the stricter guidance used by London trusts in recording MSAs and this will be aligned to the rest of the country in September when an improvement is expected. The A&E waits remain a concern as the trust is unlikely to achieve the required 95% standard in 2013/14. ENHCCG patients are more likely to access Chase Farm where performance is much better than at the Barnet site. Of greater concern is the issue that has arisen around high numbers of patients waiting more than 52 weeks for their first definitive treatment. The target for referral to treatment times is that 90% of all admitted patients should be seen within 18 weeks. The Trust Development Authority and Enfield CCG are jointly holding fortnightly meetings to address the concerns and discussions are taking place around how to address the Trust’s limited capacity to deal with the backlog and also to be able to treat new patients within 18 weeks, particularly in the specialties of Ear, Nose and Throat (ENT) and Trauma and Orthopaedic (T&O). The Trust has already highlighted capacity issues in these specialties and alternative providers are currently being sought. Practices that refer into BCF are aware of the situation. The CCG will work with the practices to identify alternative capacity should redirecting to other providers become a problem. • Quality Premium Although ENHCCG has had 3 cases of MRSA attributed to ENHCCG patients, no definitive decision has been reached as to whether these will impact on the QP. This remains an area of risk and could result in an automatic reduction to the QP of £351k. Progress in achieving the QP measures is being monitored on a monthly basis and there are risks around meeting the required

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targets for the local measures in relation to diabetes, but plans are in place to address this and to get performance back on track. Achieving the required performance for ambulance response times remains the greatest risk to the QP for the CCG as current performance is below the required target of 75%, and the winter months pose more pressures to meeting required response times. There are plans in place at EEAST to recruit more paramedics and therefore the current forecast position remains at £2.8m.

4. Commissioner View – Performance against key national indicators and local targets This section highlights the performance from a commissioner perspective for all ENHCCG

patients, irrespective of where they receive their care. In the main this will be local acute trusts, but will also include non-local providers such as London trusts. All but one of the cancer targets are being met for ENHCCG patients. There are issues around stoke performance which are largely due to ENHHT and PAH. Performance at PAH has improved significantly for August with all key targets being met, and performance has improved for ENHHT. All the total RTT performance metrics were achieved for July for ENHCCG patients. Performance of EEAST at ENHCCG level remains a concern in relation to Red 1 Category A 8 minute response times, but all other Red and Green targets are being met.

ENHCCG is over trajectory for cases of C Difficile and is predicted to be significantly so at year

end, if the trend seen in the first 6 months continues. The Infection Prevention & Control Nurse Specialist for the Herts CCGs has now commenced in post and ENHCCG is also working with the Prescribing Team to increase the focus on primary care antibiotic prescribing.

Reporting of SIs by providers within the deadline of 2 working days has been a cause for concern

at ENHHT and HCT, this has been raised at the Quality Review meetings with both providers and the CCG are closely monitoring performance.

5. Provider View – Performance against key national indicators and local targets

ENHHT ENHT is failing to meet key stroke targets and has submitted an action plan against which progress is being monitored by the CCG at stroke performance meetings. Although the performance for August has shown a marked improvement, the Trust are not yet meeting required standards and the stroke meetings will continue to be held until performance is back on track. Indicative performance figures for September suggest that the Trust is making good progress to meet required standards for stroke. With the exception of stroke, ENHHT are meeting key performance metrics. RTT total performance targets are being met although there remain some issues in relation to admitted T&O patients but the submitted action plan shows that performance is expected to be back on track by October. The majority of cancer targets were met for July with 1 patient breach resulting in the Trust narrowly missing the required target for 62 day screening waits. The Trust continues to exceed the required targets for A&E 4 hour waits and diagnostic 6 week waits. The SHMI for July 2013 (rolling year Jan – Dec 2012) rose to 113.9, placing the Trust 134th out of 142 trusts. However this figure is predicted to fall in the next 2 SHMI releases due at the end of this month and in January 2014.The CCG is working closely with ENHHT on their approach to reducing Mortality and this has been bolstered by the inclusion of the ENHCCG Medical Advisor, whom has Public Health expertise at the joint Trust – CCG Mortality Review Group Meetings. PAH Despite concerns around stroke performance, August figures show a significant improvement with all key metrics being met. The CCG are in the process of validating the information to provide assurance that the performance has improved. A contract query has been served on the Trust by West Essex CCG as a consequence of the Trust not consistently meeting targets and performance will be closely monitored going forward. On the whole performance was good against cancer metrics with a very small number of patient breaches resulting in the Trust not meeting 3 of the 9 key metrics. Increases in A&E attendances resulted in the Trust just failing to meet the 95% target for A&E waits within 4 hours for July, but were back on track for August.

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Diagnostic waits were met overall but the Trust continues to fail to meet the required standard for flexi-sigmoidoscopy and is in the process of submitting a recovery plan to commissioners. The Quality and Performance meetings hosted by West Essex CCG are being restructured to give a greater emphasis on quality concerns and will also address some of the issues around data quality. BCF There are many significant concerns at BCF around the Trust’s continued failure to meet key targets around RTT waits, A&E 4 hour waits and diagnostic waits. Of most concern is the fact that the Trust has a large number of patients breaching 52 weeks and the CCG is involved in discussions with the Trust in conjunction with Enfield, Barnet and Haringey CCGs and the Trust Development Authority on how it will address the backlog. The Trust’s Friends and Family Test response rates and scores have been poor (the Trust’s first published A&E score was so low that it attracted media attention over the summer). The Trust believes that the building work at Barnet A&E and the interface with social care were responsible for the low score and have taken action to improve both their response rates and scores, including increasing the number of patient held trackers and planning of a multiagency workshop to look at Delayed Transfer of Care (DTC) and partnership working with social care. Improvement was seen in August and Performance will be monitored through the Quality Review meetings. The CQC undertook unannounced visits to both Trust hospital sites, the A&E Department at Barnet and Canterbury Ward at Chase Farm. The CQC judged that action was required at both sites, however the Trust stated that they were already aware of the concerns relating to Canterbury Ward and action was being taken. Action plans are in place and progress will be monitored regularly at the Trust Board and also through the Quality Review Meetings. The Trust remains consistently above its threshold for Caesarean Section rates and earlier in the year was contacted by The CQC in relation to being an outlier (high) for emergency Caesarean Section. The Trust has revised their action plan in response and this is currently being reviewed at the Quality Review Group meetings. EEAST The Trust published its integrated action plan in September following publication of the Turnaround Plan in April. One of the main aims is to significantly increase the number of paramedics resulting in a rise in the number of double staffed ambulances across the patch, particularly in rural areas. A 'review of operations' is underway as part of the restructuring required to provide support for the investment of £20m in frontline services. Response times and handover times remain an area of concern, particularly with the onset of winter. HPFT

In relation to IAPT, there has been a drop in recovery rates, but they are currently above the 50% threshold for ENCCG. In terms of numbers entering treatment, August has been a traditionally challenging month for HPFT, but overall the numbers remain below trajectory. Training for the extra capacity has started, although the benefits of that will likely not be seen until January, and this needs to be coupled with an increase in referrals from GPs - and also the continued work from HPFT as part of the CQUIN to drive up self-referrals (through radio adverts and billboard adverts etc).

ENHCCG has recently met with HPFT’s Senior Executive to discuss recent Serious Incidents and

Safeguarding concerns, including the death of a patient and agree a number of actions to deliver a greater level of assurance. HCT Sickness absence and staff turnover are an area of concern, the performance in these areas having exceeded the limit for each month in the period covered in this report (April – August 2013). The Trust believes their staff turnover will come down once fixed term contracts are removed from the data. ENHCCG continues to seek assurance from the Trust on workforce and that there is no adverse impact on the responsiveness, safety and quality of services. The

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number of grades 3 & 4 pressure ulcers reported by the Trust continue to be monitored carefully by the CCG and all investigation reports are individually thoroughly critiqued and also evaluated in the collective to ensure any trends are identified e.g. staffing levels. HUC There are National Quality Requirements for Out-of-Hours Providers and ENHCCG will be working with HUC to ensure that going forward, planning and service design enables all standards to be met. NHS111 There is a large amount of information collected in relation to NHS 111. This report details the key metrics in line with those monitored by the Area Team and shows that the key performance target is being met for the percentage of calls answered within 60 seconds. All the performance information is currently being reviewed alongside a benefits realisation process now that the service has been up and running for a year in order to measure the impact of the service on the different elements of the urgent and emergency care system.

6. Submission to Area Team ENHCCG submitted its Balanced Scorecard for Q1 to the Area Team. This is included within the Performance and Quality Report. It is an assessment of how the CCG is performing against the Domains in the NHS Outcomes Framework 2013/14 and how main providers are performing. Main providers are detailed as those providers where ENHCCG commissioning constitutes more than 5% of the provider’s income.

