Overview and Executive SummarySection A: Introductionadmin.fifedirect.org.uk/.../c64_Item16a-IPRJanuary2018.docx · Web view0.05 5.5100000000000003E-2 5.3100000000000001E-2 5.1400000000000001E-2

Integrated Performance Report

Produced in January 2018

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Contents

Section A IntroductionOverview

3Performance Summary

4Executive Summary

5Performance Assessment Methodology

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Section B:1 Clinical GovernanceExecutive Summary

11HAI/SABS

13Complaints

16HAI/SABS Drill-Down

20Complaints Drill-Down

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Section A Overview and Executive SummaryOverview 5Performance Summary Table 6Performance Data Sources 7Executive Summary 8Performance Assessment Methodology 14

Section B:1 Clinical GovernanceExecutive Summary 16Performance Summary Table 17Performance Assessment Methodology 18HAI/SABS Drill-down 19Complaints Drill-down 21

Section B:2 Finance, Performance & ResourcesExecutive Summary 22Performance Summary Table 26Performance Assessment Methodology 27Performance Drill-down

NHS Acute Division4-Hour Emergency Access 29Cancer 62 Day Referral-to-Treatment 30Patient Treatment Time Guarantee 31Diagnostics Waiting Times 3218 Weeks Referral-to-Treatment 33

Health & Social Care PartnershipDelayed Discharge 34Smoking Cessation 36Child and Adolescent Mental Health Service (CAMHS) Waiting Times 38Psychological Therapies Waiting Times 41

Capital Programme 43Financial Position 48

Section B:3 Staff GovernanceExecutive Summary 57Performance Summary Table 58Performance Assessment Methodology 59Sickness Absence 60Sickness Absence Drill-down 65

Section A: Introduction

OverviewThe purpose of the Integrated Performance Report (IPR) is to provide assurance on NHS Fife’s performance relating to National Standards, local priorities and significant risks.

The IPR comprises 4 sections:

Section A Introduction Section B:1 Clinical Governance Section B:2 Finance, Performance &

Resources Section B:3 Staff Governance

The section margins are colour-coded to match those identified in the Corporate Performance Reporting, Governance Committees Responsibilities Matrix.

A summary report of the IPR is produced for the NHS Fife Board.

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Performance Summary Current Period Current

PerformancePrevious Period

Previous Performance

Direction of Travel Period Performance Rank Scotland

HAI - C Diff Safe 0.32 12 months to Nov 2017 0.25 12 months to

Oct 2017 0.25 ↔ 0.23 y/e Sep 2017 0.24 4th 0.28

Complaints (Stage 1 Completion) Person-centred 80.0% Oct 2017 91.1% Sep 2017 85.3% ↑ 79.5%

HAI - SABs Safe 0.24 12 months to Nov 2017 0.36 12 months to

Oct 2017 0.35 ↓ 0.39 y/e Sep 2017 0.37 7th 0.33


IVF Treatment Waiting Times Person-centred 90.0% 3 months to Nov 2017 100.0% 3 months to

Oct 2017 100.0% ↔ 100.0%

4-Hour Emergency Access * Clinically Effective 95.0% 12 months to Nov 2017 95.3% 12 months to

Oct 2017 95.1% ↑ 95.8% y/e Sep 2017 94.9% 5th 93.8%

Cancer 31-Day DTT Clinically Effective 95.0% Nov 2017 99.0% Oct 2017 99.0% ↔ 98.7% q/e Sep 2017 97.8% 4th 94.5%

Antenatal Access Clinically Effective 80.0% 3 months to Mar 2017 88.2% 3 months to

Feb 2017 87.4% ↑ N/A

Drugs & Alcohol Treatment Waiting Times Clinically Effective 90.0% q/e Sep 2017 94.8% q/e Jun 2017 96.8% ↓ 95.8% q/e Sep 2017 94.8% 7th 93.8%

Outpatients Waiting Times Clinically Effective 95.0% Nov 2017 93.3% Oct 2017 93.1% ↑ N/A End of September 93.8% 1st 69.7%

Dementia Post-Diagnostic Support Person-centred 100.0% 2015/16 89.5% 2014/15 95.8% ↓ N/A

18 Weeks RTT Clinically Effective 90.0% Nov 2017 79.4% Oct 2017 77.8% ↑ 82.4% Sep-17 81.4% 6th 81.4%

Patient TTG Person-centred 100.0% Nov 2017 92.0% Oct 2017 91.0% ↑ 88.8% q/e Sep 2017 92.0% 1st 80.2%

Diagnostics Waiting Times Clinically Effective 100.0% Nov 2017 86.0% Oct 2017 82.3% ↑ N/A End of September 84.1% 6th 81.6%

Cancer 62-Day RTT Clinically Effective 95.0% Nov 2017 89.9% Oct 2017 98.7% ↓ 93.3% q/e Sep 2017 94.4% 4th 87.2%

Detect Cancer Early Clinically Effective 29.0% 2 years to Jun 2017 27.2% 2 years to Mar

2017 28.1% ↓ N/A

Delayed Discharge (Delays > 2 Weeks) Person-centred 0 30th Nov Census 21 26th Oct

Census 24 ↑ N/A 28th Sep Census 10.26 6th 9.79

Dementia Referrals Person-centred 1,289 6 months to Sep 2017 271 3 months to

Jun 2017 150 ↓ 271

Alcohol Brief Interventions Clinically Effective 4,187 q/e Sep 2017 1,880 q/e Jun 2017 1,165 ↓ 1,880

Smoking Cessation Clinically Effective 779 Aug 2017 188 Jul 2017 154 ↓ 188

CAMHS Waiting Times Clinically Effective 90.0% 3 months to Nov 2017 62.8% 3 months to

Oct 2017 63.7% ↓ 67.4% q/e Sep 2017 65.1% 7th 73.3%

Psychological Therapies Waiting Times Clinically Effective 90.0% 3 months to Nov 2017 71.3% 3 months to

Oct 2017 70.2% ↑ 69.6% q/e Sep 2017 69.4% 5th 76.6%

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Sickness Absence Clinically Effective 4.50% 12 months to Nov 2017 5.42% 12 months to

Oct 2017 5.39% ↓ 5.39%

* The 4-Hour Emergency Access performance in November alone was 96.2% (all A&E and MIU sites) and 94.7% (VHK A&E, only)

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Only published annually: NHS Fife was 11th for FY 2016-17

Only published annually: NHS Fife was 3rd for FY 2015-16

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Only published annually: NHS Fife was joint 7th for FY 2016-17 (Fife performance 5.11%, Scotland performance 5.20%)

Treatment provided by Regional Centres so no comparison applicable

Standard Quality Aim Target for 2017-18

National Comparison (with other 10 Mainland Boards)FY 2017-18 to Date

National Data not yet published


Only published annually: NHS Fife was 1st for 2-year period 2015 and 2016

Performance Data


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Performance Data Sources

LDP Target / Standard LMI / Published LMI Source Period Covered by Published Data

Time Lag in Published Data

IVF Treatment Waiting Times LMI ISD Management Report Quarter 2 months

18 Weeks RTT LMI Information Services Quarter 2 months

4-Hour Emergency Access LMI Information Services Month 1 month

Delayed Discharge Published (ISD) N/A Month 1 month

Alcohol Brief Interventions LMI Addiction Services Year 3 months

Drugs & Alcohol Waiting Times Published (ISD) N/A Quarter 3 months

CAMHS Waiting Times LMI Mental Health Quarter 2 months

Psychological Therapies Waiting Times LMI Mental Health Quarter 2 months

Hospital-Acquired Infection: Sabs LMI Infection Control Quarter 3 months

Hospital-Acquired Infection: C Diff LMI Infection Control Quarter 3 months

Dementia: Referrals LMI ISD Management Report Quarter TBD

Dementia: Post-Diagnosis Support LMI ISD Management Report Quarter TBD

Smoking Cessation LMI Smoking Cessation Database Year 6 months

Sickness Absence LMI HR (SWISS) Year 12+ months

Detect Cancer Early LMI Cancer Services 2 Years 7 months

Antenatal Access LMI ISD Discovery Year 6 months

Cancer Waiting Times: 62-Day RTT LMI Cancer Services Quarter 3 months

Cancer Waiting Times: 31-Day DTT LMI Cancer Services Quarter 3 months

Patient TTG LMI Information Services Quarter 2 months

Outpatient Waiting Times LMI Information Services Final Month of Quarter 2 months

Diagnostics Waiting > 6 Weeks LMI Information Services Final Month of Quarter 2 months

GREEN Local Management Information (LMI) and Published data almost always agree

AMBER LMI and Published data may have minor (insignificant) differences

RED LMI and Published data will be different due to fluidity of Patient Tracking System

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Executive SummaryAt each meeting, the Standing Committees of the NHS Fife Board consider targets and Standards specific to their area of remit.

This section of the IPR provides a summary of performance Standards and targets that have not been met, the challenges faced in achieving them and potential solutions. Topics are grouped under the heading of the Committee responsible for scrutiny of performance.

This section also provides a summary of the Capital Programme and Financial position.

CLINICAL GOVERNANCE

Hospital Acquired Infection (HAI) - Staphylococcus Aureus Bacteraemia (SAB) target: We will achieve a maximum rate of SAB (including MRSA) of 0.24.

During November, there were 7 Staphylococcus aureus Bacteraemias (SAB) across Fife, 3 being hospital-associated infections and 4 being community-associated infections. The number of cases in November was 3 more than in October but one fewer than in November 2016. The infection rate over the last 12-month period (taking account of all infection sources) remains above the Standard.

Assessment: Much progress has been made in terms of reducing the number of avoidable vascular access device infections across ASD. The Dialysis Line Management Improvement Group achieved their stretch aim of “100 days since the last dialysis line related SAB”, achieving 174 days as of 8th January This improvement work has dramatically improved the clinical outcomes for our patients in dialysis day care.

Vascular access device (VAD) improvement work continues to be addressed via the SPSP Stakeholders Group, Quality and Safety Governance Group, Infection Control Committee, Acute Services Division Governance Committee and the NHS Fife Vascular Access Strategy Group. The HSCP is also involved via its Clinical and Care Governance Groups. A number of actions have been identified and will be progressed throughout 2018.

A structured programme of education had been co-produced to support Hand Hygiene improvement activities across ASD and the HSCP. This supportive work was extremely well received during November and early December 2017 and will be evaluated during the coming months.

Complaints local target: At least 80% of Stage 1 complaints are completed within 5 working days of receipt; at least 75% of Stage 2 complaints are completed within 20 working days; 100% of Stage 2 complaints are acknowledged in writing within 3 working days.

The rate for completion of Stage 1 complaints in October was 91.1%, the highest since the first month of the FY. The rate for completion of Stage 2 complaints was 63.0% (96.3% acknowledged on time), the highest since December 2016.

