Appendix-2012-62

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Borders NHS Board

MANAGING OUR PERFORMANCE OUT TURN REPORT 2011/12 Aim The aim of the 2011/12 Managing Our Performance (MOP) Out Turn Report is to report progress during 2011/12 on the full range of HEAT targets and other key priority areas for the organisation. Background For a number of years, the organisation has produced a MOP report as a summary of progress across the range of targets and indicators at the mid way point and also at the end of each financial year. In 2011/11 the organisational reporting framework was refreshed with the introduction of the Clinical Board Performance Scorecards, Clinical Executive Scorecard, HEAT Scorecard and KPI Scorecard. It was agreed that a mid year and end of year MOP would continue to be produced to capture and report on performance against key national targets and priorities. This 2011/12 Out Turn MOP Report has been updated to show performance in relation to the HEAT targets, Single Outcome Agreement and Corporate Objectives. Summary The 2011/12 Out Turn MOP is an important part of the organisational performance management framework as it provides a mechanism to report progress across the full range of HEAT targets and summarise performance over the 12 month period along with a selection of priority areas and Corporate Objectives. Recommendation The Board is asked to note the 2011/12 Managing Our Performance Out Turn Report. Policy/Strategy Implications

Regular and timely performance reporting is an expectation of the Scottish Government

Consultation

Performance against key indicators within this report have been reviewed by each Clinical Board and members of the Clinical Executive

Consultation with Professional Committees

See above

Appendix-2012-62

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Risk Assessment

Good progress is being made against key targets and pressure areas are identified in this report. Continuous monitoring of performance is a key element in identifying risks affecting Health Service delivery to the people of the Borders

Compliance with Board Policy requirements on Equality and Diversity

The implementation and monitoring of targets will require that Lead Directors, Managers and Clinicians comply with Board requirements

Resource/Staffing Implications

The implementation and monitoring of targets will require that Lead Directors, Managers and Clinicians comply with Board requirements

Approved by Name Designation Name Designation June Smyth Director of

Workforce & Planning

Author(s) Name Designation Name Designation Karen Shakespeare Planning &

Performance Officer

MANAGING

OUR PERFORMANCE

OUT TURN REPORT

2011/12

June 2012

Planning & Performance

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Contents

Page

1 Executive Summary 3

2 Introduction 4 3 HEAT Targets 2011/12 6 Dashboard of Monthly Heat Targets 6 Progress on Targets Not Reported on a Monthly Basis 11 4 Single Outcome Agreement 15

5 Corporate Objectives 17

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1. EXECUTIVE SUMMARY Background For a number of years, the organisation has produced a key performance indicator (KPI) report. This reporting cycle has included a summary of progress across the range of targets and indicators at the mid way point and also at the end of each financial year and this was called the Managing Our Performance (MOP) Report. In addition to the HEAT targets reported monthly, this has included a progress update on targets which could not be reported monthly. In 2010/11 the organisational reporting framework was refreshed with the introduction of the Clinical Board Performance Scorecards, Clinical Executive Scorecard, HEAT Scorecard and KPI Scorecard. It was agreed that a mid year and end of year MOP would continue to be produced to capture and report on performance against key local and national targets and priorities. This 2011/12 Out Turn MOP Report has been updated to show performance in relation to the HEAT targets, contributions to the Single Outcome Agreement and Corporate Objectives. Key Findings 2011/12 Performance on HEAT Targets The following table summarises performance across the range of HEAT targets during 2011/12. Performance against these has been considered against the full 12 months and is not just based on the end of year position unless stated.

For these targets, performance was significantly in excess of trajectory throughout

the year:

The following HEAT targets were delivered:

A9 Cancer Treatment within 31 days H8 Cardiovascular Heart Checks H4 Alcohol brief interventions E8 Reduction in energy efficiency Std Smoking Cessation in most deprived

areas Std A9

Online triage of referrals Cancer treatment within 62 days

A10 Waiting times for inpatients1 Waiting times for outpatients1

A12 Waiting times for CAMHS T11 Reduce CDAD (C Diff) infections 2 Std Admittance to stroke unit within 1

day of admission Std No delayed discharges over 6 weeks

Performance was outwith the trajectory for the following HEAT targets:

Performance was significantly outwith the trajectory for the following HEAT targets:

E8 Reduction in C02 emissions Std New patient DNA Rate Std Sickness Absence T9 Diagnosis of dementia Std Std

eKSF Annual Reviews 4 week waiting target for diagnostics

T10 Reduction in rate of A&E and MIU attendances

T11 Reduce SAB (Staph aureus bacteraemia) infections 2

1 9 week target looked at over 2011/12, however going forward in 2012/13 will review at 12 week national HEAT Target 2 This target is to be delivered over a 2 year period (2011/12 & 2012/13). Progress will continue to be closely monitored during 2012/13.