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CONTENTS

ENHCCG PATIENT SUMMARY

PROVIDER VIEWEast and North Herts NHS TrustPrincess Alexandra NHS TrustBarnet and Chase Farm NHS TrustTrust ComparisonHertfordshire Partnerships University NHS Foundation TrustHertfordshire Community TrustEast of Englan Ambulance Service NHS TrustHerts Urgent Care - out of HoursNHS111

QUALITY PREMIUM

Q1 SUBMISSION TO AREA TEAM

East and North Herts CCG Performance and Quality Report

October 2013

ENHCCG SUMMARY

Domain Measure DetailTarget/Threshold Apr May Jun Jul Trend Comments

People who have had a stroke and are admitted to an acute stroke unit within four hours of arrival to hospital 90% 51.40% 74.30% 71.43% 47.37%

Proportion of people who have had a stroke who spend at least 90% of their time in hospital on a stroke unit 80% 75.00% 76.30% 83.78% 58.14%

Proportion of people at high risk of stroke who experience a TIA are assessed and treated within 24 hours

60% 80.00% 80.00% 66.67% 65.71%

Non haemorrhagic strokes receive thrombolysis within 3 hours of onset 12% 6.50% 8.80% 14.71%

Patients with low risk TIA have access to MRI or carotid scan within 7 days 65% 45.50% 59.50% 56.25% 61.90%

MRSA 1 0 0 1 See commentary below

C.difficle 10 9 13 15 Aug total is 6, Sep total is 4See commentary below

Maximum two-week wait for first outpatient appointment for patients referred urgently with suspected cancer by a GP

93% 97.10% 97.30% 96.40% 97.40%

Maximum two-week wait for first outpatient appointment for patients referred urgently with breast symptoms (where cancer was not initially suspected)

93% 94.40% 96.30% 96.20% 97.70%

Maximum one month (31-day) wait from diagnosis to first definitive treatment for all cancers 96% 97.80% 99.50% 98.30% 96.60%

Maximum 31-day wait for subsequent treatment where that treatment is surgery 94% 97.50% 100.00% 100.00% 95.90%

Maximum 31-day wait for subsequent treatment where that treatment is an anti-cancer drug regime 98% 100.00% 100.00% 100.00% 100.00%

Maximum 31-day wait for subsequent treatment where that treatment is a course of radiotherapy 94% 97.10% 100.00% 97.70% 98.60%

Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer 85% 92.20% 85.70% 88.30% 84.90% Awaiting publication of Cancer figures for

Barnet and Chase Farm for JulyMaximum 62-day wait from referral from an NHS screening service to first definitive treatment for all cancers

90% 90.90% 95.20% 93.80% 100.00%

Maximum 62-day wait for first definitive treatment following a consultant's decision to upgrade the priority of the patient (all cancers)

85% 90.50% 100.00% 92.90% 91.70%

RTT - admitted patients to start treatment within a maximum of 18 weeks from referral - ALL 90% 84.29% 88.69% 88.83% 90.84%

RTT - Non-admitted patients to start treatment within a maximum of 18 weeks from referral - ALL 95% 96.64% 97.07% 97.16% 96.64%

Patients on incomplete non-emergency pathways (yet to start treatment) should have been waiting no more than 18 weeks from referral

92% 94.89% 95.26% 95.63% 94.98%

Total numbers waiting at the end of the month on an incomplete RTT pathway 24,831 25,118 25,445 20,904

Diagnostic test waiting times Patients waiting for a diagnosis test should have been waiting less than 6 weeks from referral 99% 99.01% 99.62% 99.78% 99.65%

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Cancer waits - 31 days

Cancer waits - 2 week wait

There are issues at PAH and which are being addressed through a contract query by West Essex CCG.Progress against the action plan submitted by ENHHT is being monitored at monthly stroke performance meetings, and figures for August already show an improvementStroke

Incidence of healthcare associated infection

Referral to Treatment Times

3

5

ENHCCG SUMMARY

Domain Measure DetailTarget/Threshold Apr May Jun Jul Trend Comments

A&E WaitsPROXY INFO CCG

Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department 95% 95.48% 96.10% 96.15% 95.76%

Limit for cases for period Number of cases

39 57 114ENHCCG

C.Difficlile cases

The Infection Prevention & Control Nurse Specialist for the Herts CCGs has now commenced in post and will provide leadership to the work across the county and specifically to the work of the C Difficile Task Force. The CCG is also working with the Prescribing Team to increase the focus on primary care antibiotic prescribing, and has written to each GP practice and raised this as part of quality monitoring of Herts Urgent Care in respect of the Out of Hours Service.

ENCCG PositionHealthcare acquired infectionsThere is a DH limit of zero cases of MRSA bactaraemia for all CCGs and all Providers. To date there are 3 cases attributed to ENHCCG: 1 patient at ENHHT in April, one patient at University College Hospitals NHS Foundation Trust in July and a non-acute patient treated in Suffolk in August. This patient is resident abroad and the CCG is challenging the attribution. The deadline for submitting this Post Infection Review was missed. The CCG is over trajectory for cases of C Difficile and is predicted to be significantly so at year end*, if the trend seen in the first 6 months continues.

April to Sept 2013 2013/14

End of year limit Predicted end of year*

75

EAST AND NORTH HERTS HOSPITALS TRUST

Domain Measure Detail Target/Threshold

Apr May Jun Jul Aug Trend Comments

Overall SHMI (emergency and elective) 100 (national average) 111.4 113.9

SHMI- Stroke 100 118.6 128SHMI- COPD 100 104.9 102.4SHMI- MI 100 135.6 129.6SHMI- #NOF 100 125 123.2SHMI- Pneumonia 100 122.8 121.2SHMI- CHF 100 117.3 119.2SHMI- Renal 100 117.7 107.1SHMI- Diabetes 100 139.5 114.3

People who have had a stroke and are admitted to an acute stroke unit within four hours of arrival to hospital 90% 51.30% 77.40% 75.00% 57.58% 70.50%

Proportion of people who have had a stroke who spend at least 90% of their time in hospital on a stroke unit

Local contractual requirement 90% 73.20% 73.80% 81.80% 64.86% 71.40%


60% 61.90% 81.00% 78.90% 70.59% 45.00%

Non haemorrhagic strokes receive thrombolysis within 3 hours of onset 12% 5.71% 13.16% 17.20% 6.06% 9.10%

Patients with low risk TIA have access to MRI or carotid scan within 7 days 65% 67.90% 57.90% 58.30% 62.96% 61.50%

4 Complaints Number of new complaints received For information 80 64 58 62 70Inpatient Friends and Family score For information 72 71 76 79 82A&E Friends and Family Score For information 73 70 72 66 60

4 Mixed Sex Accommodation (MSA) Number of clinically unjustified MSA breaches 0 0 0 0 0 0

Number of SIs declared (excluding pressure ulcers) For information 5 7 2 8 2 See Appendix 1Never Events 0 0 0 0 2 0 1 confirmed, 1 awaiting decision

5 VTE VTE Risk Assessment 98% 97.88% 97.50% 96.10% 97.93% 97.41%Performance has dropped from 2012-13. Trust investigating as no change in practice. Q1 CQUIN target of 98% not met.

5 Pressure Ulcers Number of Hospital Acquired Pressure Ulcers (Grades 3 and 4) 2 1 2 3 0 The trust have not reported an avoidable Grade 4 PU since

October 2011

Number of patients diagnosed with C-diff >48 hours post admission Annual ceiling 14 1 2 4 1 2

Number of patients diagnosed with MRSA >48 hours post admission 0 1 0 0 0 0

Percentage Caesarean Section rate (total) 26% 27% 24% 24% 20% 27%Trust report high number of twin births in month – no other reason identified, & trust expect rate to fall again next month.

Percentage of planned Caesarean Section For information 11% 8% 13% 8% 12%Percentage of unplanned Caesarean Section For information 16% 16% 11% 12% 15%

All CQUIN scheme achievement Percentage of CQUIN scheme paid per quarter as a proportion of total money available not available 70% confirmed, 5% not achieved; additional 25% under

discussionPercentage sickness absence rate 3.50% 3.44% 3.43% 3.44% 3.46% 3.46%Percentage staff turnover rate 10% 10.29% 10.31% 10.29% 10.07% 10.09%


93% 98.40% 98.10% 97.30% 98.30%


93% 97.10% 99.20% 95.90% 96.50%

(data published quarterly)

Stroke

All

5


5

5

An action plan has been submitted and reviewed by the CCG. Following improvements in August, stroke performance meetings will be held monthly unless performance deteriorates. The CCG are reviewing progress against the action plan.

See Commentary below

The trust is exceeding both its MRSA and C Difficile ceilings, with an additional case of C-Difficile declared in October, bringing the total to 12 ytd. The trust have reported several cases as indicative of infection prior to admission, but not tested within the 72 hour window. The trust underwent a two day TDA HCAI inspection in September, with positive feedback received and only minor actions required. The CCG has requested the action plan once developed.