Assessment: Performance against Stage 2 complaint handling was significantly below the 75% target during the first quarter of FY 2017/18, but

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improvements have been seen since August as extreme staffing challenges have been addressed.

In addition to staffing within Patient Relations, the principle reasons for failing to meet the 20-day completion target is a delay in the provision of statements from the Divisional Teams and delay in approval and sign off.

An Improvement Plan has been in place since May 2017, and IMPACT are supporting the development of a project plan which will focus on further improving the Stage 2 performance. A review of data for the 3-month period from September to November is continuing.

FINANCE, PERFORMANCE & RESOURCES

NHS Acute Division

4-Hour Emergency Access target: At least 95% of patients (stretch target of 98%) will wait less than 4 hours from arrival to admission, discharge or transfer for Accident and Emergency treatment.

The annually measured performance increased at the end of November, remaining above the Standard. In November itself, 94.7% of the patients attending the VHK Emergency Department were treated, discharged or transferred within 4 hours of arrival, equating to 268 breaches out of 5,071 attendances.

Assessment: The position shows significant improvement, particularly evidenced in a reduced number of patients waiting for first assessment. Work continues with the A&E teams to review pathways and look for improvement. Staffing models are reviewed and agreed on a weekly basis.

Cancer 62 day Referral to Treatment target: At least 95% of patients urgently referred with a suspicion of cancer will start treatment within 62 days.

In November, performance fell to 89.9%, below the Standard after two successive months where the Standard was exceeded. There were 7 breaches out of 69 patients who started treatment, across 5 specialties.

Assessment: The 62 day Standard performance remains variable due to a number of areas of risk, particularly in Radiology, and surgical capacity in NHS Fife and NHS Lothian, for Urology and Gynaecology. The Lung, Head & Neck and Upper GI pathways continue to be at risk due to complexity and number of steps involved. Whilst there has been improvement in Quarter 2 (94.4%) and we have met the Standard in 3 out of the last 6 months, it is anticipated that performance will continue to be variable in Quarter 4 of 2017/18, despite efforts made to prioritise cancer patients during the winter season.

Patient Treatment Time Guarantee target: We will ensure that all eligible patients receive Inpatient or Day-case treatment within 12 weeks of such treatment being agreed.

In November, 92.0% of patients were seen within 12 weeks, a 1% improvement on the performance in October. Trauma & Orthopaedics

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(58) and Urology (24) reported the highest number of breaches out of a total of 120.

Assessment: Additional activity to mitigate the demand/capacity gap and reduce the backlog continues to be delivered. There are renewed efforts to secure additional activity in particular outsourcing activity and to recruit to vacant posts. Three Consultant Anaesthetists have been recruited, and will take up post in February and March 2018. It is anticipated that performance will be a significant challenge in Quarter 4 of 2017/18 due to the impact of unscheduled care pressures over the winter period.

Diagnostics Waiting Times target: No patient will wait more than 6 weeks to receive one of the 8 Key Diagnostics Tests.

At the end of November, 86.0% of patients on the waiting list had waited less than 6 weeks for their test, a 4% improvement compared to the position at the end of October, with the number of breaches decreasing for MRI and CT scanning.

Assessment: Meeting the target for non-obstetric ultrasound, MRI and CT continues to be a challenge. There are continued efforts to manage both demand and provide additional capacity to meet the gap and to recruit to vacant posts. Additional capacity is being delivered through redesign of services and with support from regional partners, the regional reporting network and outsourcing MRI. It is anticipated that performance will begin to recover in Quarter 4 of 2017/18.

18 Weeks Referral-to-Treatment target: 90% of planned/elective patients to commence treatment within 18 weeks of referral.

During November, 79.4% of patients started treatment within 18 weeks of referral, a small improvement on the performance in October.

Assessment: We anticipate that with the challenges with performance in TTG, Outpatients and Diagnostics against this Standard will continue to be a challenge in Quarter 4 of 2017/18 with some improvement towards the end of Quarter 4 2017/18, if the projected recovery for diagnostics and outpatients are achieved as planned.

Health & Social Care Partnership

Delayed Discharge target: No patient will be delayed in hospital for more than 2 weeks after being judged fit for discharge.

At the Delayed Discharge Census on 30th November, 21 patients had been delayed in hospital for more than 2 weeks after being judged fit for discharge, 3 less than the number in delay at the October Census. The overall number of patients in delay (54) was unchanged.

Assessment: The partnership continues to rigorously monitor patient delays through a daily and weekly focus on transfers of care, flow and resources. Our improvements have been focused on improving earlier supported discharge and earlier transfers from our acute setting to community models of care. It continues to be a significant challenge to eradicate delays of greater than 14 days.

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Smoking Cessation target: In 2017/18, we will deliver a minimum of 779 post 12 weeks smoking quits in the 40% most deprived areas of Fife.

Local management information shows that 188 people who attempted to stop smoking in the first five months of the 2017/18 had successfully quit at 12 weeks. This is slightly more than the quit number for the first five months of 2016/17.

Assessment: New and additional sessions are due to start in Auchmuty Learning Centre, Kirkcaldy Leisure Centre, Lochgelly Health Centre and Cowdenbeath Clinic in January. Linburn clinic has moved from fortnightly to weekly in line with evidenced based practice. Staff member to be sited in Hayfield House one day a week from January to support service developments in the Victoria Hospital.

Child and Adolescent Mental Health Services (CAMHS) target: At least 90% of clients will wait no longer than 18 weeks from referral to treatment for specialist Child and Adolescent Mental Health Services (note: performance is measured on a 3 month average basis).

Performance against the CAMHS Standard for the 3 month period ending November was 62.8%, continuing the downward trend evident since the start of 2017/18. The number of patients on the waiting list has continued to increase.

Assessment: Significant focus has been placed on providing appointments for the Children and Young People with the longest waits (approximately 30% of clinical activity).

Additional resources have been identified to focus specifically on the longest waits and to allow substantive staff to provide timely interventions to those with the greatest need. This will be fully operational by February.

Psychological Therapies Waiting Times target: At least 90% of clients will wait no longer than 18 weeks from referral to treatment for psychological therapies (note: performance is measured on a 3 month average basis).

For the 3 month period ending November, the percentage of patients starting treatment within 18 weeks of referral was 71.3%, marking the best performance across the services since June-August 2016. The number of patients waiting over 18 weeks at the end of November was 566, the lowest since March 2015. Despite continued improvement in performance, services face ongoing challenges as monthly referrals in November were the highest yet reported and continue to increase.

Assessment: Services providing brief therapies for people with less complex needs are meeting the RTT 100%; overall performance reflects the longer waits experienced by people with complex needs who require longer term treatment. We continue to address the needs of this population through service redesign with support from the ISD/HIS Mental Health Access Improvement Support Team, and anticipate further significant progress towards the Standard by March 2018.

Capital Programme

The total anticipated Capital Resource Limit for 2017/18 is £7.935m. The capital expenditure position for the 9 months to December reflects spend of £4.968m. It is projected that the Board will spend the Capital Resource Limit in full.

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Financial Position

The revenue expenditure position for the 9 months to 31 December 2017 reflects an overspend of £3.680m. This overspend comprises an underspend of £1.256m attributable to Health Board; and £4.936m to the Integration Joint Board. The report provides further detail on the assumptions underpinning the forecast outturn; however it is reasonable to note the improved position for the nine month period to the end of December as a positive indication that a breakeven outturn may be achieved. Members of the Committee and NHS Board should note that the December Financial Monitoring Return to the Scottish Government Health & Social Care Directorates will set out a break even forecast, with supporting narrative on the key issues and risks.

Specific points to note include:

Financial flexibility of £6.551m has been reflected in the year to date position to mitigate, in part, slippage in savings delivery. This relates to financial plan commitments not required and is a crucial element of the Board’s ability to deliver against the statutory financial target of a break even position against the revenue resource limit.

A further £1.6m DEL funding (above the £2.5m assumed in the financial planning process) has been assumed as forthcoming in year. The total £4.1m compares with £2.8m received in 2016/17. Plans are underway to identify a further £0.4m qualifying expenditure, with a residual risk re the £1.1m balance remaining under review. Work is also underway to assess the extent to which the DEL funding might be utilised for the replacement of obsolete beds across the system; and whilst this will not result in a corresponding reduction in the current forecast outturn, it will address a number of clinical priorities.

A national shortage in supply of some medicines has impacted adversely on costs in months 7 to 9. This is reflected in the position and sees a change to the positive trend on both the volume and cost per item in respect of GP prescribing to the half year. Information received in early December is being scrutinised to determine the likely impact on the position to the year end.

An updated assessment of the recurring delivery of savings has been established with an identified shortfall of £15.558m at this point in the year. Whilst the overall shortfall may be mitigated in year through non recurring measures, it will impact on the financial planning for 2018/19 and beyond. This includes £8.810m for the Health Board and £6.748m for the Integration Joint Board. In addition, there is a degree of legacy savings from prior years and these are also recognised through the work already undertaken on the financial outlook for future years.

The reported position for the period to date reflects the impact of a risk sharing of the total IJB overspend with Fife Council, based on November forecasts. This approach has been taken due to the different reporting timeframes of the respective partners.

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The forecast year end outturn position ranges between break even (best case) and an overspend of £4.039m (prudent position). All 3 forecasts comprise a mid range operational position as informed by individual Directors, adjusted for both a best case and prudent assessment of financial flexibility. This is consistent with the approach outlined to the Finance, Performance & Resources Committee in August and NHS Board in September. The current mid range forecast reflects an overspend of £1.188m.

The forecast outturn includes projected underspends on in-year allocations from Scottish Government; this is a key component of the financial flexibility described above. Given NHS Boards cannot carry forward income to future years, any unspent funding has been reflected within the in-year and forecast position. The decision to spend on these areas in future years is a decision for budget holders to manage.

Sections 7 and 8 of the full Finance Report within the IPR provide further details on the year end forecast and the next steps toward securing a balanced position. Members are invited to review the issues highlighted in these sections and to note the potential risks and benefits described.

STAFF GOVERNANCE

Sickness Absence target: We will achieve and sustain a sickness absence rate of no more than 4%, measured on a rolling 12-month basis (note: we measure performance on an annual basis to eliminate monthly/seasonal variations, however supporting text focuses on month to month performance)

The sickness absence rate in November was 5.69%. The sickness absence rate for the 2016/17 financial year was 5.02% and the SWISS average sickness absence rate for 2017/18 to date is 5.42%.

Assessment: The Acute Services Division trend has fluctuated over the last six months, reducing to 5.31% in June, 5.14% in July, 4.98% in August, 4.81% in September, increasing to 5.15% in October and decreasing to 5.11% in November.