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2. INTRODUCTION Monitoring of Performance

Each Clinical Board, BGH, Primary and Community Services, Mental Health and Learning Disability produce a monthly Performance Scorecard. These are presented to the Clinical Executive Group on a monthly basis. Each Clinical Board attends a quarterly performance review where performance is monitored by the relevant Management Teams. The Board also review the HEAT Scorecard at each Board meeting.

HEAT Targets

Every year the Scottish Government Health Department (SGHD) asks each Health Board to report to them on their performance and delivery plans for the next financial year. This report is called the Local Delivery Plan (LDP) and forms an agreement on what Health Boards will achieve in the next year with SGHD. Boards are asked to work towards a number of key targets for the year which fit with the Government’s health objectives. These targets are called HEAT targets because they are separated under 4 different headings: H Health Improvement E Efficiency and Governance A Access to Services T Treatment for the individual

Planned work with local partners such as Scottish Borders Council is also included. This 2011/12 Out-turn MOP includes a summary of performance for all HEAT targets, including those which cannot be reported on a monthly basis. A dashboard is included for targets where data is available on a monthly basis. For targets which are not reported on a monthly basis Leads have provided narrative to indicate whether targets have been delivered.

Performance Key for HEAT Dashboard

The Dashboard of HEAT targets is included and shows the performance of each HEAT target which can be reported on a monthly basis as at the end of March 2011 (or in the cases where there is a lag, the most up to date data available). So that end of year performance can be judged symbols are used to show whether the trajectory has been achieved. These are shown in the table below: The Dashboard of HEAT Targets shows the performance of each target against a set trajectory. So that current performance can be judged symbols are used to show whether the trajectory is being achieved. These are shown in the table below:

Current Performance Key

R

Under Performing Current performance is significantly outwith the trajectory set.

Exceeds the target by 16% or greater

A

Slightly Below Trajectory

Current performance is moderately outwith the trajectory set.

Exceeds the target by up to 15%

G

Meeting Trajectory Current performance matches or exceeds the trajectory set

Overachieves, meets or exceeds the target, or rounds up to target

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So that the direction of travel towards the achievement of the target can be viewed direction symbols are also included in the dashboard on page 8 which summarises performance of targets over the year. These are shown below:

Direction Symbols

Better performance than previous month No change in performance from previous month Worse performance than previous month Data not available or no comparable data -

Please note:

• Some anomalies may occur in data due to time lags in data availability and national reporting

schedules.

Single Outcome Agreement

A summary of the performance of a number of selected contributions which are related to the Single Outcome Agreement are found in section 4.

Corporate Objectives

A summary of the performance of a number of selected actions which are related to the Corporate Objectives is found in section 5.

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3. HEAT TARGETS Dashboard of HEAT Targets * for these targets there is a lag in reporting and data included is the most up to date data available which may not be

March 2012

Target no Target Descriptor 2011/12 Target Actual

Performance Status

H4 Alcohol brief intervention 1,247 2727 G

Std Smoking cessation successful quits in most deprived areas 280 474 G

H8 Number of inequalities targeted cardiovascular

health checks 390 402 G

Std New patient DNA rate 4% 6% R

Std Same day surgery 86% 84.4% A

Std Pre-operative stay (Feb 2012 Data)* 0.51 0.21 G

2% reduction in energy efficiency 2%

3.3%

G

E8

6% reduction in CO2 emissions 6%

5.68%

A

Std Online Triage of Referrals 90% 93% G

Std eKSF annual reviews complete 80% 73.0% A

Std Sickness Absence Reduced 4% 4.63% A

Treatment within 62 days for Urgent Referrals of Suspicion of Cancer (Feb 2012 data)* 95.0% A

A9

Treatment within 31 days of decision to treat for all Patients diagnosed with Cancer (Feb 2012 data)*

100%

100% G

18 Wk RTT: 12 wks for outpatients 0 0 G

18 Wk RTT: 12 wks for inpatients 0 0 G

18 Wk RTT: Admitted Pathway Performance 77.9% A

18 Wk RTT: Admitted Pathway Linked Pathway 99.2% G

18 Wk RTT: Non-admitted Pathway Performance 94.5% G

18 Wk RTT: Non-admitted Pathway Linked Pathway 92.9% G

Combined Performance 91.6% G

A10

Combined Performance Linked Pathway

90%

94.0% G

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A12 No CAMHS waits over 26 wks 0 0 G