1

Patient Survey4

3

Mortality- SHMI Standardised at National mean (100%).Computed in respect of actual death rates (per condition) of patients dying in hospital and 30 days after discharge. This is reported against expected death rates (for the same condition) adjusted for local population demographics.

All data from National Website published April 13. All mortality data has long lags in

Workforce

Maternity Services


Serious Incidents (SI)

Healthcare Acquired Infections (HCAI)

EAST AND NORTH HERTS HOSPITALS TRUST

Domain Measure Detail Target/Threshold

Apr May Jun Jul Aug Trend Comments

Maximum one month (31-day) wait from diagnosis to first definitive treatment for all cancers 96% 96.80% 97.50% 98.30% 97.70%

Maximum 31-day wait for subsequent treatment where that treatment is surgery 94% 96.43% 100.00% 100.00% 100.00%

Maximum 31-day wait for subsequent treatment where that treatment is an anti-cancer drug regime 98% 98.40% 98.50% 100.00% 100.00%

Maximum 31-day wait for subsequent treatment where that treatment is a course of radiotherapy 94% 100.00% 98.30% 98.40% 99.40%

Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer 85% 85.70% 86.50% 85.10% 85.80%

Maximum 62-day wait from referral from an NHS screening service to first definitive treatment for all cancers

90% 100.00% 91.70% 94.10% 88.90% 1 patient breach - patient presented at day 64 to ENHHT and was treated within 10 days. Not ENHCCG patient


85% 100.00% N/A 81.80% N/A Clinical reasons for delay - complex diagnostics. Reached ENHHT at day 56 and were treated within 14 days

RTT - admitted patients to start treatment within a maximum of 18 weeks from referral - ALL 90% 90.19% 93.85% 90.97% 93.99% 95.30%

Trust meeting target overall but failing in T&O. Action plan has been submitted and Trust has advised that they are on track to meet target by beginning of October 2013

RTT - Non-admitted patients to start treatment within a maximum of 18 weeks from referral - ALL 95% 96.53% 96.69% 96.94% 96.40% 97.50%


92% 95.21% 95.73% 95.94% 96.00% 96.10%

Total numbers waiting at the end of the month on an incomplete RTT pathway 16,247 16,532 16,739 17,171 17,607

Diagnostic test waiting times Patients waiting for a diagnosis test should have been waiting less than 6 weeks from referral 99% 99.03% 99.85% 100.00% 99.79% 99.45%

A&E Waits Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department 95% 94.01% 95.77% 96.57% 97.38% 96.45%




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Mortality ratesAs anticipated in the July Governing Body report the SHMI for July 2013 (rolling year Jan – Dec 2012) rose to 113.9, placing the trust 134th out of 142 trusts. This figure is based on 4 quarterly scores from Q4 2011-12, and is predicted to fall in the next 2 SHMI releases due at the end of this month and in January 2014 as higher rates for earlier quarters are replaced. The HSMR for April – June 2013 is 89.8, continuing a downward trend, with the crude mortality rate for April – August at 1.9%, continuing a steep downward trend from December 2012. The trust has been issued this month with a HSMR alert by the CQC in respect of their acute bronchitis SHMI, which was significantly elevated at 146.3 and to which they must respond. They have compared their approach to mortality reduction to the findings of the Keogh Reviews, and are introducing a standardised approach to the review of patient deaths across the trust. The trust continues to share information openly with the CCG within the Mortality Review Meeting. This group has reviewed the progress on & audit results for each of the identified 9 care pathways, and the meeting on October 9th 2013, included direct discussion with the Clinical Director for Cardiology, and the Heart Failure Specialist Nurse. The CCG has strengthened the team at these meetings, with the addition of the CCG Medical Advisor who has public health expertise. In all of the pathways under review the trust is continuing to implement the audit (or re-audit) and improvement programme, with audit results & progress shared with the CCG. The CCG has identified areas for further work and provision of audit information, and is seeking more frequent meetings of the Review Group, as well as exploring acquiring an analysis tool for our own use. The CCG is also considering whether an audit of palliative care coding would be of benefit. Key issues from this meeting included CCG support for trust consideration of an additional Heart Failure Specialist Nurse to ensure that all patients receive a 2 week follow up assessment; CCG concerns raised to ensure centralised and improved tracking of medical records; and the need for an in-depth review of respiratory pathways (bronchitis, COPD and pneumonia) at the next meeting, with the Clinical Director also attending.CQCThe CQC made an unannounced visit to the Lister Hospital in September, visiting 6 patient wards/areas. The trust was assessed against 6 outcomes, and was found to be compliant in all (Respecting & Involving people, Consent to care and treatment, Care & Welfare of people who use services, Staffing, Supporting workers and Assessing & Monitoring the quality of service provision).

PRINCESS ALEXANDRA HOSPITAL NHS TRUST

Domain Measure DetailTarget/Threshold Apr May Jun Jul Aug Trend Comments

Overall SHMI (emergency and elective) 100 (national average) 106.2 105

SHMI- Stroke 100 121.1 118.7SHMI- COPD 100 86.4 113.3SHMI- MI 100 103.3 105.7SHMI- #NOF 100 87.7 100.2SHMI- Pneumonia 100 108.8 103SHMI- CHF 100 110.3 110.7SHMI- Renal 100 113.1 94.9SHMI- Diabetes 100 120.5 115

People who have had a stroke and are admitted to an acute stroke unit within four hours of arrival to hospital

90% 47.60% 65% 52.90% 68.80% 90.00%


80% 76.20% 95% 88.20% 77.80% 92%


60% 26.30% 40% 46.20% 22.22% 60%

Non haemorrhagic strokes receive thrombolysis within 3 hours of onset 12% 5.30% 5.60% 0.00% 20.00% 7.70%

Patients with low risk TIA have access to MRI or carotid scan within 7 days 65% 57.10% 70% 57.70% 61.54% 87.50%

4 Complaints Number of new complaints received For information 33 26 15 25 24

Inpatient Friends and Family score For information 85 75 82 69 81A&E Friends and Family Score For information 72 72 80.2 86 85

4 Mixed Sex Accommodation (MSA)

Number of clinically unjustified MSA breaches 0 0 0 0 0 0

Number of SIs declared (excluding pressure ulcers) For information 4 8 10 20 30 August figure includes pressure ulcers reported to W Essex CCG which

are yet to be determined as avoidable/not and excluded.

Never Events 0 0 1 0 0 0 The May never event relates to a Hertfordshire patient, and involved a retained swab in maternity.

5 VTE VTE Risk Assessment Increasing %age to 98% from September

95.92% 96.11% 96.30% 96.28% not available

The trust’s performance in screening patients is failing to improve as their monthly target rises. In June- August 2013 there were 10 cases of VTE, 4 of which were assessed after RCA as avoidable, ie hospital acquired thrombosis. The trust is reviewing the process and tool being used for screening, and both ENCCG and WECCG are maintaining close scrutiny.

5 Pressure Ulcers Number of Hospital Acquired Pressure Ulcers (Grades 3 and 4) <5 per quarter 3 4 2 5 3 Numbers may be amended due to PAH:WECCG validation process


The Trust is over trajectory for C Difficile and have already breached their year-end ceiling. They underwent a TDA Inspection Visit in September and are awaiting the report; however the trust report that the verbal feedback was generally positive, with the use of cannulas, care of cannulas and the care bundle as areas for improvement. The CCG have requested routine reporting of ENCCG attributed figures, and the Trust Director of Nursing has been invited to join the Hertfordshire C Dif. Task Force.


Percentage Caesarean Section rate (total)

25% from 1 April to 30 Sep. From 1 Oct

it is 24%25.00% 24.10% 25.30% 26.30% 25.70%

Percentage of planned Caesarean Section 10% 12.30% 10.90% not available not available not available

Percentage of unplanned Caesarean Section 14% 12.90% 13.20% not available not available not available

4


Healthcare Acquired Infections (HCAI)5

5

A contract query notice was served to PAH on 14 October due to failure of the Trust to meet the required stroke standards and to provide commissioners with assurance that improvements will be delivered.

The Trust has undergone an external review of maternity services, with ENCCG contributing to the terms of reference. The report has not yet been shared with ENCCG. A maternal death is being investigated separately.