Despite being the only area in the 4% range in June, the Corporate Directorates rate has increased to 5.01% in July, 5.68% in August, 6.13% in September 6.49% in October and 6.52% in November.

Within the Health & Social Care Partnership, the rate has also fluctuated over the last six months reducing to 5.44% in June, increasing to 5.47% in July, reducing to 5.24% in August, increasing to 5.41% in September, 5.61% in October and 5.94% in November.

The main focus going forward continues to be implementing the actions from the staff and managerial surveys which were run in June 2017.

iMatter Update

The iMatter implementation programme has completed phase 1, providing all staff with the opportunity to participate in the staff engagement monitoring process. All members of NHS Fife staff and the Fife Council Staff working in the Health and Social Care Partnership have now commenced iMatter. There are currently 815 teams established within the iMatter system representing in excess of 10,000 staff. The current Board

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report for 2017 is representative of the teams which have gone through their anniversary cycles this year to date and represents the views of 6,008 out of 9,552 staff.

KSF Update

KSF performance is regularly reported to EDG and APF and Staff Governance Committee. The completion figure for the 12-month period ending 31 December was 61%, an 11% improvement compared to the position at 31 March 2017 and 13% higher than at 31 December 2016.

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Performance Assessment MethodologyThe Scottish Government requires all Health Boards to attain a defined level of performance against a number of measures (known as Standards) which are included in the Local Delivery Plan (LDP). In addition, NHS Fife scrutinises its performance relating to Complaints.

At initial assessment of performance, targets and Standards are grouped into three categories; those where performance always (or usually) achieves the required target (i.e. ‘on track’), those where performance has either ‘not met’ the required level or has dropped below it for a prolonged period (i.e. is ‘variable’) and those generally ‘not met’.

1 Targets and Standards; On TrackNHS Fife continues to meet or perform ahead of the following National Standards:

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Cancer Waiting Times: 31 Day Decision to Treat target: We will treat at least 95% of cancer patients within 31 days of decision to treatIn-Vitro Fertilisation (IVF) target: At least 90% of eligible patients to commence IVF treatment within 12 months of referral from Secondary CareDetect Cancer Early target: At least 29% of cancer patients will be diagnosed and treated in the first stage of breast, colorectal and lung cancerHospital Acquired Infection (HAI), Clostridium Difficile (C-Diff) target: We will achieve a maximum rate of C- Diff infection in the over 15 year olds of 0.32Antenatal Access target: At least 80% of pregnant women in each SIMD quintile will book for antenatal care by the 12th week of gestationAlcohol Brief Interventions target: In 2017/18, we will deliver a minimum of 4,187 interventions, at least 80% of which will be in priority settingsDrug and Alcohol Waiting Times target: At least 90% of clients will wait no longer than 3 weeks from referral to treatment

2 Targets and Standards; Variable PerformanceNHS Fife has met the following National Standards for a sustained period however performance varies from month-to-month. If performance drops significantly below the Standard for 3 consecutive months, a drill-down process is instigated.

Outpatients Waiting Times target: 95% of patients to wait no longer than 12 weeks from referral to a first outpatient appointment.

Performance remains consistently within a few % points of the Standard, with 93.3% of patients having waited less than 12 weeks at the end of November.

It is anticipated that performance in the majority of specialities will improve as additional capacity is delivered. However due to consultant vacancies, gaps in capacity and an inability to deliver enough additional capacity for Neurology, Orthopaedics, Surgical Paediatrics, Dermatology, Ophthalmology and Breast outpatients achieving the target will continue to be a challenge in Quarter 4 of 2017/18 with slow recovery anticipated towards the end of Quarter 4.

Dementia Care target: Deliver expected rates of diagnosis and ensure that all people newly diagnosed will have a minimum of a year’s worth of post-diagnostic support (PDS) coordinated by a link worker.

Although targets for Dementia performance have not yet been defined, management information for the first two quarters of 2017/18 has been made available to Health Boards, and covers two aspects – Referral Rates and Completion of Post-Diagnostic Support.

In the first two quarters of the year, there were 271 patient referrals to the PDS. With the SG-calculated expectation for the year being 1,289, we are significantly behind the local trajectory, and this measure is assessed with a RED RAG status in the table on Page 6 of this report. However, it should be noted that NHS Fife’s referral rate is higher than most other Mainland Health Boards.

For Post-Diagnostic Support, the situation is less clear due to the nature of the measure, which requires that no assessment is possible until after the 1-year support period is complete. For 2015/16, which is the most recent period where data analysis is meaningful, NHS Fife recorded a performance of 89.5%, above the Scottish average.

We have subjectively assigned an AMBER RAG status to this measure, and await further guidance from the Scottish Government.

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3 Targets and Standards; Not Being Met - Drill-DownFor each of the LDP Standards and targets not being met (or where performance is high-profile and key to the delivery of safe patient care), a more in-depth report is provided and is structured as follows:

A summary box, describing the measure, current performance and the latest published performance and status (Scotland)

A trend chart covering the last 12 months of local performance data

A past performance box showing the last 3 data points (previous to the ‘current’ position)

An improvements/benefits box, outlining key actions being taken, expected benefits and current status.

Drill downs are located in the Clinical Governance, Finance, Performance & Resources and Staff Governance sections.

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Section B:1 Clinical Governance

Executive Summary

Hospital Acquired Infection (HAI) - Staphylococcus Aureus Bacteraemia (SAB) target: We will achieve a maximum rate of SAB (including MRSA) of 0.24.

During November, there were 7 Staphylococcus aureus Bacteraemias (SAB) across Fife, 3 being hospital-associated infections and 4 being community-associated infections. The number of cases in November was 3 more than in October but one fewer than in November 2016. The infection rate over the last 12-month period (taking account of all infection sources) remains above the Standard.

Assessment: Much progress has been made in terms of reducing the number of avoidable vascular access device infections across ASD. The Dialysis Line Management Improvement Group achieved their stretch aim of “100 days since the last dialysis line related SAB”, achieving 174 days as of 8th January This improvement work has dramatically improved the clinical outcomes for our patients in dialysis day care.

Vascular access device (VAD) improvement work continues to be addressed via the SPSP Stakeholders Group, Quality and Safety Governance Group, Infection Control Committee, Acute Services Division Governance Committee and the NHS Fife Vascular Access Strategy Group. The HSCP is also involved via its Clinical and Care Governance Groups. A number of actions have been identified and will be progressed throughout 2018.

A structured programme of education had been co-produced to support Hand Hygiene improvement activities across ASD and the HSCP. This supportive work was extremely well received during November and early December 2017 and will be evaluated during the coming months.

Complaints local target: At least 80% of Stage 1 complaints are completed within 5 working days of receipt; at least 75% of Stage 2 complaints are completed within 20 working days; 100% of Stage 2 complaints are acknowledged in writing within 3 working days.

The rate for completion of Stage 1 complaints in October was 91.1%, the highest since the first month of the FY. The rate for completion of Stage 2 complaints was 63.0% (96.3% acknowledged on time), the highest since December 2016.

Assessment: Performance against Stage 2 complaint handling was significantly below the 75% target during the first quarter of FY 2017/18, but improvements have been seen since August as extreme staffing challenges have been addressed.

In addition to staffing within Patient Relations, the principle reasons for failing to meet the 20-day completion target is a delay in the provision of statements from the Divisional Teams and delay in approval and sign off.

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An Improvement Plan has been in place since May 2017, and IMPACT are supporting the development of a project plan which will focus on further improving the Stage 2 performance. A review of data for the 3-month period from September to November is continuing.

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Performance Summary

Current Period Current Performance

Previous Period



HAI - C Diff Safe 0.32 12 months to Nov 2017 0.25 12 months to

Oct 2017 0.25 ↔ 0.23 y/e Sep 2017 0.24 4th 0.28


HAI - SABs Safe 0.24 12 months to Nov 2017 0.36 12 months to

Oct 2017 0.35 ↓ 0.39 y/e Sep 2017 0.37 7th 0.33


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Performance Data

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Performance Assessment MethodologyThe Scottish Government requires all Health Boards to attain a defined level of performance against a number of measures (known as Standards) which are included in the Local Delivery Plan (LDP). In addition, NHS Fife scrutinises its performance relating to Complaints.



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Hospital Acquired Infection (HAI), Clostridium Difficile (C-Diff) target: We will achieve a maximum rate of C- Diff infection in the over 15 year olds of 0.32


N/A for Clinical Governance this month






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HAI: SAB Drill Down

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Measure We will achieve a maximum rate of SAB (including MRSA) of 0.24

Current Performance 0.36 cases per 1,000 acute occupied bed days, for year ending Nov 2017

Scotland Performance 0.33 cases per 1,000 acute occupied bed days, for year ending Sep 2017

6 9 8 6 6 9 8 15 11 6 6 4 7

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0.10

0.15

0.20

0.25

0.30

0.35

0.40

Nov-

16

Dec-

16

Jan-

17

Feb-

17

Mar

-17

Apr-

17

May

-17

Jun-

17

Jul-1

7

Aug-

17

Sep-

17

Oct

-17

Nov-

17

# of

Cas

es

Infe

ction

rate

(per

1,0

00 A

OBD

)

HAI: SABsNumber of Cases Standard NHS Fife Scotland Average (HPS)

Previous 3 Months12 Months to Aug 2017 12 Months to Sep 2017 12 Months to Oct 2017

0.36 ↑ 0.37 ↓ 0.36 ↑

Current Issues Vascular Access Device (VAD) SAB

Context Never met Standard7th highest infection rate of all Mainland Boards for 12-month period to end of September 2017

Key Actions for Improvement Planned Benefits Due By StatusRemit of NHS Fife Vascular Access Strategy Group

Improvements in: VAD insertion and

maintenance compliance education and training operational guidance governance arrangements reduction in VAD associated

SAB

Mar 2019 On Track

Support ePVC compliance and monitoring via Patientrack across Acute Services Division (ASD)

Emergence of common themes, which will be used in quality improvement activities by ASD

Mar 2018 On Track

Adopt a multi-modal Infection Prevention and Control (IPC) strategy to support improvement in SAB rates across Fife

Report on measures which will support SAB reduction via the Infection Control Committee, NHS Fife Quality and Safety Governance Group, ASD Clinical Governance Group and take appropriate action for improvement via the multidisciplinary teams

Mar 2018 On Track

23

Overview

Vascular Access Strategy Group

A work plan to support the development, implementation and monitoring of policy, procedures and practice, governance and reporting arrangements for all vascular access devices is well underway.

SAB Reduction Initiatives

Hand Hygiene Compliance

Compliance is monitored monthly by clinical teams and quality assured by the Infection Prevention and Control Team as part of the Healthcare Associated Infection (HAI) Prevention and Control Assurance Framework. Any area which falls below the nationally agreed compliance rate of 95% is revisited and support for improvement offered by the IPCT and senior teams.