Std 4 Week Waiting Target for Diagnostics 0 1 A

Std 4-Hour Waiting Target for A&E 98% 96.0 A

T9 Diagnosis of dementia1 995 917 R

T10 Reduction in rate (per 100,000) of A&E & MIU Attendees 1624 2173 R

15% Reduction in Rate Staph aureus bacteraemia (Cumulative) 2 3 26.4 32 R

T11 30% Reduction in Rate C. Diff (CDAD) (Cumulative)

3 42.1 40 G

Stroke Admitted to the Stroke Unit within 1 day of admission 80% 91.67% G

No Delayed Discharges over 6 Wks 0 0 G

Std

Delayed Discharges under 6 wks

As at the 15th of March there were 22 delayed discharges under 6 weeks. A target has not been set for delayed discharges under 6 weeks

1 This target was due for delivery in March 2011. Work is ongoing to achieve the target. 2 The infection control team record all SABS across NHS Borders and for every incident a root cause analysis is performed. 3 This target is to be delivered over a 2 year period (2011/12 & 2012/13). Progress will continue to be closely monitored during

2012/13.

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Performance on a total of 20 HEAT targets and standards are detailed within in this report. The following table summarises the achievements for the financial year 2011/12 to date, indicating performance and direction of travel towards achieving targets compared to previous month: Indicator April 11 May 11 Jun 11 Jul 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12

Alcohol brief intervention

R

R

A

G

G

G

G

Smoking cessation successful quits in most deprived areas

G G R G G

Number of inequalities targeted cardiovascular health checks

A

G

G A G G G

New patient DNA rate

A R R R R

Same Day Surgery N/A N/A N/A N/A N/A N/A G A A

Pre-operative stay

G

G

G G G R G

2% reduction in energy efficiency

N/A N/A N/A N/A N/A N/A R-

N/A N/A N/A N/A

6% reduction in CO2 emissions N/A N/A N/A N/A N/A N/A R

-N/A N/A N/A N/A A

Online Triage of Referrals

A

A

G G G G A

eKSF annual reviews complete on the system

N/A N/A N/A N/A R-

R R R

Sickness Absence Reduced to 4%

G A R R R

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Indicator April 11 May 11 Jun 11 Jul 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Treatment within 62 days for Urgent Referrals of Suspicion of Cancer

G

G

G G G G A

Treatment within 31 days of decision to treat for all Patients diagnosed with Cancer

G G G G G

18 Wk RTT: 12 wks for outpatients N/A N/A N/A N/A

-R R R G

18 Wk RTT: 12 wks for inpatients N/A N/A N/A N/A R

-R R R

18 Wk RTT: Admitted Pathway Performance

A

A

A A A R N/A A-

A

18 Wk RTT: Admitted Pathway Linked Pathway

R

A

A A A A N/A G-

G

18 Wk RTT: Non-admitted Pathway Performance

G G G N/A -

18 Wk RTT: Non-admitted Pathway Linked Pathway

A

A

A A A A N/A G-

G

Combined Performance

G

G

G G G G N/A -

G

Combined Performance Linked Pathway

N/A A-

G A A N/A G-

No CAMHS waits over 26 wks

G

G

N/A G-

G G R R G

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Indicator April 11 May 11 Jun 11 Jul 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12

4 Week Waiting Target for Diagnostics

R R R G A

4-Hour Waiting Target for A&E

G

A

G A G G A

Diagnosis of dementia

A A R R R

Reduction in rate (per 100,000) of A&E and MIU Attendees

R R R R G

15% Reduction in Staph aureus bacteraemia

G

G

R G G R R

30% Reduction in C. Diff (CDAD)

G G G R G

Admitted to the Stroke Unit within 1 day of admission

N/A A

R R R G G

No Delayed Discharges over 6 Wks

G

R

R R G G G

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Managing Our Performance – Progress on Targets Not Reported on a Monthly Basis The table below provides a summary of progress towards the delivery of HEAT targets which are not reported on a monthly basis. Health Improvement Reduce suicide rate between 2002 and 2013 by 20%

During 2011 – 12, the suicide prevention training programme continued and 250 people took part in training. There was a decline in the number from frontline NHS services, due in part to the plan to deliver more specialist (STORM) training for mental health services staff in 2012 -13 . The Joint Health Improvement Team continues to work with Clinical Boards on action plans and board-specific staff training and development needs. A discharge pack for mental health service users, developed with direct input from local service user groups, is nearing completion. Work is underway with the BGH Emergency Dept to develop supports and signposting for those discharged who would benefit from support with social and emotional health issues. An innovative programme for men with low mood and at potential risk of suicide has been developed with good results and will be promoted in conjunction with non NHS services.