Mortality- SHMI (data

published quarterly)


1

Maternity Services5

Stroke3

Patient Survey



All CQUIN scheme achievement

Percentage of CQUIN scheme paid per quarter as a proportion of total money available

not available Discussions on-going regarding Q1 achievement

Percentage sickness absence rate <3% 4.54% 4.46% not available 4.35% 3.36% Raised as part of qulaity monitoring meeting

Percentage staff turnover rate <12% 12.60% 12.60% not available not available 12.30%


93% 95.30% 95.60% 94.10% 93.10%


93% 91.50% 94.40% 95.40% 95.00%

Maximum one month (31-day) wait from diagnosis to first definitive treatment for all cancers

96% 98.40% 100.00% 100.00% 98.60%

Maximum 31-day wait for subsequent treatment where that treatment is surgery

94% 100.00% 100.00% 100.00% 86.70%

Maximum 31-day wait for subsequent treatment where that treatment is an anti-cancer drug regime

98% 100.00% 100.00% 100.00% 90.90%

Maximum 31-day wait for subsequent treatment where that treatment is a course of radiotherapy

94% N/A N/A N/A N/A

Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer

85% 87.03% 78.80% 90.30% 85.60%


90% 90.90% 100.00% 100.00% 84.60% 1 West Essex patient breached


85% 91.80% 98.00% 93.90% 96.50%

RTT - admitted patients to start treatment within a maximum of 18 weeks from referral - ALL

90% 93.20% 93.80% 95.10% 93.60% 91.00%Trust exceed total target but failed for the following specialties: gen surgery, urolgy and T&O. Action plan is in place but further assurance being sought from West Essex CCG

RTT - Non-admitted patients to start treatment within a maximum of 18 weeks from referral - ALL

95% 98.15% 98.45% 98.26% 97.90% 98.20%


92% 97.6% 97.89% 97.75% 97.60% 97.20%


Diagnostic test waiting times

Patients waiting for a diagnosis test should have been waiting less than 6 weeks from referral

99% 99.4% 99.7% 99.7% 99.7% 99.6% Trust met overall target but continue to fail to meet standard for flexisigmoidoscopy. Recovery plan will be shared with CCGs

A&E WaitsPatients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department

95% 94.03% 97.1% 96.5% 94.80% 97.1%

NH

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The number of breaches is 2 patients, none of which are ENHCCG

WorkforceAll



The CCG Director of Nursing & Quality met with their West Essex CCG (West Essex CCG being the host commissioner for PAH) counterpart on 9th October to discuss a number of concerns regarding the Quality Surveillance for PAH, in particular the efficacy of the current combined contract performance and quality meeting, the submission of data to the CCG, mechanism of escalation of concerns and the external maternity review. It was agreed that:• The Quality & Performance meeting would be restructured to facilitate a proper exploration and challenge of quality concerns, with clinical quality being placed at the start of every meeting• A schedule of commissioner pre-meets would be established for these meetings• The CCG Director of Nursing and Quality would join the West Essex CCG and PAH DoN meetings on alternate dates• The CCG Director of Nursing and Quality will have an open channel of communication with West Essex in order to raise any concerns and a proportionate and timely agreed plan for resolutionThe outcome of the unannounced visit in July found the trust was compliant with Outcome 21 (Management of Records).

BARNET AND CHASE FARM HOSPITALS NHS TRUST


Overall SHMI (emergency and elective) 100 (national average) 85.3 84.8

SHMI- Stroke 100 80.5 77.1SHMI- COPD 100 80 87.5SHMI- MI 100 78.4 73.9SHMI- #NOF 100 86.7 78.8SHMI- Pneumonia 100 78 82.8SHMI- CHF 100 77.8 75.1SHMI- Renal 100 72.8 72.6SHMI- Diabetes 100 105.8 90.7People who have had a stroke and are admitted to an acute stroke unit within four hours of arrival to hospital

90%


80%


60%

Non haemorrhagic strokes receive thrombolysis within 3 hours of onset 12%

Patients with low risk TIA have access to MRI or carotid scan within 7 days 65%

4 Complaints Number of new complaints received For information 35 29 26 28 17Inpatient Friends and Family score For information 55 54 52 53 53 See commentary below

A&E Friends and Family Score For information 6 -2 -13 -17 42 Negative score highlighted in recent BBC news article following publication of data


The Trust performs badly on Mixed Sex Accommodation, having reported 84 breaches April to August against an annual zero tolerance threshold; 7 of these cases related to ENCCG patients. BCF along with other London Trusts have interpreted the MSA guidance in a stricter way than those in other parts of the country and has therefore likely reported a greater number of breaches as a consequence, a letter has been sent to all London Trusts clarifying the interpretation of the guidance and this can be expected to lead to a reduction in the number of breaches going forward. BCFH are meeting with other London Trusts to look at this further. In response to other factors believed to be contributing to the breaches the Trust has launched an improved discharge process for critical care. The Trust’s MSA performance will continue to be reviewed at the monthly Quality Review Meetings until all issues are resolved.

Number of SIs declared (excluding pressure ulcers) For information 5 7 not

availablenot

availablenot

available

Never Events 0 0 1 0 0 0 The never event reported in May does not relate to a Herts patient.

5 VTE VTE Risk Assessment 90% 95.31% 95.39% 95.50% 95.53% 95.20%

5 Pressure Ulcers Number of Hospital Acquired Pressure Ulcers (Grades 3 and 4) 3 not

available

Data regarding pressure ulcers, falls, and medication errors provided quarterly. Latest report being chased by host commissioner




Healthcare Acquired Infections (HCAI)

5

5


Mortality- SHMI 1

Patient Survey4

3 Stroke



Percentage Caesarean Section rate (total) 26% 25.4% 34.70% 32.50% 31.70% 32.60%

Percentage of planned Caesarean Section For information 9.10% 14.30% 12.40% 14.30% 14.70%

Percentage of unplanned Caesarean Section

For information 16.30% 20.40% 20.10% 17.50% 17.90%

All CQUIN scheme achievementPercentage of CQUIN scheme paid per quarter as a proportion of total money available


Percentage sickness absence rate 3.25% 2.90% 2.92% 2.86% 3.09% 2.89%Percentage staff turnover rate For information 13.00% 13.47% 13.85% 13.83% 14.56%Maximum two-week wait for first outpatient appointment for patients referred urgently with suspected cancer by a GP

93% 93.10% 93.10% 94.10% not available


93% 93.70% 93.50% 95.10% not available


96% 100.00% 99.10% 98.10% not available

Maximum 31-day wait for subsequent treatment where that treatment is surgery 94% 100.00% 100.00% 100.00% not

available


98% 100.00% 100.00% 100.00% not available


94% No patients No patients No patients

not available


85% 86.10% 85.00% 88.20% not available


90% 90.00% 100.00% 91.30% not available


85% 100.00% 100.00% 94.20% not available


90% 90.81% 93.17% 92.60% 90.95%

The CQC wrote to BCF earlier in the year alerting then to the fact they were an outlier (high) for emergency Caesarean Section rates. The CQC requested the Trust conduct an investigation and submit to them the findings together with a remedial action plan. The Trust are currently still exceeding their threshold for C-Section rate (total) at just under 33% for the month of August. HVCCG as host commissioner were not satisfied with the level of detail in the Trust’s action plan and requested the Trust resubmit their plan to the Contract Quality Meeting, including more granular detail on how Caesarean Section rates will reduce together with clear trajectories. The revised plan is currently being reviewed at the Quality Review Group meeting and there will be a focus on Maternity Services and review of progress made against planned action in November 2013. The Trust is confident the Barnet, Enfield and Haringey (BEH) Strategy will have a positive impact on their Caesarean Section rate.

There are significant concerns in relation to the high numbers of 52 week breaches and the Trust's capacity to deal with the backlog and also it's ability to treat any new patients within 18 weeks, particularly in relation to ENT and T&O. This is being monitored very closely by CCGs and the Trust Development Authority with fortnightly meetings and decisions need to be

The Trust has failed to publish Cancer performance information on UNIFY within the required timescales.

NH

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Workforce

Maternity Services

All

5




95% 97.90% 98.77% 98.90% 98.63%


92% 89.7% 90.16% 90.64% 87.72%


Diagnostic test waiting timesPatients waiting for a diagnosis test should have been waiting less than 6 weeks from referral

99% 94.87% 96.77% 96.91% 97.73%The Trust is continuing to make improvement in this area and is currently meeting its trajectory to meet the standard by September 2013


95% 90.32% 91.52% 89.90% 90.64% 89.11%

The Trust has not met this target at all this year and is unlikely to do so citing building works as the major problem. A&E waits are now going to be picked up in the fortnightly RTT meetings involving the TDA. Performance at Chase Farm is better than at the Barnet site

CQC VisitsThe CQC undertook unannounced visits to both Trust hospital sites, a visit to the A&E Department at Barnet took place on 7th May 2013 and a visit to Canterbury Ward, Chase Farm took place on 20th June. The CQC reports for both visits have been received by the Trust and have been shared with HVCCG. With regards to Barnet A&E the CQC judged that action was required for ‘care and welfare of people who use services’. For Canterbury Ward, Chase Farm site remedial action has been required from the Trust against the following standards: ‘respecting and involving those who use the service’, ‘care and welfare of people who use services’, ‘staffing’ and ‘assessing and monitoring the quality of service provision’. The Trust reported that they were already aware of concerns relating to Canterbury Ward and action was already being taken to address those concerns, this action plan was shared and discussed directly with the CQC who were satisfied that the Trust had recognised improvements were required. Since the CQC visit the action plan has been refreshed and will be shared with the Trust Board and then HVCCG, ENHCCG will of course ensure they are also directly sighted on this. Progress against all planned action will be monitored regularly at the Trust Board and also through the Quality Review Meetings to ensure that safe, high quality care is provided to patients.

y g y g

taken in relation to whether to continue to refer patients to BCF for these specialties. The RTT figures will also need validating in light of the issues around the large numbers of patients waiting. A fully validated PTL is expected in early November.