Hand Hygiene Quality Assurance audits, carried out by the IPCT in November 2017 demonstrated a decline in compliance with this key measure to reduce HAI. This was noted in a number of Acute Hospital and Community Hospital wards, where figures were between 55% and 65%. Senior Managers were informed and a structured education programme was co-produced to support improvement. This programme of work was extremely well received and an evaluation of effectiveness will be undertaken in the coming months.

Standard Infection Control Precautions (SICP) Improvement Project in the Health & Social Care Partnership (HSCP)

This work is now merging with improvements in the SICPs monitoring tool in ASD. Implementation is planned for early 2018.

Dialysis Line Management Improvement Group in Renal

Group has now disbanded as improvement work has seen sustainable performance.

Intravenous Drug Use SAB Prevention Project in the HSCP

No new update –improvement work continues

Meticillin Resistant Staphylococcus aureus (MRSA) Clinical Risk Assessment compliance in ASD

Compliance is consistently above the national compliance rate of 90%. Any area which falls below this receives improvement support from senior managers and IPCT.

24

Clinical G

overnance

ComplaintsDrill Down

25

Measures(Local Targets)

At least 80% of Stage 1 complaints are completed within 5 working days of receiptAt least 75% of Stage 2 complaints are completed within 20 working days

Current Performance 91.1% (72 out of 79) Stage 1 complaints completed within 5 working days in October63.0% (17 out of 27) Stage 2 complaints completed within 20 working days in October

Scotland Performance Stage 2 Complaints: 72.0% for 2016-17 (data published annually)

47 38 55 77 77 75 7921 37 32 29 31 29

30

32

36

32 42 31 27

0

20

40

60

80

100

120

140

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Oct

-16

Nov-

16

Dec-

16

Jan-

17

Feb-

17

Mar

-17

Apr-

17

May

-17

Jun-

17

Jul-1

7

Aug-

17

Sep-

17

Oct

-17

Stag

e 1

and

Stag

e 2

Com

plai

nts

Stag

e 1

and

Stag

e 2

Com

pleti

on R

ates

ComplaintsStage 1 Complaints Stage 2 Complaints Target (Stage 1 Complaints)Stage 1 Completion Rate Stage 2 Complation Rate Target (Stage 2 Complaints)Stage 2 Acknowledgement Rate

Previous 3 Months Stage 1Stage 2

July 2017 August 2017 September 201761.0% ↓ 66.2% ↑ 85.3% ↑

31.3% ↓ 35.7% ↑ 38.7% ↑

Current Issues Delayed statements from Delivery Units, complexity of complaintsDelay in sign-off process within Partnership

Context NHS Fife had the 7th best completion rate for Stage 2 Complaints in 2016/17

Key Actions for Improvement Planned Benefits Due By StatusDevelop Quality Improvement Plan, with support from IMPACT, working closely with ASD and the Partnership

Reduced delays as a result of improved content of staff statements and processes

Jan 2018 DelayedRevised to Feb 2018

Resolve staffing issues in Patient Relations team

Improved complaints response timesImproved quality of responses

Jan 2018 On Track

26

Section B:2 Finance, Performance & Resources

Executive SummaryNHS Acute Division

4-Hour Emergency Access target: At least 95% of patients (stretch target of 98%) will wait less than 4 hours from arrival to admission, discharge or transfer for Accident and Emergency treatment.

The annually measured performance increased at the end of November, remaining above the Standard. In November itself, 94.7% of the patients attending the VHK Emergency Department were treated, discharged or transferred within 4 hours of arrival, equating to 268 breaches out of 5,071 attendances.

Assessment: The position shows significant improvement, particularly evidenced in a reduced number of patients waiting for first assessment. Work continues with the A&E teams to review pathways and look for improvement. Staffing models are reviewed and agreed on a weekly basis.

Cancer 62 day Referral to Treatment target: At least 95% of patients urgently referred with a suspicion of cancer will start treatment within 62 days.

In November, performance fell to 89.9%, below the Standard after two successive months where the Standard was exceeded. There were 7 breaches out of 69 patients who started treatment, across 5 specialties.

Assessment: The 62 day Standard performance remains variable due to a number of areas of risk, particularly in Radiology, and surgical capacity in NHS Fife and NHS Lothian, for Urology and Gynaecology. The Lung, Head & Neck and Upper GI pathways continue to be at risk due to complexity and number of steps involved. Whilst there has been improvement in Quarter 2 (94.4%) and we have met the Standard in 3 out of the last 6 months, it is anticipated that performance will continue to be variable in Quarter 4 of 2017/18, despite efforts made to prioritise cancer patients during the winter season.

Patient Treatment Time Guarantee target: We will ensure that all eligible patients receive Inpatient or Day-case treatment within 12 weeks of such treatment being agreed.

In November, 92.0% of patients were seen within 12 weeks, a 1% improvement on the performance in October. Trauma & Orthopaedics (58) and Urology (24) reported the highest number of breaches out of a total of 120.

Assessment: Additional activity to mitigate the demand/capacity gap and reduce the backlog continues to be delivered. There are renewed efforts to secure additional activity in particular outsourcing activity and to recruit to vacant posts. Three Consultant Anaesthetists have been recruited, and will take up post in February and March 2018. It is anticipated that performance

27

Finance, Performance &

Resources

will be a significant challenge in Quarter 4 of 2017/18 due to the impact of unscheduled care pressures over the winter period.

Diagnostics Waiting Times target: No patient will wait more than 6 weeks to receive one of the 8 Key Diagnostics Tests.

At the end of November, 86.0% of patients on the waiting list had waited less than 6 weeks for their test, a 4% improvement compared to the position at the end of October, with the number of breaches decreasing for MRI and CT scanning.

Assessment: Meeting the target for non-obstetric ultrasound, MRI and CT continues to be a challenge. There are continued efforts to manage both demand and provide additional capacity to meet the gap and to recruit to vacant posts. Additional capacity is being delivered through redesign of services and with support from regional partners, the regional reporting network and outsourcing MRI. It is anticipated that performance will begin to recover in Quarter 4 of 2017/18.

18 Weeks Referral-to-Treatment target: 90% of planned/elective patients to commence treatment within 18 weeks of referral.

During November, 79.4% of patients started treatment within 18 weeks of referral, a small improvement on the performance in October.

Assessment: We anticipate that with the challenges with performance in TTG, Outpatients and Diagnostics against this Standard will continue to be a challenge in Quarter 4 of 2017/18 with some improvement towards the end of Quarter 4 2017/18, if the projected recovery for diagnostics and outpatients are achieved as planned.

Health & Social Care Partnership

Delayed Discharge target: No patient will be delayed in hospital for more than 2 weeks after being judged fit for discharge.

At the Delayed Discharge Census on 30th November, 21 patients had been delayed in hospital for more than 2 weeks after being judged fit for discharge, 3 less than the number in delay at the October Census. The overall number of patients in delay (54) was unchanged.

Assessment: The partnership continues to rigorously monitor patient delays through a daily and weekly focus on transfers of care, flow and resources. Our improvements have been focused on improving earlier supported discharge and earlier transfers from our acute setting to community models of care. It continues to be a significant challenge to eradicate delays of greater than 14 days.

Smoking Cessation target: In 2017/18, we will deliver a minimum of 779 post 12 weeks smoking quits in the 40% most deprived areas of Fife.

Local management information shows that 188 people who attempted to stop smoking in the first five months of the 2017/18 had successfully quit at 12 weeks. This is slightly more than the quit number for the first five months of 2016/17.

28

Assessment: New and additional sessions are due to start in Auchmuty Learning Centre, Kirkcaldy Leisure Centre, Lochgelly Health Centre and Cowdenbeath Clinic in January. Linburn clinic has moved from fortnightly to weekly in line with evidenced based practice. Staff member to be sited in Hayfield House one day a week from January to support service developments in the Victoria Hospital.

Child and Adolescent Mental Health Services (CAMHS) target: At least 90% of clients will wait no longer than 18 weeks from referral to treatment for specialist Child and Adolescent Mental Health Services (note: performance is measured on a 3 month average basis).

Performance against the CAMHS Standard for the 3 month period ending November was 62.8%, continuing the downward trend evident since the start of 2017/18. The number of patients on the waiting list has continued to increase.

Assessment: Significant focus has been placed on providing appointments for the Children and Young People with the longest waits (approximately 30% of clinical activity).

Additional resources have been identified to focus specifically on the longest waits and to allow substantive staff to provide timely interventions to those with the greatest need. This will be fully operational by February.

Psychological Therapies Waiting Times target: At least 90% of clients will wait no longer than 18 weeks from referral to treatment for psychological therapies (note: performance is measured on a 3 month average basis).

For the 3 month period ending November, the percentage of patients starting treatment within 18 weeks of referral was 71.3%, marking the best performance across the services since June-August 2016. The number of patients waiting over 18 weeks at the end of November was 566, the lowest since March 2015. Despite continued improvement in performance, services face ongoing challenges as monthly referrals in November were the highest yet reported and continue to increase.

Assessment: Services providing brief therapies for people with less complex needs are meeting the RTT 100%; overall performance reflects the longer waits experienced by people with complex needs who require longer term treatment. We continue to address the needs of this population through service redesign with support from the ISD/HIS Mental Health Access Improvement Support Team, and anticipate further significant progress towards the Standard by March 2018.

Capital Programme

The total anticipated Capital Resource Limit for 2017/18 is £7.935m. The capital expenditure position for the 9 months to December reflects spend of £4.968m. It is projected that the Board will spend the Capital Resource Limit in full.

Financial Position

29


Resources

The revenue expenditure position for the 9 months to 31 December 2017 reflects an overspend of £3.680m. This overspend comprises an underspend of £1.256m attributable to Health Board; and £4.936m to the Integration Joint Board. The report provides further detail on the assumptions underpinning the forecast outturn; however it is reasonable to note the improved position for the nine month period to the end of December as a positive indication that a breakeven outturn may be achieved. Members of the Committee and NHS Board should note that the December Financial Monitoring Return to the Scottish Government Health & Social Care Directorates will set out a break even forecast, with supporting narrative on the key issues and risks.

Specific points to note include:

Financial flexibility of £6.551m has been reflected in the year to date position to mitigate, in part, slippage in savings delivery. This relates to financial plan commitments not required and is a crucial element of the Board’s ability to deliver against the statutory financial target of a break even position against the revenue resource limit.

A further £1.6m DEL funding (above the £2.5m assumed in the financial planning process) has been assumed as forthcoming in year. The total £4.1m compares with £2.8m received in 2016/17. Plans are underway to identify a further £0.4m qualifying expenditure, with a residual risk re the £1.1m balance remaining under review. Work is also underway to assess the extent to which the DEL funding might be utilised for the replacement of obsolete beds across the system; and whilst this will not result in a corresponding reduction in the current forecast outturn, it will address a number of clinical priorities.