Achieve agreed completion rates for child healthy weight intervention programme over the three years ending March

The Fit4fun programme has had a very successful first year, delivered in 3 primary schools with high deprivation catchments. The target completion rate for the year was 121, exceeding the target of 100. This was achieved, using a whole school approach to maximise engagement and avoid stigmatising children who are overweight or obese. A range of complementary programmes and activities focusing on activity and healthy food were delivered in other schools and community settings, including the Borders Healthy Living Network.

At least 60% of 3 and 4 year olds in each SIMD to receive at least two applications of fluoride varnish (FV) per year by March 2014

The original target of 38% by December 2011 was not met in NHS Borders, it was below trajectory at 1.35%. The target was also not met nationally and therefore all Health Board areas were given the opportunity to revise their trajectory in light of the risk to achieving H9. This was primarily due to the potential impact of the measurement mechanism which looked at whether every 4 year old had 2 FV applications when they were 3 or whether every 5 year old had 2 FV applications when they were 4. The revised trajectory of 4 % by March 2012 was set which had to be achieved across all quintiles for the trajectory to be met by the Board. Although there has been improvement in the best performing quintile, which are the 4 year olds in quintile 1 (most deprived) from 24.70% to 33.20%, the lowest performing quintile was 3 year olds in quintile 5 (most affluent) was below trajectory at 2.25%. The figures do show an improvement in all quintiles for both 4 and 5 year olds which is due to recent changes to the SDR and a reflection of the work being undertaken within the Childsmile School and Nursery and Practice programmes. This will continue as a HEAT target into 2012/13.

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Increase the proportion of new-born children breastfed at 6-8 weeks

Latest available data shows that the proportion of new born children breastfed at 6-8 weeks was 35.8% at the end of September 2011, exceeding the trajectory of 33.3%. NHS Borders is committed to the highest possible standards of maternity care and in 2011 began work formally towards accreditation under the UNICEF Baby Friendly Initiative for maternity and community services. In late 2011 a BFI Lead was appointed and the UNICEF implementation visit took place. Significant progress has been achieved to develop policies on infant feeding and to prepare for an intensive programme of staff training and skills updates in 2012 -13. Stage 1 accreditation was achieved in April 2012. A pilot has begun in one area of a volunteer breastfeeding peer support programme and, if successful, will be extended to other parts of Borders. Changes to data reporting mean that it is now possible to feed data back to local GP practices on breastfeeding rates for their practice population.

Efficiency Boards to operate within agreed revenue resource limit, capital resource limit and meet cash requirement

All targets were achieved both in terms of revenue and capital budgets. The Board ended the year with a small under spend of £0.1m on revenue budgets.

Boards to deliver 3% efficiency saving to reinvest in frontline services

NHS Borders delivered £7.1m (4.2%) of savings in 2011/12 which were reinvested in frontline services, which was below the 2011/12 trajectory of £8,572,000. However, when taking into account the full year effect of savings schemes which started part way through the financial year the recurring savings target was fully achieved.

NHS Scotland to reduce CO2 emissions for oil, gas, butane and propane usage based on a national average year-on-year reduction of 3% each year to 2015-16

The targets for E8 are: 2% reduction in energy efficiency and 6% reduction in CO2 emissions compared to the baseline of 2009/10. To 31 March 2012 the cumulative reduction for NHS Borders was an energy efficiency of 3.83% which exceeded the 2% target and a 5.68% reduction in CO2 emissions which was slightly below the 6% trajectory. These figures were achieved through close monitoring of operating times, temperatures, and other parameters or the existing installed equipment as well as the co-operation of the staff throughout the organisation during the last twelve months. The Estates Department will continue to install energy efficient equipment as well as reviewing the operating procedures and other parameters of the existing installed equipment to endeavor to maintain the target figures. This will continue as a HEAT target into 2012/13.

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NHS Scotland to reduce energy-based carbon emissions and to continue a reduction in energy consumption to contribute to the greenhouse gas emissions reduction targets set in the Climate Change (Scotland) Act 2009

See narrative above

Access to Services By March 2013, 90% of clients will wait no longer than 3 weeks from referral received to appropriate drug or alcohol treatment that supports their recovery

Performance against this target is summarised below:

Quarter 1 April – June 2011

92% of clients requiring drug and alcohol treatment started treatment to support their recovery within 3 weeks

99% of clients requiring drug and alcohol treatment started their treatment to support their recovery within 5 weeks

100% of all tier 3 and 4 drug and alcohol treatment services submitted data to the Waiting Times Framework.