InformationThe CCG has significant concerns regarding the level of information provided by BCF and these have already been shared with HVCCG as the host commissioner, however in order for ENHCCGH to be confident of securing the requisite level of assurance, going forward ENHCCG will be working with HVCCG collegiately to ensure that an appropriate suite of contemporaneous information is available, the strength of challenge to the provider is robust and that sufficient traction and improvement are obtained in all areas of concern. The lack of contemporaneous Serious Incident data, available for this report – both figures and narrative, is of particular concern and the resolution to which will be a focus of early discussion with HVCCG and BCF.

Friends and Family TestThis has been an area of significant underperformance for the Trust, with its first published and very low A&E score (they were the only Trust to have a negative inpatient score in June) having attracted media interest over the summer; the Trust believed that its poor performance could be attributed to the building works in A&E at Barnet Hospital and poor internal processes between health and social care and has undertaken work to improve both the response rate and the score. The Trust has explored a text messaging service to promote the FFT, but has found this to have been of limited benefit, other steps to improve performance include Increasing the number of patient held trackers within the in-patient units, creation of a “competitive” environment in order that Junior Doctors to encourage patients to feedback their experiences and liaison with Imperial College Healthcare NHS Trust, which has performed well in this area, the Trust are also considering a “token in a box” system, which has proved successful at Luton and Dunstable Hospitals Trust and PAH. The Trust were forecasting an improvement in August and this proved accurate with regard to the A&E score which improved from -17 in July to 42 in August. The A&E response rate also improved from 5.7% in July to 12.1% in August.

A workshop is being held to look at Delayed Transfer of Care (DTC) and the partnership working with social care, this will be attended by Barnet Social Services, Barnet CCG and HVCCG and through this event actions to ensure improvement will be agreed, should improvement not be seen within 6 months the issue will be taken back to the Contract Quality Meeting. To further improve their position the Trust has approached the NHS England Area Team for help and a meeting was scheduled for September. The Trust has produced a paper setting out how they intend to improve their FFT scores and a copy of this will be obtained and reviewed by ENHCCG. The Trust believe that that they are on track to implement the FFT in the Maternity Unit from October 2013 and they will be participating in a meeting which has been convened for all London Trusts for the purpose of discussing the roll out of FFT to Maternity and to share best practice.


NHS TRUST COMPARISON

Domain Measure DetailTarget/Threshold Month ENHHT PAH BCF

Overall SHMI (emergency and elective) 100 (national average) July 113.9 105 84.8

SHMI- Stroke 100 July 128 118.7 77.1SHMI- COPD 100 July 102.4 113.3 87.5SHMI- MI 100 July 129.6 105.7 73.9SHMI- #NOF 100 July 123.2 100.2 78.8SHMI- Pneumonia 100 July 121.2 103 82.8SHMI- CHF 100 July 119.2 110.7 75.1SHMI- Renal 100 July 107.1 94.9 72.6SHMI- Diabetes 100 July 114.3 115 90.7People who have had a stroke and are admitted to an acute stroke unit within four hours of arrival to hospital

90% Aug 87.50% 90.00%


80% Aug 87.50% 92%


60% Aug 57.14% 60%

Non haemorrhagic strokes receive thrombolysis within 3 hours of onset 12% Aug 28.57% 7.70%

Patients with low risk TIA have access to MRI or carotid scan within 7 days 65% Aug 60.00% 87.50%

4 Complaints Number of new complaints received For information Aug 70 24 17Inpatient Friends and Family score For information Aug 82 81 53A&E Friends and Family Score For information Aug 60 85 42

4 Mixed Sex Accommodation (MSA) Number of clinically unjustified MSA breaches 0 Aug 0 0 22

Number of SIs declared (excluding pressure ulcers) For information Aug 2 30 not

availableNever Events 0 Aug 0 0 0

5 VTE VTE Risk Assessment 90% Aug 97.41% not available 95.20%

5 Pressure Ulcers Number of Hospital Acquired Pressure Ulcers (Grades 3 and 4) Aug 2 7

Number of patients diagnosed with C-diff >48 hours post admission Annual ceiling 25 Aug 2 2 1

Number of patients diagnosed with MRSA >48 hours post admission 0 Aug 0 0 0

Percentage Caesarean Section rate (total) 26% Aug 27% 25.70% 32.60%

Percentage of planned Caesarean Section For information Aug 12% not

available 14.70%

Percentage of unplanned Caesarean Section For information Aug 15% not

available 17.90%


Aug

Percentage sickness absence rate 3.25% Aug 3.46% 3.36% 2.89%Percentage staff turnover rate For information Aug 10.09% 12.30% 14.56%

All Workforce

5 Serious Incidents (SI)

5 Healthcare Acquired Infections (HCAI)

5 Maternity Services

Mortality- SHMI

3 Stroke

4 Patient Survey

1


93% July 98.30% 93.10% not posted on UNIFY





Maximum 31-day wait for subsequent treatment where that treatment is surgery 94% July 100.00% 86.70% not posted

on UNIFY




94% July 99.40% N/A not posted on UNIFY




90% July 88.90% N/A not posted on UNIFY


85% July N/A 96.50% not posted on UNIFY


90% Aug 95.30% 91.00%


95% Aug 97.50% 98.20%


92% Aug 96.10% 97.20%

Total numbers waiting at the end of the month on an incomplete RTT pathway Aug 17,171

Diagnostic test waiting timesPatients waiting for a diagnosis test should have been waiting less than 6 weeks from referral

99% Aug 45.00% 99.6%


95% Aug 96.45% 97.1% 89.11%

Mixed sex accommodation breaches Number of breaches 0 Aug 0 0 22

NH

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HERTFORDSHIRE PARTNERSHIPS UNIVERSITY NHS FOUNDATION TRUST


3Proportion of people with depression and/or anxiety disorders who received psychological therapies

6581 362 378 320 393 321 Trust estimate 4,258 by year end

3 % Prevalence Starting Treatment 10% 0.55% 0.57% 0.49% 0.60% 0.49% Trust estimate 6.5% by year end. Training for extra capacity has started but benefits will not be seen until January.

3 The proportion of people who are moving to recovery 50% 58% 64% 59% 51% 50%

4 Complaints Number of new complaints received For information Q1 Total =72 20 19

The Trust are reporting a total of 52 complaints for Q2 which is the drop back down from the Q1 position that they were forecasting, the Q1 figures were unusually high (72), which the Trust postulated may have been attributable to the public engagement events that were held to publicise the transformation of the Trust services and also events designed to assist the organisation in their understanding of patient and carers’ views on the constituent parts of a positive experience.


Number of SIs declared (excluding pressure ulcers) For information 2 (0

ENCCG)1 (0

ENCCG)4 (1

ENCCG) 3 4 See Appendix 1Never Events 0 0 0 0 0 0

5 Incidence of newly acquired category 3 and 4 pressure ulcers 0 0 0 0 0

5Number of cases of MRSA occurring on the providers premises where onset of symptoms is 2 days following admission

Zero 0 0 0 0 0

5Number of cases of C Diff occurring on the providers premises where onset of symptoms is 2 days following admission

<2 per quarter 0 0 0 0 0



Percentage sickness absence rate <4% 4.10%

Percentage staff turnover rate For information 16%

IAPT

CQC VisitThe CQC have undertaken an unannounced visit to Elizabeth Court. The results of this have not yet been published.