A national shortage in supply of some medicines has impacted adversely on costs in months 7 to 9. This is reflected in the position and sees a change to the positive trend on both the volume and cost per item in respect of GP prescribing to the half year. Information received in early December is being scrutinised to determine the likely impact on the position to the year end.

An updated assessment of the recurring delivery of savings has been established with an identified shortfall of £15.558m at this point in the year. Whilst the overall shortfall may be mitigated in year through non recurring measures, it will impact on the financial planning for 2018/19 and beyond. This includes £8.810m for the Health Board and £6.748m for the Integration Joint Board. In addition, there is a degree of legacy savings from prior years and these are also recognised through the work already undertaken on the financial outlook for future years.

The reported position for the period to date reflects the impact of a risk sharing of the total IJB overspend with Fife Council, based on November forecasts. This approach has been taken due to the different reporting timeframes of the respective partners.

30

The forecast year end outturn position ranges between break even (best case) and an overspend of £4.039m (prudent position). All 3 forecasts comprise a mid range operational position as informed by individual Directors, adjusted for both a best case and prudent assessment of financial flexibility. This is consistent with the approach outlined to the Finance, Performance & Resources Committee in August and NHS Board in September. The current mid range forecast reflects an overspend of £1.188m.

The forecast outturn includes projected underspends on in-year allocations from Scottish Government; this is a key component of the financial flexibility described above. Given NHS Boards cannot carry forward income to future years, any unspent funding has been reflected within the in-year and forecast position. The decision to spend on these areas in future years is a decision for budget holders to manage.

Sections 7 and 8 of the full Finance Report within the IPR provide further details on the year end forecast and the next steps toward securing a balanced position. Members are invited to review the issues highlighted in these sections and to note the potential risks and benefits described.

31

Performance Summary


Previous Period



IVF Treatment Waiting Times Person-centred 90.0% 3 months to Nov 2017 100.0% 3 months to

Oct 2017 100.0% ↔ 100.0%

4-Hour Emergency Access * Clinically Effective 95.0% 12 months to Nov 2017 95.3% 12 months to

Oct 2017 95.1% ↑ 95.8% y/e Sep 2017 94.9% 5th 93.8%

Cancer 31-Day DTT Clinically Effective 95.0% Nov 2017 99.0% Oct 2017 99.0% ↔ 98.7% q/e Sep 2017 97.8% 4th 94.5%

Antenatal Access Clinically Effective 80.0% 3 months to Mar 2017 88.2% 3 months to

Feb 2017 87.4% ↑ N/A

Drugs & Alcohol Treatment Waiting Times Clinically Effective 90.0% q/e Sep 2017 94.8% q/e Jun 2017 96.8% ↓ 95.8% q/e Sep 2017 94.8% 7th 93.8%

Outpatients Waiting Times Clinically Effective 95.0% Nov 2017 93.3% Oct 2017 93.1% ↑ N/A End of September 93.8% 1st 69.7%

Dementia Post-Diagnostic Support Person-centred 100.0% 2015/16 89.5% 2014/15 95.8% ↓ N/A

18 Weeks RTT Clinically Effective 90.0% Nov 2017 79.4% Oct 2017 77.8% ↑ 82.4% Sep-17 81.4% 6th 81.4%

Patient TTG Person-centred 100.0% Nov 2017 92.0% Oct 2017 91.0% ↑ 88.8% q/e Sep 2017 92.0% 1st 80.2%

Diagnostics Waiting Times Clinically Effective 100.0% Nov 2017 86.0% Oct 2017 82.3% ↑ N/A End of September 84.1% 6th 81.6%

Cancer 62-Day RTT Clinically Effective 95.0% Nov 2017 89.9% Oct 2017 98.7% ↓ 93.3% q/e Sep 2017 94.4% 4th 87.2%

Detect Cancer Early Clinically Effective 29.0% 2 years to Jun 2017 27.2% 2 years to Mar

2017 28.1% ↓ N/A

Delayed Discharge (Delays > 2 Weeks) Person-centred 0 30th Nov Census 21 26th Oct

Census 24 ↑ N/A 28th Sep Census 10.26 6th 9.79

Dementia Referrals Person-centred 1,289 6 months to Sep 2017 271 3 months to

Jun 2017 150 ↓ 271

Alcohol Brief Interventions Clinically Effective 4,187 q/e Sep 2017 1,880 q/e Jun 2017 1,165 ↓ 1,880

Smoking Cessation Clinically Effective 779 Aug 2017 188 Jul 2017 154 ↓ 188

CAMHS Waiting Times Clinically Effective 90.0% 3 months to Nov 2017 62.8% 3 months to

Oct 2017 63.7% ↓ 67.4% q/e Sep 2017 65.1% 7th 73.3%

Psychological Therapies Waiting Times Clinically Effective 90.0% 3 months to Nov 2017 71.3% 3 months to

Oct 2017 70.2% ↑ 69.6% q/e Sep 2017 69.4% 5th 76.6%

* The 4-Hour Emergency Access performance in November alone was 96.2% (all A&E and MIU sites) and 94.7% (VHK A&E, only)

Sec

tion

RA

G


Only published annually: NHS Fife was 3rd for FY 2015-16

Fina

nce,

Per

form

ance

and

Res

ourc

es

GR

EE

NA

MB

ER

RE

D

Treatment provided by Regional Centres so no comparison applicable





Only published annually: NHS Fife was 1st for 2-year period 2015 and 2016

Performance Data


32

Performance Assessment MethodologyThe Scottish Government requires all Health Boards to attain a defined level of performance against a number of measures (known as Standards) which are included in the Local Delivery Plan (LDP). In addition, NHS Fife scrutinises its performance relating to complaints.



33

Cancer Waiting Times: 31 Day Decision to Treat target: We will treat at least 95% of cancer patients within 31 days of decision to treatIn-Vitro Fertilisation (IVF) target: At least 90% of eligible patients to commence IVF treatment within 12 months of referral from Secondary CareDetect Cancer Early target: At least 29% of cancer patients will be diagnosed and treated in the first stage of breast, colorectal and lung cancerAntenatal Access target: At least 80% of pregnant women in each SIMD quintile will book for antenatal care by the 12th week of gestationAlcohol Brief Interventions target: In 2017/18, we will deliver a minimum of 4,187 interventions, at least 80% of which will be in priority settingsDrug and Alcohol Waiting Times target: At least 90% of clients will wait no longer than 3 weeks from referral to treatment


Outpatients Waiting Times target: 95% of patients to wait no longer than 12 weeks from referral to a first outpatient appointment.

Performance remains consistently within a few % points of the Standard, with 93.3% of patients having waited less than 12 weeks at the end of November.

It is anticipated that performance in the majority of specialities will improve as additional capacity is delivered. However due to consultant vacancies, gaps in capacity and an inability to deliver enough additional capacity for Neurology, Orthopaedics, Surgical Paediatrics, Dermatology, Ophthalmology and Breast outpatients achieving the target will continue to be a challenge in Quarter 4 of 2017/18 with slow recovery anticipated towards the end of Quarter 4.

Dementia Care target: Deliver expected rates of diagnosis and ensure that all people newly diagnosed will have a minimum of a year’s worth of post-diagnostic support (PDS) coordinated by a link worker.

Although targets for Dementia performance have not yet been defined, management information for the first two quarters of 2017/18 has been made available to Health Boards, and covers two aspects – Referral Rates and Completion of Post-Diagnostic Support.

In the first two quarters of the year, there were 271 patient referrals to the PDS. With the SG-calculated expectation for the year being 1,289, we are significantly behind the local trajectory, and this measure is assessed with a RED RAG status in the table on Page 6 of this report. However, it should be noted that NHS Fife’s referral rate is higher than most other Mainland Health Boards.

For Post-Diagnostic Support, the situation is less clear due to the nature of the measure, which requires that no assessment is possible until after the 1-year support period is complete. For 2015/16, which is the most recent period where data analysis is meaningful, NHS Fife recorded a performance of 89.5%, above the Scottish average.

We have subjectively assigned an AMBER RAG status to this measure, and await further guidance from the Scottish Government.

34






35


Resources

Performance Drill Down – Acute Services Division

36

4-Hour Emergency AccessDrill Down

Measure At least 95% of patients (stretch target of 98%) will wait less than 4 hours from arrival to admission, discharge or transfer for Accident and Emergency treatment

Current Performance 95.3% for 12-month period to 30th November 2017

Scotland Performance 93.8% for 12-month period to 30th November 2017

92.5%

93.0%

93.5%

94.0%

94.5%

95.0%

95.5%

96.0%

0

100

200

300

400

500

600

Nov-

16

Dec-

16

Jan-

17

Feb-

17

Mar

-17

Apr-

17

May

-17

Jun-

17

Jul-1

7

Aug-

17

Sep-

17

Oct

-17

Nov-

17

Perf

orm

ance

Num

ber o

f Bre

ache

s

4-Hour Emergency Access4 (less than 8) hour breaches 8 (less than 12) hour breaches 12 hour breaches

NHS Fife A&E Performance Scotland Average (ISD)

Previous 3 MonthsAugust 2017 September 2017 October 2017

94.9% ↑ 94.9% ↔ 95.1% ↑

Current Issues Continued work to ensure appropriate skill mix

Context Has risen back above the Standard after a short period beneath itConsistently above the Scottish average

Key Actions for Improvement Planned Benefits Due By StatusRobust weekend planning in place; weekly review of staffing to ensure that all shifts are safely covered

Reduce pressure in A&E N/A Continuing

Weekly Winter Planning Meetings to review performance (started 27th October)

Reduce barriers to flow across Acute and HSCP

N/A Continuing

Cancer Treatment Waiting Times: 62-Day RTT

37


Resources

Drill Down

Measure At least 95% of patients urgently referred with a suspicion of cancer will start treatment within 62 days of urgent referral

Current Performance 89.9% of patients (62 out of 69) started treatment in November within 62 days

Scotland Performance 87.3% of patients started treatment within 62 days in November 2017

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

0

2

4

6

8

10

12

14

16

18

Nov-

16

Dec-

16

Jan-

17

Feb-

17

Mar

-17

Apr-

17

May

-17

Jun-

17

Jul-1

7

Aug-

17

Sep-

17

Oct

-17

Nov-

17

% P

atien

ts <

62

Days

# Pa

tient

s > 6

2 Da

ys

Cancer Waiting Times: 62 day RTTBreast Cervical ColorectalHead & Neck Lung LymphomaMelanoma Ovarian Upper GIUrological Standard NHS FifeScotland Average (DISCOVERY)