Quarter 2 July – September 2011

90% of clients requiring drug and alcohol treatment started treatment to support their recovery within 3 weeks.

98% of clients requiring drug and alcohol treatment started their treatment to support their recovery within 5 weeks.

100% of all tier 3 and 4 drug and alcohol treatment services submitted data to the Waiting Times Framework.

Quarter ending Total % seen within 3 weeks % seen within 5 weeks 30th June 2011 162 92 99 30th September 2011 192 90 98 31st December 2011 168 93 99 31st March 2012 128 95 98

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Quarter 3 October – December 2011 93% of clients requiring drug and alcohol treatment started treatment to support their recovery

within 3 weeks. 99% of clients requiring drug and alcohol treatment started their treatment to support their recovery

within 5 weeks 100% of all tier 3 and 4 drug and alcohol treatment services submitted data to the Waiting Times

Framework. Quarter 4 January – March 2012

95% of clients requiring drug and alcohol treatment started treatment to support their recovery within 3 weeks

98% of clients requiring drug and alcohol treatment started their treatment to support their recovery within 5 weeks

100% of all tier 3 and 4 drug and alcohol treatment services submitted data to the Waiting Times Framework.

This will continue as a HEAT target into 2012/13.

18 weeks referral to treatment for Psychological Therapies from December

A Steering Group remains in place to oversee ongoing delivery of this target. An audit of staff delivering psychological therapies is outstanding but currently being worked on. Data is available to identify individuals with over 18 week waits and plans are in place to address these long waits; these are few in number with performance predominantly in line with the target. In the most recent return to the Scottish Government (June 2012), the Mental Health lead has indicated that there are local issues in identifying resources to generate all data relevant to measuring and monitoring this HEAT target. It is anticipated that this will be addressed by using new improvement support funds made available by QuEST (Quality and Efficiency Support Team). This return rated target performance as Amber. This will continue as a HEAT target into 2012/13.

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4. Managing Our Performance – Update on Contributions to Single Outcome Agreement Poverty & Financial Exclusion The Early Years strategy identifies as its primary objective “breaking the cycles of poverty, inequality and poor outcomes in and through the early years for children and families within the Scottish Borders.” On the ground, a wide range of community programmes and capacity building activities are delivered in five areas of disadvantage through the Healthy Living Network. This work continues to have good engagement with young families through the provision of programmes on cooking on a budget, weaning support, physical activity promotion with mothers and babies, community capacity building, information, advice and signposting events for expectant and new mothers. Increasingly these programmes will be integrated within the early years locality networks that are being developed as part of the joint Early Years strategy. As part of the integrated Early Years Assessment Team, the SureStart midwives continue to support the most vulnerable families (12% of births pa) and financial housing and social issues are the primary reason for referral in 20% of these families. NHS Borders is currently preparing an Expression of Interest for the Family Nurse Partnership programme recognising the potential benefits of this in supporting young first time mothers to improve a range of outcomes including education and employability. In the context of the new HEAT target on antenatal access, the Health Improvement Team is working with maternity services on the antenatal education programme not only for maternity staff but also to include key services in contact with pregnant women to address wider social risks and concerns including financial pressures that impact on maternal and child health. Links are in place to ensure that issues of maternal and child health are considered in the process of reviewing the Tackling Poverty and Financial Inclusion Strategy, which encompasses the impacts of current welfare reforms. It is planned that more focused work with early years staff in the NHS and other sectors will be developed in the coming 12 months to raise awareness, identify local good practice and facilitate effective signposting for families affected by poverty and financial exclusion. Substance Misuse The Alcohol and Drugs Partnership in collaboration with the Child Protection Committee has developed interim guidelines to strengthen and align to the GIRFEC (Getting it Right for Every Child) principles and multi agency working practices with families where children are living with substance misuse. A workshop for managers to inform them of the interim guidelines is planned for September 2012. Once the named person role has been rolled out across the Borders, the guideline will be developed further to reflect this crucial role and be aligned with the new Lothian guideline. It is anticipated that this will be in place in early 2013 with a supporting training package.