All Workforce Reported Quarterly

Serious Incidents (SI)5

HERTFORDSHIRE COMMUNITY NHS TRUST


4 Complaints Number of new complaints received For information 23 19 9 20 9


Number of SIs declared (excluding pressure ulcers) For information 9 (ENCCG

3)3 (ENCCG

1)7 (ENCCG

2) 15 13See Appendix 1

Never Events 0 0 0 0 0 0

5 VTE VTE Risk Assessment 100% 100% 99% 100% 100% 100% May's performance meant that the Q1 CQUIN was failed

5 Pressure Ulcers Number of Acquired Pressure Ulcers (Grades 3 and 4) For information 19 (ENCCG

8)17 (ENCCG

5)10 (ENCCG

3)11 (ENCCG

5)10 (ENCCG

3)

The CCG has agreed with HCT to ensure contempoaraneous reporting of pressure ulcers


HCT has reported 7 cases of C Difficile to the end of August, 2 of which are attributed to ENCCG: however an additional ENCCG case has been reported in September. The CCGs are monitoring the HCT action plan drawn up as a result of the June TDA Inspection Visit, including changes to both the RCA process and to some cleaning contracts.


all CQUIN scheme achievementPercentage of CQUIN scheme paid per quarter as a proportion of total money available

97%3% failed due to VTE screening item 5

Percentage sickness absence rate 4% 4.54% 4.53% 4.52% 4.52% 4.53% This is currently flagged on the National Quality Dashboard

Percentage staff turnover rate 12% 15.50% 16.40% 16.40% 17.00% 17.00%

The CCGs continue to seek assurance from HCT regarding their workforce issues, with HCT presenting their approach to the July Quality Review Meeting. The trust will be sharing their “pulse” survey results for the November QRM, and are including all staff in this year’s Annual NHS Staff Survey, rather than a sample. HCT report that their underlying turnover is 12.6% once fixed term contracts are removed, and are reviewing the data: the CCG has asked for transparency so that benchmarking with other trusts is consistent.

5 Healthcare Acquired Infections (HCAI)


all Workforce

EAST OF ENGLAND AMBULANCE SERVICE


Outcome from cardiac arrest measured by ROSC (Return of spontaneous circulation) at point of handover of the patient to hospital

21.5% 20.6%

20.1% (14.1% in

West sector)

19% (23.2% in

West sector)

15.4% (18.2% West

sector)

not available

Percentage of patients who survive cardiac arrest to discharge from hospital 6.0% 7.5%

5.5% (5.1% West

sector)

9% (11.7% in West sector)

5.9% (9.1% West

sector)

not available

Percentage of patients suffering a STEMI who are directly transferred to a centre capable of delivering PPCI (Primary Percutaneous Coronary Intervention) and receive angioplasty within 150 minutes of call

95.0% 80.4% 82.1% 96.2% 95.2% not available

Percentage of STEMI patients receiving appropriate care bundle 80.0% 79.5%

82.2% (81% West

sector)

86.9% (87.9% West

sector)

82.9% (79.6% West

sector)

not available

Percentage of suspected stroke patients who received appropriate care bundle 95.0% 96.2%

94.8% (94.7% West

sector)

95% (96.7% West

sector)

95.3% (95.7% West

sector)

not available

Percentage of FAST positive stroke patients who arrived at a hyper acute stroke centre within 60 minutes of call

56.0% 43.3%

58.8% (64.1% West

sector)

49.6% 52.8% not available

Percentage of calls abandoned before answered 1.50% 0.53% 0.58% 0.75% 0.87% 0.91%

Time to answer call (median) 3 seconds 1 sec 1 sec 1 sec 1 sec 1 secTelephone advice (hear and treat) 5% 7.21% 7.21% 7.53% 8.13% 7.83%

4 Complaints Number of new complaints received For information 85 62 80 61 56 The majority of complaints received relate to delays

Number of SIs declared For information 2 1 2 2 2Never Events 0 0 0 0 0 0

5 Incidents Number of incidents reported For information 500 439 427 not available

not available

Total station cleanliness 95% 97.21% 98.10% 95.80%Total vehicle cleanliness 95% 98.10% 95.00% 97.97% 97.83% 98.27%Hand hygiene cleanliness 95% 88.30%Uniform audit compliance 95% 96.20%

Percentage sickness absence rate 5% 6.99% 6.25% 6.11% 6.10% not available

Percentage rate of leavers

Provider LevelCategory A calls resulting in an emergency response arriving within 8 minutes (Red 1 Critical)

75% 75.77% 79.64% 72.32% 71.91% 74.36%

Provider LevelCategory A calls resulting in an emergency response arriving within 8 minutes (Red 2 serious)

75% 72.63% 74.15% 71.95% 69.83% 75.31%

Category A response times remain an area of concern particular with the onset of winter. The Trust are in the process of recruiting paramedics to alleviate some of the pressures and to address some of the issues around high sickness levels.

not availableAll Workforce

4


Infection prevention and control

5

5

Call handling

1

Stroke

STEMI (ST segment elevation myocardial infarction)

3

3

Cardiac arrest

EAST OF ENGLAND AMBULANCE SERVICE


Provider Level Category A calls resulting in an ambulance arriving at the scene within 19 minutes 95% 93.88% 94.56% 93.72% 92.62% 96.30%

Provider Level All handovers between ambulance and A&E must take place within 15 minutes 100%

ENHCCG PatientsCategory A calls resulting in an emergency response arriving within 8 minutes (Red 1 Critical)

75% 70.00% 75.53% 67.71% 80.52% 74.36%

ENHCCG PatientsCategory A calls resulting in an emergency response arriving within 8 minutes (Red 2 serious)

75% 75.04% 77.14% 72.16% 70.49% 75.31%

ENHCCG Patients Category A calls resulting in an ambulance arriving at the scene within 19 minutes 95% 97.19% 97.18% 96.94% 96.95% 96.30%

ENHCCG Patients All handovers between ambulance and A&E must take place within 15 minutes 100%

No information currently available from the provider

No information currently available from the provider

Per

form

ance

HERTS URGENT CARE


4 Complaints Number of new complaints received For information 3 OOH 11NHS111

7 OOH 15NHS111

1 OOH 4 NHS111

2 OOH2 NHS111

4 OOH 1 NHS111

Percentage of calls answered within 60 seconds 95% 89% 96% 98% 98% 99%

Total number of abandoned calls <5% 5.20% 4.70% 4.40% 3.21% 2.69%

Longest wait for call back (minutes) For information 43:24 01:00:05 35:42 12:58 34:57Average waiting time for call back (minutes) For information 11:09 07:35 06:32 06:42 04:14

Number of SIs declared For information 2 0 0 See Appendix 1Never Events 0 0 0 0 0 0

Urgent visits undertaken within 2 hours 95% 98% 96% 97% 97% 95%

Routine visits undertaken within 6 hours 95% 97% 97% 99% 96% 98%

Base face to face consultations following definitive clinical assessment

Urgent consultations undertaken within 2 hours 95% 91% 97% 97% 98% 97%

Routine consultations undertaken within 6 hours 95% 100% 100% 100% 100% 100%

Urgent clinical assessment within 20 minutes of patient arriving 95% 57% 71% 100% 14% 67%

Routine clinical assessment within 60 minutes of patient arriving 95% 75% 78% 79% 80% 74%

Urgent calls: definitive clinical assessment commenced within 20 minutes 95% 97% 97% 98% 96% 98%

Routine calls: definitive clinical assessment commenced within 60 minutes

95% 96% 96% 97% 95% 97%

Ambulance dispatch as a percentage of total calls offered For information 5% 5% 5% 5% 4%

Total number of non conveyed 999 dispatches For information 463 500 382 471 447

CQC VisitsDuring September the CCG undertook an unannounced visit to the HUC out of hours base at the Lister Hospital. The visit focussed on the storage and use of medication, staff awareness of policies and procedures relating to patient safety and safeguarding procedures, staffing levels and overall patient experience. Overall the visit was positive with all patients spoken to very satisfied with their contact with NHS111 as well as the HUC team at the Lister. A recommendation from the visit was for review of some aspects of security.

Base face to face walk in clinical assessment5

It should be noted that the percentages reported represent a small number of patients. The 14% reported for urgent clinical assessment completed within 20 minutes of the patient arriving, in July, equates to one out of a total of seven patients being triaged within the prescribed timeframe; in August the figure of 67% equates to two out of a total of three patients being seen within the requisite timeframe.


Call Handling4

5

5

5

5

Ambulance dispatch

Home visits

Telephone clinical assessment

NHS 111

Domain Measure Detail Target/Threshold Apr May Jun Jul Aug Trend Comments

Total number of calls answered 23,490 23,027 21,215 21,734 21,733

Total number of abandoned calls ringing for over 30 seconds

Not reported 193 142 165 90

Abandoned calls as a percentage of total <5% 5% 0.8% 0.6% 0.7% 0.4%

Total number of calls answered within 60 seconds 20,976 22,139 20,762 21,282 21,482

Total answered calls within 60 seconds as a percentage of total 95% 89% 96% 98% 98% 99%

Longest wait for an answer (seconds) Not reported 1710 907 755 660

Longest wait for call back (hh:mm:ss) 10 Mins Not reported 01:00:05 00:35:42 01:39:22 00:34:57

Work has been done to improve call back times

Ambulance dispatch as a percentage of total Area Team indicator <10% 5% 5% 5% 5% 6%

A&E Referrals as a % of total calls offered Not reported 11% 11% 12% 12%

Warm transfers as a percentage of total directed to Clinical Advisor 100% Not

reported 82% 83% 81% 86%

As mentioned as part of the benefits realisation process due to commence now that the service has been running for a year and to measure the impact of the NHS 111 service on the different elements of the urgent and emergency care system, data is also collected through the UNIFY2 data collection system. This includes monthly data for each of the 12 months leading up to the introduction of the NHS 111 service to control for seasonality and to allow a meaningful before/after comparison of the service. To measure the impact, the baseline covers the total number of GP Out of hours service consultations; total number of A&E attendances; total number of urgent care centres attendances; total number of walk in centres attendances; total number of ambulance incidents resulting in an emergency response at the scene and number of ambulances dispatched by 111 service that subsequently transport the patient.