93.5% ↑ 95.4% ↑ 98.7% ↑

Current Issues Cancer patients are prioritised and capacity issues in Radiology can still result in delays particularly in specialist areasDelay to Robotic Assisted Laparoscopic Radical Prostatectomy in LothianDelays to OPAs/Surgery in Gynae-Oncology and Urology due to capacity issues; Cancer patients prioritised

Context Standard achieved in three of the last 6 months4th best performing Mainland Health Board for the quarter ending September 2017, and above Scotland average since start of 2017/18

Key Actions for Improvement Planned Benefits Due By StatusTrain 2nd consultant in lap nephrectomy To increase capacity Nov 2018 On Track

Further training for TRUS To increase capacity Mar 2018 On Track

38

39

Patient Treatment Time GuaranteeDrill Down

Measure We will ensure that all eligible patients receive Inpatient or Day Case treatment within 12 weeks of such treatment being agreed

Current Performance 120 patients breaches (out of 1,500 patients treated) in November (92.0%)

Scotland Performance 80.2% of patients treated within 12 weeks during quarter ending Sep 2017

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

-

50

100

150

200

250

Nov-

16

Dec-

16

Jan-

17

Feb-

17

Mar

-17

Apr-

17

May

-17

Jun-

17

Jul-1

7

Aug-

17

Sep-

17

Oct

-17

Nov-

17

% P

atien

ts <

= 12

Wee

ks

# Pa

tient

s > 1

2 W

eeks

Patient TTGEmergency ENT General SurgeryGynaecology Ophthalmology OMSPlastics T & O UrologyOther Rheumatology NHS FifeScotland Average (DISCOVERY) Standard

Previous 3 MonthsAugust 2017 Septembert 2017 October 2017

86.5% ↓ 87.7% ↑ 91.0% ↑

Current Issues Theatre, Anaesthetic and Consultant staff vacancies (but three Consultant Anaesthetists now recruited and will take up post early in 2018)Cancellations due to unscheduled care pressuresUnable to deliver or outsource additional capacity

Context Fife has consistently outperformed the Scottish average

Key Actions for Improvement Planned Benefits Due By StatusDeliver Surgical Efficiency Programme Elective capacity use optimised Mar 2018 On Track

Secure funding and deliver additional capacity

TTG projected performance delivered

Mar 2018 On Track

Review Capacity and Demand for first 9 months of 2017/18, and identify gaps

Understanding of capacity and demand for elective procedures, enabling planning and trajectories for next 6 months and into 2019/20

Mar 2018 On Track

Diagnostics Waiting Times

40


Resources

Drill Down

Measure No patient will wait more than 6 weeks to receive one of the 8 key diagnostic tests

Current Performance 86.0% of patients waiting no more than 6 weeks at end of November

Scotland Performance 81.6% of patients waiting no more than 6 weeks at end of September 2017

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%100.0%

0

200

400

600

800

1,000

1,200

Nov-

16

Dec-

16

Jan-

17

Feb-

17

Mar

-17

Apr-

17

May

-17

Jun-

17

Jul-1

7

Aug-

17

Sep-

17

Oct

-17

Nov-

17

% P

atien

t's <

= 6

Wee

ks

# Pa

tient

's >

6 W

eeks

Diagnostics Waiting > 6 WeeksUpper Endoscopy Lower Endoscopy ColonoscopyCystoscopy Magnetic Resonance Imaging Computer TomographyNon-obstetric ultrasound Barium Studies StandardNHS Fife Scotland Average (ISD)


82.4% ↓ 84.1% ↑ 82.3% ↓

Current Issues Radiology Consultant and radiographer vacancies, increased demand for MRI/CTReporting capacity Variable capacity for additional Ultrasound and MRI

Context Standard last achieved in April 20166th out of the 11 Mainland Health Boards at the end of September 2017

Key Actions for Improvement Planned Benefits Due By StatusSecure funding and staff to deliver additional capacity, based on revised demand and capacity figures

Diagnostic projected performance delivered

Mar 2018 On Track

Identify opportunities and develop implementation plan to reduce demand in Radiology modalities

Stabilisation of demand and increased capacity

Mar 2018 On Track

Identify opportunities for joint appointments to Consultant Radiology posts within the East Region

Reduction in number of Consultant Radiology vacancies

Jul 2018 On Track

Review Capacity and Demand for first 9 months of 2017/18, and identify gaps and need for improvements for 2018/19

Understanding of capacity and demand for diagnostic procedures, enabling planning and trajectories for 12 months 2018/19

Mar 2018 On Track

41

18 Weeks Referral-to-TreatmentDrill Down

42

Measure 90% of planned/elective patients to commence treatment within 18 weeks of referral

Current Performance 79.4% of patients started treatment within 18 weeks in November

Scotland Performance 81.4% of patients started treatment within 18 weeks in September 2017

783

619

705

697

712

619

737

889

979

1,06

8

1,15

3

1,39

2

1,39

1

0

200

400

600

800

1,000

1,200

1,400

1,600

75.0%

77.0%

79.0%

81.0%

83.0%

85.0%

87.0%

89.0%

91.0%

93.0%

Nov-

16

Dec-

16

Jan-

17

Feb-

17

Mar

-17

Apr-

17

May

-17

Jun-

17

Jul-1

7

Aug-

17

Sep-

17

Oct

-17

Nov-

17

# of

Pati

ents

>18

Wee

ks

% o

f Pati

ents

< 1

8 W

eeks

18 Weeks RTT# Patients >18 wks Standard NHS Fife Scotland Average (Discovery)


81.9% ↑ 81.4% ↓ 77.8% ↓

Current Issues The current challenges with performance in Outpatients and Diagnostics is impacting on non-admitted and admitted pathway performanceThe challenges in TTG performance is impacting on admitted pathway performance

Context Standard last achieved in September 20165th out of 10 Mainland Health Boards in September 2017 (no data available for NHS Tayside)

Key Actions for Improvement Planned Benefits Due By StatusThe Recovery Plan for 18 Weeks RTT is covered by the delivery of the Patient Treatment Time Guarantee, Diagnostics and Outpatient Waiting Times Recovery Plans; there are no new specific actions

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Performance Drill Down – Health & Social Care Partnership

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Delayed DischargeDrill Down

Measure No patient will be delayed in hospital for more than 2 weeks after being judged fit for discharge

Current Performance 21 patients in delay for more than 14 days at November 2017 census, out of a total of 54 patients overall in delay – this equates to 5.67 patients per 100,000 population in NHS Fife

Scotland Performance 9.79 patients per 100,000 population at September 2017 census

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Delayed Discharges

Delays 0-2 Weeks Delays 2-4 Weeks Delays 4-6 Weeks Delays Over 6 Weeks Delays Over 2 Weeks


30 ↔ 38 ↓ 24 ↑

Current Issues Assessments becoming increasingly complexWinter planning arrangements completed in readiness for November to March

Context Never met 14-day target6th-ranked Mainland Board per capita at September census, both for all patients in delay and for patients in delay more than 14 days

Key Actions for Improvement Planned Benefits Due By StatusStreamline ICASS and START pathway for patients being discharged from VHK, to ensure all are discharged within 72 hours

More effective discharge profile before midday and within 72 hours

Dec 2017 Completed

Review of workforce involved in direct discharge planning (SW and PFC)

Optimal staff teams to ensure the demand in workload is managed effectively

Mar 2018 On Track

Consolidate intermediate care and support a planned increase where gaps have been identified

More integrated patient pathways to ensure whole system flow is achieved

Jan 2018 On Track

Develop and test a model to reduce Reduce delayed discharges Jan 2018 On Track

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emergency admissions, focusing on High Health Gain individuals Reduce length of stay from

emergency admissionsEarlier pro-active patient centred support

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Smoking CessationDrill Down

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Measure In 2017/18, we will deliver a minimum of 779 post 12 weeks smoking quits in the 40% most deprived areas of Fife

Current Performance 188 successful quits in first 5 months of 2017/18

Scotland Performance No data available

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Smoking CessationTrajectory NHS Fife

Previous 3 MonthsMay 2017 June 2017 July 2017

95 ↓ 123 ↓ 154 ↓

Current Issues Accommodation in VHK withdrawn at short notice, using estates room which is not easily accessible. Unable to get a desk in the VHK one day a week to site member of staff, accommodation is available in Hayfield House but reduces service profile and reduces access to staff member for patients and visitors.

Context 188 quits in the 40% most deprived communities of Fife in the first 5 months of 2017/18, above Scotland average

302 quits across all Fife in the first 5 months of 2017/18, above Scotland average

Q1 (April to June 2017) (most deprived data)Non Pharmacy Service = 171 attempts, 70 @ 12 week successful quits (41% quit rate)

Pharmacy Service = 319 attempts, 53 @ 12 week successful quits (17% quit rate)

Key Actions for Improvement Planned Benefits Due By StatusAssessment and support to Community Pharmacies regarding missing dataNote: Support ongoing in 2018

Completeness of data from CPs allows for more accurate data

Dec 2017 Complete

Service development opportunities to increase service engagement

Increased throughput Dec 2017 Complete

Pharmacy Minimum Quality Standard Proposal to be disseminated to 85 Community PharmaciesNote: Going to APC in January

Increase number of successful quits against LDP Target

Jan 2018 On Track

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Service Promotion across Fife for No Smoking Day 2018

Increased throughput Mar 2018 On Track

National Branding to be adopted across all service and resources (non pharmacy, maternity and community pharmacies)

Increase awareness of integrated services across Fife to increase engagement with service

Apr 2018 On Track

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CAMHS Waiting TimesDrill Down

Measure At least 90% of clients will wait no longer than 18 weeks from referral to treatment for specialist Child and Adolescent Mental Health Services

Current Performance 62.8% of patients treated within 18 weeks for 3 months ending November

Scotland Performance 73.3% of patients treated within 18 weeks for 3 months ending Sep 2017

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613

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667

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735

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3 Months Ending

CAMHS Waiting TimesPatients Waiting Standard NHS Fife Scotland Average (ISD)

Previous 3 Months3 months to Aug 2017 3 months to Sep 2017 3 months to Oct 2017

69.0% ↓ 65.1% ↓ 63.7% ↓

Current Issues Vacancy management progressing well, with 1 vacancy (currently at advert) remaining in West CAMHS - improved workforce capacity will improve activityReferral numbers continue to be significant compared to available new appointmentsSignificant increase of Children & Young People presenting with urgent/priority needs

Context Below Standard since May 2014, and has dropped by over 20% since the start of 2017/187th out of the 11 Mainland Health Boards for the quarter ending September 2017

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Key Actions for Improvement Planned Benefits Due By StatusAdditional staffing resource identified to target longest waits

Reduction of longest waits Jan 2018 On Track

CAMHS Service Current Provision

In order to improve access to mental health services for children and young people, Fife CAMHS has instigated a number of initiatives that will provide a sustainable solution to the increasing demand on this specialist Tier 3 / Tier 4 service.