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Violence Against Women & Domestic Abuse NHS Borders is an active partner in the current redesign of Violence Against Women (VAW) services which aims to achieve a more integrated set of approaches locally that facilitate prevention and early intervention, promote recovery and community integration of those affected including families with children. The VAW partnership is developing a training, education and prevention work stream which includes targeted prevention work at locality level working within with Nurseries, Primary Schools and involving Health Visitors and Midwives. Approximately 25 of the 60 midwives identified have had gender based violence training (outlined in CEL 41) and this will continue to be rolled out. As a partner in the redesign of VAW services, NHS Borders carried out the participation work for the successful bid, in partnership with other agencies. This included active engagement with mothers of young children through community groups and nurseries, as well as with children and young people. The VAW training programme includes a course for partner agencies, including NHS staff, on children’s experiences of domestic abuse. “My Family Hurts” is co-delivered by an experienced NHS trainer (a Health Improvement practitioner) working with Children 1st. The sessions have evaluated extremely well. The VAW training programme is available to all staff including midwifery and public health nursing staff and continues to be well attended and evaluated More recently, domestic abuse training has been extended for Registered Social Landlords, who have agreed to adopt a joint policy.

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5. CORPORATE OBJECTIVES Below is an update on selected actions progressed during 2011/12 which are outlined in the Corporate Objectives.

Corporate Objective Action to Be Delivered Progress to Date Improving Critical Care, General Ward and peri-operative outcomes

Good progress has been made in all the measures. Spread of all the key changes (including testing, training, communication) is underway beyond the pilot populations throughout the BGH within the five initial work streams: general ward, peri-operative, medicines management, critical care and leadership. Teams are in place and testing, implementation and spread are well underway. The General Ward team have introduced a new system of reporting called LanQIP, which despite some teething problems is ensuring that data is more readily collected on the wards. Ward 6 remains the pilot ward, but other BGH areas have implemented the measurement plan. Areas have improved, but with some variation still present, this variation is not wholly sustained. Continued work from all team members is helping to progress this is the new financial year. Peri Operative continues to have a committed team, reflected by sustained improvement of all but one measures. As with general ward, work is underway to improve this. Overall, Critical Care work-stream continues to make sustained improvements in process and outcome data. As with previous months, the lag time in data for Critical Care is due to the data being verified externally by Ward Watcher.

Patient Safety:

We will ensure patients confidence in our services by always putting patient

safety first

Ensuring alignment of the Clinical Quality Indicators with the Leading Better Care Initiative

In January 2012, a new way of demonstrating compliance against NHS Scotland Healthcare Quality Strategy was introduced; the Quality Improvement Portal (LanQIP) designed by NHS Lanarkshire. The portal measures a range of quality processes for the Scottish Patient Safety Programme (SPSP) and the Leading Better Care (LBC) programme clinical quality measures. The information is entered on the portal at the point of care. LanQIP is fully implemented with governance structures being developed.

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Corporate Objective Action to Be Delivered Progress to Date

Patient Safety:

We will ensure patients confidence in our services by always putting patient

safety first

Ensuring ‘Executive Safety Walkrounds’ take place according to an agreed timetable

The aim is to conduct two Scottish Patient Safety Programme (SPSP) leadership walkrounds per month. From April 2011- March 2012 there were 10 SPSP executive walkrounds which was below the trajectory. As a result of these walkrounds there were 20 actions in total identified for the executive team. Of these, 15 have been actioned and 5 remain outstanding. These 5 outstanding actions have been carried forward into 2012-13 and progress is being tracked to ensure they are delivered. Assurances have been made that improvements are already evident for the financial year 2012/2013. There have been a number of extenuating circumstances for the previous year, but work is well underway to review the process and ensure that the walkrounds do indeed take place and the actions executed.

Developing a Health Protection Plan in collaboration with SBC

Joint Health Protection Plan endorsed by full council and NHS Board. Successful implementation evidenced by, for example, high uptakes of immunisation and screening programmes.

Achieving “Gold” status in relation to Healthy Working Lives

NHS Borders are maintaining their Silver Healthy Working Lives Award whilst continuing to work towards both the Healthy Working Lives Gold and Mental Health Commendation Awards in line with CEL 2012:01 Health Promoting Health Service: Action In Hospital Settings.

Health Improvement & Inequalities:

We will promote and

protect health and well-being

Continuing to implement the Child Health and Child & Young People Mental Health Strategy and Workplan

Following discussion with all stakeholders a decision was made to separate accountability for the multi-agency and specialist CAMHS (Child & Adolescent Mental Health Services) aspects of the work plan. The work plan will continue to hold both aspects of the plan but the accountability for the specialist outcomes will sit with the CAMHS Steering Group and the multi-agency aspects with the CYPPP (Children & Young Peoples Planning Partnership). There is clarity in the work plan re this division of accountability but it continues to sit as a complete document so that the overview of all aspects of the work plan are understood by all stakeholders.