EAST AND NORTH HERTS CCG 560,129 5 2800645

QUALITY PREMIUM

Date Updated:

Ref Domain/Area Detail Threshold 100% £2,800,645 Baseline position Target Timing Apr May Jun Jul Aug Status

1a.i1a.ii

Domain 1Preventing people from dying prematurely

Potential years of life lost (PYLL) from causes considered amenable to healthcare: adults, children and young people

Potential years of life lost (adjusted for sex and age) from amenable mortality for CCG population will need to reduce by at least 3.2% between 2013 and 2014.This is based on the 10 year average reduction in potential years of life lost from amenable mortality

12.5% 350,081 1,975 1,912 Annual - Calendar year

Annual info

2.3.iUnplanned hospitalisation for chronic ambulatory care sensitive conditions

719 719 Monthly 104 99 85 95

2.3.iiUnplanned hospitalisation for asthma, diabetes and epilepsy in under 19s

227 227 Monthly 3 6 6 21

3a

Emergency admissions for acute conditions that should not usually require hospital admission

821 821 Monthly Awaiting information

3.2Emergency admissions for children with lower respiratory tract infection

222 222

Monthly (provisional) Quarterly

(HES)

1 2 1 2

Roll out of Friends and Family TestA CCG's local providers deliver the nationally agreed roll-out plan to the national timetable - maternity services by the end of October 2013 and additional services (TBC) by the end of March 2014

Assurance that all relevant local providers of services commissioned by a CCG have delivered the nationally agreed roll-out plan to the national timetable

TBC Awaiting confirmation of who is able to provide this information

4c

Patient experience for acute inpatient care and A&E services, as measured by the Friends and family Test

An improvement in average FFT scores for acute inpatient care and A&E services between Q1 2013/14 and Q1 2014/15 for acute hospitals that serve a CCG population

72 TBC Awaiting confirmation of who is able to provide this information

5.2.iIncidence of healthcare associated infection (HCAI) i) MRSA

1.58 per 100,000 0 Monthly 2 0 0

5.2.iiIncidence of healthcare associated infection (HCAI) ii) C.difficile

15.1 per 100,000 = 84 cases

15.1/100,000 = 84 cases

Monthly 3 9 13 2

Domain 4Ensuring that people have a positive experience of care

12.5% 350,081

Domain 5Treating and caring for people in a safe environment and protecting them from avoidable harm

No cases of MRSA bacteraemia for the CCG's population; andC.difficile cases are at or below defined thresholds for the CCGs

12.5% 350,081 ENHCCG has failed this element of the Quality Premium worth £350k) as a consequence of a case of MRSA at ENHHT

Domain 2Enhancing quality of life for people with long term conditions

A reduction or a 0% change in emergency admissions for these conditions for a CCG population between 2013/14 and 2014/15

25% 700,161

Domain 3Helping people to recover from episodes of ill health or following injury

Ref Domain/Area Detail Threshold 100% £2,800,645 Baseline position Target Timing Apr May Jun Jul Aug Status

Local measure 1

90% of patients newly diagnosed with Diabetes undertake an accredited and structured education programme (DAFNE and DESMOND).

12.5% 350,081

Number of diabetes patients in East & North Herts CCG (from QOF registers 2011/12) = 22,971

NICE suggest 189 patients per 100,000 population are newly diagnosed each year (Type 2), for this CCG this would be 1045 patients

90% of newly diagnosed patients

941 patients diagnosed with Diabetes (Type 1 and 2) will be offered a structured education programme

Quarterly

Offered 166

Attended128

DNAs38

The provider, HCT, has maintained that the Trust does not have capacity to deliver structured education to 941 patients. The average waiting time from referral to start of programme is between 2 and 3 months. Meetings have been held with Trust senior management to resolve this.

Local Measure 2Care planning is completed for 20% of the practice population diagnosed with Diabetes and COPD

12.5% 350,081

Number of patients diagnosed with diabetes in East & North Herts CCG (from QOF registers 2011/12) = 22,971

Number of patients diagnosed with COPD in East & North Herts CCG (from QOF registers 2011/12) = 8,231

20% of patients with COPD and Diabetes have a care plan initiated

Diabetes = 4,594COPD = 1,646

6,420 care plans initiated

Quarterly

Diabetes1731

COPD195

Total1926

A LTC COPD clinical lead was agreed in June. Practices should be actively encouraged to complete personal health plans with patients who have been issued with BLF packs

Local Measure 3

National find your 1% campaign to ensure practice end of life registers are representative of all end of life patients, not just those with malignant illness.

Advanced Care Planning is completed for 50% of patients identified to be in the last 12 months of the end of their life

12.5% 350,081 1% of CCG practice population (552,900) = 5,529

50% of practice 1% End of Life registers (5,529) have an Advanced Care Plan

2,765 patients to be in the last 12 months of the end of their life have Advanced Care Plans initiated

Quarterly 212

It was reported at the LTC leads meeting in June that clinicians had found it difficult to approach the subject of ACP with patients. Online learning resources and workshops by the EoE GP end of life care educator/ facilitator were provided earlier in the year to raise awareness.An EoL workshop was also held in August. Further work to embed ACP as a key component of the EoL workstream. Clinical lead is confident that Q2 performance will have improved.

£2,800,645

90% Admitted 90% Monthly 84.29% 88.69% 88.83% 90.84%

95% Non-Admitted 95% 96.64% 97.07% 97.16% 96.64%

Maximum 4 hour waits in A&E Departments (Proxy) 95%

Reduction of 25% if not met - 700,161 95% Monthly 95.48% 96.10% 96.15% 95.76%

Maximum 62 day waits from urgent GP referral to first definitive treatment for cancer

85%Reduction of 25% if

not met - 700,161 85% Monthly 92.20% 85.70% 88.30% 84.90%

Red 1 Monthly 70.00% 75.53% 67.61% 73.20% 74.36%

Red 2 Monthly 75.04% 77.14% 72.16% 73.71% 75.31%

CCG Regulations

CCG to manage within its total resource envelope for 2013/14 and does not exceed the agreed level of surplus drawdown

Pre-qualifying criterion for any

paymentReduction of 100%

- 2,800,645 On track to deliver

£2,800,645

This is the total amount of QP due at the moment. Amounts at risk include £700,161 as a result of the number of unplanned hospitalisation for chronic ambulatory care sensitive conditions, and £350,081 as there have been 3 cases of MRSA attributed to ENHCCG patients although no definitive decison has been reached as to the impact on QP as yet. Of the total QP due, there is a risk that the CCG will lose a quarter of the QP if EEAST fail to improve performance and do not meet the category A Red 1/2 8 minute ambulance response times for 2013/14.

Performance is being addressed at commissioner consortium meetings and the Trust is embarking on a consultation to increase the numbers of paramedics

Maximum 18-week waits from referral to treatment

Reduction of 25% if not met - 700,161

EOE Ambulance Service 75%

Reduction of 25% if not met - 700,161 75%

NHS Constitution Rights/Pledges

Maximum 8 minute responses to Category A red ambulance calls (Red 1 and red 2)

Supporting the management of patients with long term conditions through the promotion of self- management, and the implementation of personal health plans.

ENHCCG Q1 SUBMISSION TO AREA TEAM

Domain 1CCGs to list up to 5 of their main providers (in exceptional circumstances only, up to 10)Main providers are defined as those where CCG commissioning constitutes more than 5% of the provider’s income. Please list providers in order of contract value (largest first). Providers Provider 1 Provider 2 Provider 3 Provider 4 Provider 5

Provider NameEAST AND NORTH HERTFORDSHIRE NHS TRUST

HERTFORDSHIRE PARTNERSHIP NHS FOUNDATION TRUST

THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST

HERTFORDSHIRE COMMUNITY NHS TRUST


Please identify the percentage of provider income for CCG: 92 45 30 25 10

Is this CCG the lead or associate commissioner? Lead Associate Associate Associate Associate

Has local provider been subject to local enforcement action by the CQC? No No No No No

Has local provider been flagged as a 'quality compliance risk' by Monitor and/or are requirements in place around breaches of provider licence conditions?