Fife CAMHS places a significant emphasis on ensuring that children and young people who are presenting with severe, complex and risk associated mental health issues are seen as a priority.

In addition to the work being carried out to address those with the longest waits, Fife CAMHS continues to meet the needs of those with the most acute need and provides high activity levels for complex care arrangements.

Waiting List Additional Resource

Additional staffing resource has been provided by Fife-wide services to specifically target the longest waiting children and young people

15 clinical sessions of Child Psychology time have been identified for 1 year, which will result in an additional 291 patients being seen and achieve waiting time of 12 weeks

The substantive CAMHS staff will focus on urgent, priority and those about to breach 18 weeks thus impacting directly on the waiting time targets

These additional sessions will be introduced incrementally due to recruitment of suitable clinicians and will be fully operational by February

Waiting list coordinator identified to ensure clinicians are appointing the appropriate groups of children to ensure greatest impact on waiting times

a trajectory of the waiting times figures over the next 12 months, following implementation of additional resource, is:

At 3 months (Mar 2018): 75% under 18 weeks, 25% over 18 weeks At 6 months (Jun 2018): 87% under 18 weeks, 13% over 18 weeks At 9 months (Sep 2018): 89% under 18 weeks, 11% over 18 weeks At 12 months (Dec 2018): 92% under 18 weeks, 8% over 18 weeks

It should be noted that this is a simulation based upon the additional sessions that are freed up by the waiting times initiative staff and is dependent on substantive staff working at optimum level and optimum attendance.

Fife CAMHS Referral Pathway

The Fife CAMHS on-line referral process was launched on 6 th September 2017, and all non-GP referrals are now made through the CAMHS referral form to the CAMHS inbox

Threshold has been clearly articulated to ensure children and young people with complex, persistent and acute mental health issues (Tier 3) are accepted on a more equitable and consistent basis

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Clearer signposting for inappropriate referrals to alternative sources of support

Robust screening process to ensure appropriate threshold is adhered to and equitable across Fife

Developments are well underway to redesign the SCi-referral for GPs

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Psychological Therapies Waiting TimesDrill Down

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Measure At least 90% of clients will wait no longer than 18 weeks from referral to treatment for Psychological Therapies (PT)

Current Performance 71.3% of patients treated within 18 weeks for 3 months ending November

Scotland Performance 76.6% of patients treated within 18 weeks for 3 months ending Sep 2017

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Psychological Therapies Waiting TimesPatients Waiting Standard NHS Fife Scotland Average (ISD)

Previous 3 Months3 months to Aug 2017 3 months to Sep 2017 3 months to Oct 2017

69.5% ↑ 69.4% ↓ 70.2% ↑

Current Issues Delivery of PTs across services requires further integration to enhance efficiency; Psychology and Mental Health are in transition to TIARA and Trakcare which is likely to produce challenges in reporting for a limited period

Context Never met Standard, although rolling 3-month performance is rising slightly; monthly performance normally between 65% and 75% Inconsistency across Health Boards in activity counted towards target – i.e. referrals for PT only / all mental health referrals.5th out of the 11 Mainland Health Boards for the quarter ending September 2017

Key Actions for Improvement Planned Benefits Due By StatusDevelopment of Community Mental Health Teams across Fife being progressed through the Rebalancing Care work

Allows comprehensive multidisciplinary approach to patients with complex needs including most efficient and effective use of highly specialist PTs within individual Care Programmes

Mar 2018(Teams Fully Functional)

On Track

Development of Community Mental Health Teams across Fife being progressed through the Rebalancing Care work

Allows comprehensive multidisciplinary approach to patients with complex needs including most efficient and effective use of highly specialist PTs within individual Care Programmes

Mar 2018(Teams Fully Functional)

On Track

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CAPITAL PROGRAMME

Capital Resource Limit

Health Boards are required to work within the capital resource limit set by the Scottish Government Health & Social Care Directorates (SGHSCD). This is monitored by SGHSCD via the monthly Financial Performance Return.

1. INTRODUCTION

1.1 This report provides an overview on the capital expenditure position as at the end of December 2017, based on the Capital Plan 2017/18, as approved by the NHS Board on 27 June 2017.

2. EXPENDITURE TO DATE / MAJOR SCHEME PROGRESS

2.1 Details of the expenditure position across all projects are attached as Appendix A.

2.2 Project Leads have provided an estimated spend profile against which actual expenditure is being monitored. This is based on current commitments and historic spending patterns. The overall profile will need to be adjusted once the Capital Equipment Programme has been finalised.

2.3 The estimated spend profile for the period to 31 December 2017 is £5.621m (70.83% of the total allocation).

2.4 The expenditure to date amounts to £4.968m, this is £653k less than the planned spend as shown in Appendix B – this is mostly due to slippage on some Statutory Compliance/Backlog Maintenance, Minor Works, Equipment and Information Technology schemes. The main areas of spend since the last report to the board includes:

Equipment £0.039m Statutory Compliance/Backlog Maintenance £0.080m

3. CHANGES TO CAPITAL RESOURCE LIMIT

3.1 The Board has received additional Energy Efficiency Funding of £638k.

4. CHANGES TO PLANNED EXPENDITURE 2017/18

4.1 Appendix C shows the changes in the plan since it was approved in June 2017. The changes reflect virements in budgets and the allocation of resources to the individual schemes since the last report to the Board. The main change has been the Energy Efficiency Allocation received of £638k.

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5. CAPITAL RECEIPTS

5.1 Work continues on asset sales with several disposals planned:

Lynebank Hospital Land Plot 2 (South) – Land sold in 2017/18; Lynebank Hospital Land (Plot 1) (North) – Offer accepted

subject to planning application – 18/19 sale completion date; Forth Park Maternity Hospital – Offer with CLO/ purchasers

solicitor sale date estimated April 2018; Barrie Street Clinic –Now sold 2017/18; Townhill Day Hospital – Now sold 2017/18; Abbeyview Clinic – Now sold 2017/18; Carnegie Clinic – Now sold 2017/18; 10 Acre Field – With CLO/purchaser’s solicitor; Hayfield Clinic – Offer accepted subject to change of use

application - anticipated April 2018 sale date; and Fair Isle Clinic – Property is on the market.

6. CAPITAL EXPENDITURE OUTTURN

6.1 At this stage of the financial year it is currently estimated that the Board will spend the Capital Resource Limit in full.

7. RECOMMENDATION

7.1 The Finance, Performance and Resources Committee asked to:

note the capital expenditure position to 31 December 2017;

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APPENDIX A

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NHS FIFE - TOTAL REPORTS SUMMARY

CAPITAL PROGRAMME EXPENDITURE REPORT - DECEMBER 2017

FOR FINANCIAL YEAR 2017/18

CRL Total ProjectedNew Expenditure Expenditure Projected

Funding to Date 2017/18 VarianceProject £ £ £ £

COMMUNITY & PRIMARY CAREStatutory Compliance 667,101 459,706 667,101Capital Minor Works 152,525 69,123 152,525Capital Equipment 116,884 27,778 116,884Condemned Equipment 15,664 15,664 15,664

Total Commnity & Primary Care 952,173 572,270 952,173

ACUTE SERVICES DIVISIONCapital Equipment 1,936,888 1,279,837 1,936,888GHMS - TasksStatutory Compliance 3,570,983 2,167,536 3,570,983Minor Works 432,331 151,415 432,331Other EquipmentCondemned Equipment 30,145 24,601 30,145

Total Acute Services Division 5,970,347 3,623,388 5,970,347

NHS FIFE WIDE SCHEMESCondemned Equipment 44,191 44,191Information Technology 1,041,000 763,880 1,041,000Equipment Balance 107,738 107,738Minor WorksScheme Development 40,000 8,284 40,000

Capital to Revenue Transfer - Non Value Added Expenditure (222,000) (222,000)

Total NHS Fife Wide 1,010,929 772,164 1,010,929

TOTAL ALLOCATION FOR 2017/18 7,933,449 4,967,822 7,933,449APPENDIX B

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APPENDIX C

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FINANCIAL POSITION

REVENUE RESOURCE LIMIT

Health Boards are required to work within the revenue resource limit set by the Scottish Government Health & Social Care Directorates (SGHSCD). This is monitored by SGHSCD via the monthly Financial Performance Return.

The Revenue Resource Limit position for NHS Fife for the 9 months to 31 December 2017 reflects an overspend of £3.680m. This overspend comprises an underspend of £1.256m attributable to Health Board; and an overspend of £4.936m to the Integration Joint Board as illustrated below. Following last month’s change in trend, the results for the period once again show a more favourable position than the estimated trajectory.

The report provides further detail on the assumptions underpinning the forecast outturn; however it is reasonable to note the improved position for the nine month period to the end of December as a positive indication that a breakeven outturn may be achieved.

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Financial TrajectoriesMonth May June July Aug Sept Oct Nov Dec Jan Feb MarchActual 2,615 3,105 4,213 4,666 5,057 5,339 5,154 3,680Plan 2,392 4,784 5,331 5,800 6,000 5,800 5,000 4,200 3,000 1,700 0

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1. Summary Position

1.1 At the end of December NHS Fife reports an overspend of £3.680m against the Revenue Resource Limit (RRL). This overspend comprises an underspend of £1.256m attributable to Health Board; and an overspend of £4.936m to the Integration Joint Board. The position is detailed in Table 1 below.

Table 1: Summary Financial Position for the period ended December 2017

1.2 As reported previously, the agreed 2017/18 efficiency savings targets of £29.201m have been removed in totality from opening budgets on a recurring basis. As such the positions reported each month are further analysed to show run rate performance as distinct from savings delivery performance. Whilst in totality the overall position is driven by unmet savings targets as opposed to run rate performance, it is important to signpost that the Integration Joint Board reflects an in-year and forecast overspend on both run rate performance and savings delivery. At month 9 the overall shortfall in savings targets is £6.475m which is offset by a favourable run rate position of £2.795m.

2. Revenue Resource Limit

2.1 The resource allocation at November is £720.8m (opening revenue resource allocation was £624.5m for the 2017/18 financial year). The main adjustments in month comprise the receipt of the following allocations: £0.808m for research & development; £0.456m capacity building for psychological therapies and CAMHS; and £0.544m for additional winter pressures. Discussions are underway with colleagues across the Health & Social Care Partnership and Acute Services Division on the allocation of this winter funding, in light of the emerging pressures over recent weeks.