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Corporate Objective Action to Be Delivered Progress to Date

Health Improvement & Inequalities:

We will promote and

protect health and well-being

Continuing to implement the Child Health and Child & Young People Mental Health Strategy and Workplan – continued

The specialist CAMHS section of the Borders Child and Young Persons Mental Health Strategy Work Plan has been updated to incorporate standards from the new National CAMHS ICP and Balanced Scorecard. The initial focus is on training for staff, routine recording of diagnosis, recording and sharing of information, referral and triage systems, holistic assessment and care planning. We also continue to monitor performance against the HEAT targets (CAMHS RTT and access to psychological therapies) and both these targets are currently being achieved. Specialist CAMHS now takes referrals up to 17th Birthday with a view to further raising this to 18th Birthday next year with the effect on waiting times being closely monitored. Tier 4 (inpatient and intensive treatment) services in South east Scotland are working well with significantly reduced admissions of under 18s to adult beds and overall length of stay. Work continues with Scottish Borders Council Education and Lifelong Learning to embed social and emotional health as a whole school approach, in support of the GIRFEC (Getting it Right for Every Child) values, principles and practice model, with support from the Joint Health Improvement Team. The team’s suicide prevention specialists have developed an education pack to accompany the film ‘That’s Not Me’. Pastoral staff have had training to support them in delivering the 6 sessions within the pack, which is to be evaluated in one high school by Educational Psychology. It is hoped to develop a comparable resource for use in primary schools. Getting the Lowdown has been purchased for use within both primary and secondary school settings. This focuses on a range of health related topics linked to mental health and wellbeing.

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Corporate Objective Action to Be Delivered Progress to Date Health Improvement &

Inequalities:

We will promote and protect health and well-

being

Continuing to implement the Child Health and Child & Young People Mental Health Strategy and Workplan – continued

The Borders suicide prevention team continues to foster peer support for young people. An ex-pupil from Berwickshire High school is now trained to deliver safeTALK and ASIST and has been enthusiastic in his delivery to young people, both within local secondary schools and to various youth settings in Dundee.

Performance & Delivery:

We will deliver high quality services that meet local &

national performance targets and deliver

continuous improvement

Improving pre-admission process and increase day case rates

Pre-admission Clinics NHS Borders invested in a Pre-assessment Service which is enabling all patients deemed as requiring surgery to be screened for fitness for anaesthesia, depending on the outcome a proportion of the patients are invited to attend a full Pre-assessment Clinic appointment, approx 2 weeks prior to the intended operation date. At this clinic additional tests may be carried out and information is gathered and shared by specialist nurses and an anaesthetic consultant to ensure only those individuals fit for surgery are listed for their operation. The introduction of the PAC service has seen the number of patients cancelled on the day of surgery reduce, allowing Theatres to become more productive. The same day surgery rates are captured in the Clinical Board Performance Scorecards and are a balancing measure alongside pre-op stay, if we have too high a pre-op stay it affects our ability to deliver good same day surgery rates. For some procedures or groups or patients with co-morbidities it’s appropriate though. In BGH performance improved and the introduction of the PSAU has helped the flow of patients through a better pathway to Theatre. As such during the period from March 2011 to November 2011 there was a 23% increase in activity levels. The Pre-op stay position as at 31 March 2012 for same day elective surgery has exceeded trajectories for the following specialities:

• General Surgery improved since January from 0.33 to 0.13, significantly better than target of 0.46

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Corporate Objective Action to Be Delivered Progress to Date Improving pre-admission process and increase day case rates - continued

• Trauma and Orthopaedics improved from January 0.41 to 0.29, again better than target of 0.58

• Urology has improved from 0.15 to 0.00, significantly better than target of 0.68

Increase day case rates There has been focussed attention on ensuring that when it is clinically appropriate patients are treated as a day case. A weekly report is circulated to the Heads of Clinical Service to allow each area to understand their practice and consider areas where pathways could be redesigned. For example plans are underway to look at improvements such as day case for tonsillectomy, this work is being scoped out by the anaesthetics team who will be pulling together the clinical evidence and protocols to take forward this proposed change in pathway, in addition the SCAN regional cancer group are beginning to roll out the 23 hour breast pathway, local engagement is underway.