No No No No No

Has local provider been subject to enforcement action by the NHS TDA based on 'quality' risk? No No No No No

Does feedback from the Friends and Family test (or any other patient feedback) indicate any causes for concern? No No No No Yes – Action plan in place

Has the provider been identified as a 'negative outlier' on SMHI or HSMR? Yes – Action plan in place No No No No

Do provider level indicators from the National Quality Dashboard show that MRSA cases are above zero? Yes – Action plan in place No No No Yes – Action plan in place

Do provider level indicators from the National Quality Dashboard show that the provider has reported more C difficile cases than trajectory? Yes – Action plan in place No Yes – Action plan in place Yes – Action plan in

place No

Do provider level indicators from the National Quality Dashboard show that MSA breaches are above zero? No No No No Yes – Action plan in place

Does provider currently have any unclosed Serious Untoward Incidents (SUIs)? Yes – Action plan in place Yes – Action plan in place Yes – Action plan in place Yes – Action plan in

place Yes – Action plan in place

Has the provider experienced any 'Never Events' during the last quarter? No No Yes – Action plan in place No No

Is provider meeting the 15% response rates on FFT ? (Domain 3) Yes Further development required Yes Further development

required No

Clinical Governance -has the CCG self assessed and identified any risks associated with the followingDoes the CCG have any outstanding conditions of authorisation in place on clinical governance?Concerns about quality issues being discussed regularly by the CCG governing body No

Concerns about the arrangements in place to proactively identify early warnings of a failing service No

Concerns around the arrangements in place to deal with and learn from serious untoward incidents and never events? No

Concerns around being an active participant in its Quality Surveillance Group? No

EPRR If there was an emergency event in the last quarter, has the CCG self assessed and identified any areas of concern on the arrangements in place for dealing with such an event?

No

Winterbourne View Has the CCG self assessed and identified any risk to progress against its Winterbourne View action plan? No

Response options for Domain 1 are:Yes – Enforcement Action (First question on row 11 only) Yes – Enforcement ActionYes – Action plan in place Yes – Action plan in placeYes – No action plan in place Yes – No action plan in placeNo No

Domain 3

Local priorities (Self-Certification)Are you on track to deliver against this local priority?

Local Priority 1 YesLocal Priority 2 YesLocal Priority 3 YesIs the CCG progressing as expected in the IAPT trajectory submitted during the planning round?

Further development required

Response options for Domain 3 are:YesNo Further development required

Domain 4

Assessment of internal and external audit opinions and on the timeliness and quality of returns G

No non-satisfactory audit reports in relation to finance related systems and processes and all finance returns submited on time and of satisfactory quality. Green GOne or two non-satisfactory audit reports in relation to finance related systems and processes and/or finance returns sometimes submited late and/or of a poor quality. Amber/Green AGA number of non-satisfactory audit reports in relation to finance related systems and processes and/or finance returns often submited late and/or of a poor quality. Amber/Red ARSignificant number of non-satisfactory audit reports in relation to finance related systems and processes and/or finance returns consistently submited late and/or of a poor quality. Red R

CCG:

Appendix One – Serious Incidents

1. Serious Incidents Themes and Trends

1.1 East & North Herts Trust

The position in relation to the number of overdue reports has improved since the implementation of the escalation process. The number of SIs reported outside the timescale of 2 working days remains a concern.

The above graph shows the full classifications of SIs reported in Q1 and Q2. The most serious of these are;

• Unexpected death of an inpatient • Wrong site surgery (potential Never Event) • Surgical error (Never Event)

The CCG visit following on from a maternity SI involving a retained swab found good compliance and implementation of all actions.

1.2 Hertfordshire Community NHS Trust

The position in relation to the number of overdue reports has improved since the implementation of the escalation process. The number of SIs reported outside the timescale of 2 working days remains a concern.

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There were 42 Grade 3 Pressure Ulcers reported by HCT in Q2, with 20 relating to ENCCG patients. This means that 83% of the ENCCG SIs declared by HCT were grade 3 pressure ulcers. The two grade 4 pressure ulcers related to HVCCG patients. Of the 20 declared cases, 12 investigations have been completed with 4 pressure ulcers deemed to be avoidable.

1.3 Hertfordshire Partnership NHS Foundation Trust

ENCCG’s Accountable Officer and Director of Nursing have recently met with HPFT’s Executive Team to discuss the recent serious incidents and safeguarding concerns, including the death of a patient within their care, and agree immediate actions to be taken. A further meeting was also held with the Safeguarding and Patient Safety Leads from the CCG and HPFT to discuss safeguarding and SI reporting thresholds. As a result of this meeting it has been agreed that thresholds will be developed to ensure it is easier for staff to identify when a safeguarding case also needs to be reported as a SI.

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1.4 Herts Urgent Care

The number of SIs reported by HUC continues to be small which means it is difficult to identify any themes and trends, with only 1 SI reported during Q2. The CCG Quality Team are continuing to meet with HUC to ensure their reporting processes are robust.

1.5 Spectrum (CRI) Following the letter of concern that was sent to Spectrum in March the JCT and CCGs have seen an improvement in the standard of investigation, reports submitted and organisational learning. There has been a concern raised in relation to ensuring the root cause is identified fully and both HVCCG and ENCCG are working with the JCT to improve this. There is an organisational action plan in place and this is being closely monitored by the JCT. The Quality Team continue to work with Spectrum and liaise with the JCT to ensure effective triangulation of information. Spectrum are commissioned by Public Health whom therefore have overarching responsibility for quality assurance, the CCG will be handing over management of Spectrum SIs to the Public Health Team in due course.

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2. Performance information

2.1 Delayed reporting of SIs

The above graph details the number of SIs where there has been a delay in reporting for all providers. The SI policy states that an SI should be reported to the CCG within 2 working days of the incident occurring or being identified. E&NHT have failed to report 16 SIs within two working days of the incident date over Q2, which is a slight increase from Q1. A number of these relate to pressure ulcers and there is a need for a TVN to review the pressure ulcer to confirm the grading. There were also a small number of SIs in Q2 which were reported following a retrospective review of a patients care or receipt of a letter of complaint from the patient/ family, where the delay in reporting of these cases is due to the need for senior management at the Trust to conduct an initial review to confirm whether the case met the criteria for a SI. There were delays in reporting the Never Events including one where the incident date was August 2012 and the SI reporting was triggered by the patient making a legal claim against the Trust. There were some cases which were not escalated as expected to the Risk Department at E&NHT, however the investigation was undertaken at the time of the incident. The delays in reporting are continuing to be raised with the Trust on an individual basis. There were delays in reporting all 24 SIs which related to ENCCG patients/services reported by HCT in Q2. This is a slight increase from Q1. The majority (21) of these relate to pressure ulcers and are due to Locality Managers reviewing pressure ulcer incidents in batches resulting in a delay to those being reported as a SI. We are continuing to raise this issue with the Trust via QRMs and also other informal meetings. HCT are trying to improve this by ensuring Locality Managers have protected time to review incident forms and escalate if needed. They are also encouraging staff to telephone the Locality Manager if they have reported a potential SI to avoid any delays. The issue of delayed reporting has been raised as an issue at the Quality Review Meetings with both E&NHT and HCT and we are closely monitoring this to ensure all SIs are reported within the timescale.

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2.2 Delayed submission of SI reports Within the last report it was identified that whilst HCT had improved the timeliness of 7 day reports, there were still issues in relation to the provision of clarification in response to any queries from the CCG review of reports. This has now also improved following discussions at the QRM and the implementation of the escalation process, which has been communicated to each Director of Nursing with an accompanying letter. The implementation of the escalation process has also had a positive effect on the number of overdue reports at the other providers and this position will need to be closely monitored to ensure it is maintained over the coming months. 2.3 Number of open cases (w/e 4.10.13)

The above graph details the number of open SIs relating to ENCCG patients or services on a weekly basis. The overall number open for E&NHT has decreased since the end of June and this is due to reports being submitted in a more timely manner, which has allowed cases to be closed and therefore reduced the overall number. The number of open cases for HCT initially reduced, but has increased since 20.9.13; this is due to pressure ulcer reporting and a number of these cases recently being reported as a batch. The number of open cases at HUC, HPFT and Spectrum has remained relatively steady over the reporting period.

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2.4 Number of overdue cases (w/e 4.10.13)

The above graph shows the number of overdue SIs based on the expected date of completion (this date is automatically calculated by STEIS and based on whether it is a level 1 or 2 SI). The number of overdue cases for E&NHT has decreased since the end of June and has remained steady since 30.8.13. The overdue cases are often more complex level 1 SIs where additional assurance is required following review of the 45 day report and prior to closure. These cases are regularly monitored by the Patient Experience and Safety Team and discussed on a weekly basis with the Director of Nursing & Quality and Associate Director of Nursing & Quality. As the majority of HPFT and Spectrum SI investigations require the outcome from the inquest, which can sometimes be held a number of months after the incident, the rules allow for us to apply a clock stop so this information can be incorporated in the investigation. For this reason, data for these providers has not been included here.

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Documents

Governing Body Meeting in Public - East and North ......from HPFT as part of the CQUIN to drive up self-referrals (through radio adverts and billboard adverts etc). ENHCCG has recently