Performance & Delivery:

We will deliver high quality services that meet local &

national performance targets and deliver

continuous improvement

Delivering an appropriate Hospital at Night Service for paediatrics to support sustainability of service provision

The Paediatric and Neonatal Hospital at Night project is progressing and is anticipated to deliver 88% of planned Advanced Nurse Practitioners (ANP) resource by August 2012. Recruitment difficulties, particularly to Advanced Paediatric Nurse Practitioners (APNP) posts, has impacted on the unit’s ability to fully provide emergency care out of hours overnight and at weekends without junior doctor cover at this time. There is a gap in the 17.00-21.00 period which was not included at the start of this project. It is anticipated that a second phase of this work is required to address sustainability and succession planning for the future as the junior doctor situation continues to change. This will be addressed by the Six Step Methodology workforce planning and progressed during 2012/13.

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Corporate Objective Action to Be Delivered Progress to Date

Performance & Delivery:

We will deliver high quality services that meet local &

national performance targets and deliver

continuous improvement

Eliminating discrimination and promoting equality across all of our functions

NHS Borders has established an Equalities Steering Group, to ensure the mainstreaming of equality and diversity within the organisation. This group meets bi-monthly and is Chaired by the Joint Director of Public Health. A Single Equality Scheme (including an action plan) was developed by this group and approved by NHS Borders Board. Changes have been made to NHS Borders recruitment process to bring it in line with the requirements of the Equalities Act 2010. NHS Borders has also reviewed the Equality Impact Assessment procedures to ensure they comply with best practices and the Equality Act. NHS Borders has introduced a mandatory Equality and Diversity e-learning programme - there is an expectation that all staff will complete this.

Processes & Structures:

We will develop services and structures that deliver the right thing, first time,

every time

Developing and outlining effective joint working arrangements to: Maximise the resources available to us & Deliver Seamless Care to the population we serve

The Scottish Government established a Change Fund to facilitate shifts in the balance of care from institutional to primary and community settings. The fund is designed to enable health and social care partners to implement local plans for making better use of their combined resources and achieving transformational change for the delivery of services for older people.

Reshaping Care is about changing the way older people are supported in their own community by a whole range of support providers, Scottish Borders Council, NHS Borders, the Independent Sector and Voluntary Sector as well as by the Local Community.

The Scottish Borders Partnership was established with representatives of all key partners including NHS Borders, Scottish Borders Council and Scottish Care, representing the independent and Voluntary sector. The allocation for the Scottish Borders Partnership was £1.7m for financial year 2011/12 and 22 Projects were supported by the Fund.

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Corporate Objective Action to Be Delivered Progress to Date

Processes & Structures:

We will develop services and structures that deliver the right thing, first time,

every time

Ensuring effective, co-ordinated and essential training for all staff

The Statutory & Mandatory training project was developed in response to service and partnership feedback through the Area Partnership Forum, with all decisions regarding progress being made in Partnership. The aim of the Project was to put measures in place to ensure that all NHS Borders staff would receive the Statutory & Mandatory training, appropriate to their role, to enable them to carry out their duties safely, effectively and efficiently, thereby promoting Patient Safety. Managers are accountable for the Statutory & Mandatory training of their staff, however, in practice it was evident that some Managers were not taking full responsibility for this, leaving the Organisation at risk, wasting resources & incurring avoidable cost. In 2011 year 1, the group focused on the development of measures to support Managers. A sample training plan was distributed to Line Managers to utilise and outline how the staff they are responsible for would receive their Statutory & Mandatory training. All Managers were advised to ensure that training records for their staff are correct and up-to-date, recorded on eKSF and to reflect this within Departmental Performance Scorecards. To improve the accuracy of reporting straight to line managers, mechanisms have been put in place to ensure that all Statutory & Mandatory Training is booked on eManager. In 2012 - year 2, the group will continue to meet at regular intervals to review, monitor and identify ways in which training can be more responsive to service requirements. Clinical Boards and Support Services have been requested to submit their training plans by the 31st March 2012 in order that the group has an overview of organisational training requirements and progress. The Statutory & Mandatory training project will complement the concurrent workforce development of roles, education and competency frameworks. This will lead to a safer organisation for patients and staff due to a competent workforce coupled with

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Corporate Objective Action to Be Delivered Progress to Date Ensuring effective, co-ordinated and essential training for all staff – continued

increased efficiency as a result of an increased attendance rate at all Statutory & Mandatory training of over 75%.

Processes & Structures:

We will develop services and structures that deliver the right thing, first time,

every time

Reviewing the Risk Management Process across NHS Borders, including the implementation of Datix

The review of the Risk Management processes is still ongoing and will carry forward into 2012/13. The Datix system was launched 1st April 2011.