3. Operational Financial Performance

Acute Services

3.1 The Acute Services Division reports an overspend of £5.354m for the period. This reflects an overspend in operational run rate

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performance of £2.142m, and unmet savings of £3.212m. Within the run rate performance, pay is overspent by £1.619m with the key drivers being incremental progression and observation policies. Supplies and services are overspent by £0.520m, principally on drugs and surgical sundries.

3.2 It is acknowledged that £1.9m of funding remains held back from the December budget position to cover winter costs, unscheduled care and waiting list monies which will be required in the final quarter of the financial year. This position remains under close and continuous review as additionality is monitored.

Integration Services

3.3 The Integration Joint Board health budgets report a net overspend of £4.928m for the 9 months to date. This position comprises an overspend in the run rate performance of £2.120m; and unmet savings of £2.808m.

3.4 The run rate overspend in the main relates to: GP prescribing mainly due to increased costs and a shortage in supplies which are both outwith Board control; pressure of complex care packages; and bank and agency costs across the East Division community hospitals. However this overspend is partially offset by vacancies in community nursing, health visiting, school nursing, community and general dental services. In addition, spend on Sexual Health & Rheumatology biologic drugs continues to materialise at a lower rate than expected due to some significant price reductions.

3.5 Discussions are underway with the Chief Finance Officer (CFO) to realign budgets across the Health budgets delegated to the IJB, recognising the range of budget and expenditure variances; this is an exercise that will form part of the joint budget setting approach for 2018/19.

Corporate Services

3.6 Within the Board’s corporate services, including Estates & Facilities, there is an underspend of £0.563m. This comprises an underspend on run rate of £0.971m as offset by unmet savings of £0.408m. As previously reported, this underspend is mainly due to: the holding of vacancies across Estates & Facilities, Finance, Human Resources, and Nursing Directorates; and an underspend on legal fees (with 2017/18 invoices being on average 28% lower than for 2016/17). Other pressures are driven mainly by interpretation services, provisions and property maintenance.

Non Fife and Other Healthcare Providers

3.7 The budget for healthcare services provided outwith NHS Fife reflects an overspend of £0.2m which is in line with previous month.

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Financial Plan Reserves & Allocations

3.8 As reported previously, financial plan expenditure uplifts have been allocated to budget holders, and therefore form part of devolved budgets. There are a residual number of uplifts which remain in a central budget. Each month, and in each quarterly review, an assessment is taken to release budget to the in-year position and its projected release to the year end. This detailed review of the financial plan reserves at month 9 has allowed £6.551m to be reflected in the in year position and partly mitigates slippage in savings delivery. This ‘financial flexibility’ remains a crucial element of the Board’s ability to deliver against the statutory financial target of a break even position against the revenue resource limit.

3.9 As reported last month, the most significant balances for the year to date position included employers’ national insurance, low pay award, rates and infrastructure support; as well flexibility released in respect of medicines; infrastructure support and the benefit from slippage in the Royal Hospital for Children & Young People / Department of Clinical Neuroscience (RHCYP/DCN) development in Edinburgh.

3.10 Further flexibility released at month 9 relates to: the benefit from National Specialist Services provision; and flexibility from sale of assets; and outcomes bundle funding.

3.11 It is important to note at this time, that there are a number of areas where funding from Scottish Government has been granted in-year across both Health Board and IJB for specific purposes and outcomes. Given that NHS Boards cannot carry forward income to future years (and the challenges outlined in the Financial Outlook 2018/19 make any provision for future spend a further pressure), any unspent funding has been reflected within both the in-year and forecast position as additional financial flexibility. At this point this includes: Orthopaedics; Colorectal Cancer; and Urgent Care. If funding is required next year on these areas it will result in a future in-year pressure for budget holders to manage.

3.12 The impact of these and other potential aspects of financial flexibility on the year end forecast are described in section 7 of this report.

Income

3.13 An over recovery in income of £0.065m is shown for the year to date.

4. Subjective Analysis

4.1 Analysis of the pan NHS Fife financial position by subjective heading is summarised in Table 2 below. There are notable movements, both positive and negative from previous months trends and these will be investigated further. In particular, the other non pay overspend has increased from £0.6m at the end of November, to £1.6m at the end of December.

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Table 2: Subjective Analysis for the Period ended December 2017

Annual Budget

Budget Actual Net over/ (under) spend

Pan-Fife Analysis £'000 £'000 £'000 £'000Pay 326,037 244,225 245,090 865GP Prescribing 72,166 54,835 57,562 2,727Drugs 32,513 24,161 23,618 (544)Other Non Pay 346,475 257,124 258,794 1,670Efficiency Savings (8,760) (6,475) 0 6,475Commitments 24,159 6,998 (450) (7,448)Income (72,787) (55,308) (55,373) (65)Net over spend 719,803 525,560 529,240 3,680

Pay

4.2 The overall pay budget currently shows an overspend of £0.865m. There are underspends across a number of other staff groups which are offset against the position within nursing and midwifery, where there is an overspend of £1.907m for the period. This is largely due to the residual impact of incremental progression within Acute nursing.

Drugs & Prescribing

4.3 Across the system, there is a net overspend of £2.183m on medicines of which an overspend of £2.727m is attributable to GP Prescribing; and an underspend of £0.544m relating to sexual health and rheumatology drugs in the main. The GP prescribing position is based on informed estimates for November & December, and has been discussed with, and informed and endorsed by, the Director of Pharmacy. The estimate reflects the assumptions on known future increases in the average costs and volumes of medicines as well as the price impact of a national shortage in supply of some medicines. This adverse impact is reflected in the position in respect of GP prescribing. Both volume and cost per Item are starting to rise when compared to the same period in 2016/17. Information received in early November is being scrutinised to determine the likely impact on the position to the year end.

Other Non Pay

4.4 On other non pay budgets across NHS Fife there is an overspend of £1.670m. This is predominantly within purchase of healthcare for complex care patients and equipment for service contracts / maintenance agreements. However, this is offset by a range of underspends across other non pay budgets.

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5. Delivering Safe & Effective Care at Lower Cost

5.1 The Financial Plan presented to the Board in April highlighted the requirement for £29.2m cash efficiency savings to support financial balance in 2017/18. As at December some £6.475m remains unmet for the period which reflects the savings target being removed in equal amounts over the 12 months from the outset, but the reality is that some schemes require a lead in time which end loads commencement and delivery to the latter part of the financial year.

5.2 The extent of the recurring / non recurring delivery as at December is illustrated in table 3 below. Of the £29.201m target, £13.643m has been identified on a recurring basis; this is a slight improvement from the November position. Work continues to identify further recurring savings and transformational change plans, with a number of additional proposals ‘booked’ through the system in recent weeks, but not yet reflected in the analysis below. Any unmet savings for the year on a recurring basis (currently £15.558m) will add to any financial gap for the following year 2018/19. This is being considered as part of our financial planning process. In addition, there are legacy savings from 2016/17 which are taken into consideration in the Financial Outlook 2018/19.

Table 3: Savings 2017/18

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Savings 2017/18 Target Identified Identified Total Identified UnidentifiedRecurring Non-Recurring to date Recurring

£'000 £'000 £'000 £'000 £'000

Health Board 15,828 7,018 3,750 10,768 8,810

Integration Joint Board 13,373 6,625 1,802 8,427 6,748

Total 29,201 13,643 5,552 19,195 15,558

6. Key Assumptions

6.1 As previously reported the financial planning process for 2017/18 assumed £2.5m additional DEL funding would be forthcoming in year. Any adjustment to this funding however, either upwards or downwards, will have an impact on the position, and we have built a number of different assumptions in to our forecast outturn position. For the mid range forecast, we are assuming a further £1.6m of funding; this assumed total funding of £4.1m compares with £2.8m received in 2016/17. We have approval for up to £5.6m DEL funding from the Scottish Government, however the risk is we cannot identify qualifying expenditure from existing costs and as such the mid range forecast outturn has been limited to the £4.1m at this time. This will continue to be scrutinised in detail in parallel with further discussion with finance colleagues in other Health Boards to inform our approach. Work is also underway to assess the extent to which the DEL funding might be utilised for the replacement of obsolete beds across the system; and whilst this will not result in a corresponding reduction in the current forecast outturn, it will address a number of clinical priorities.

6.2 The reported position for the period to date reflects the impact of a risk sharing of the total IJB overspend with Fife Council, based on November forecasts. This approach has been taken due to the different reporting timeframes of the respective partners.

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7. Year End Forecast Outturn

7.1 The forecast year end outturn position ranges between break even (best case) and an overspend of £4.039m (prudent position). All 3 forecasts comprise a mid range operational position as informed by individual Directors, adjusted for both a best case and prudent assessment of financial flexibility. This is consistent with the approach outlined to the Finance, Performance & Resources Committee in August and NHS Board in September. The current mid range forecast reflects an overspend of £1.188m as detailed in Table 4 below. It is important to note that this position comprises a £4.869m underspend on the Health Board budgets with a £6.475m overspend on the budgets delegated to the Integration Joint Board.

7.2 The main positive movements to the forecast position at month 9 compared to month 8 include the favourable impact of unspent allocations in-year, together with the release of National Specialist Services funding; the net revenue impact of gains/losses on sale of assets, and outcomes bundle funding.

7.3 We continue to work with the CFO and colleagues in Fife Council to clarify the timing of the risk share impact being made available at year end. This is to ensure greater clarity and timeliness in closing the NHS accounts and to address specific issues that arose at 2016/17 year end.

7.4 The forecast outturn currently recognises infrastructure support funding from SGHSCD of £1m (£0.5m has been confirmed via the allocation process to date). This revenue funding is of a non recurring nature and linked to ongoing efforts to accelerate asset disposals.

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Table 4: Mid Range Forecast

Mid Range Forecast £'000

Acute Services Division 6,498IJB Non-delegated 100Estates & Facilities (673)Board Admin & Other Services (503)Non Fife & Other Healthcare Providers 566Risk Share 1,025Health Board 7,013

Integration Joint Board 6,475

Total Expenditure 13,488

Miscellaneous Income (100)

Total Forecast prior to Financial Flexibility 13,388

Financial Flexibility:Drugs 1,112National Insurance 863Rates 1,247Underspend 16/17 333RHCYP/DCN 922OATS 600Other Financial Flexibility (inc unspent allocations) 3,623Sub total 8,700

Further Potential Financial FlexibilityHoliday Pay 600Additional DEL Funding 1,600Other Accruals 500CNORIS 500PPRS 300Sub total 3,500

Total Financial Flexibility 12,200

Total Forecast including Financial Flexibility 1,188 8. Next Steps

a. The forecast outturn position will continue to be further refined and scrutinised over the remaining months of the year. The variability of a number of factors and their combined impact means that the forecast outturn position remains fluid. Ongoing tight control of costs and run rate performance together with the pace of redesign and transformational change remain critical, respectively, for the current year position and the financial outlook for 2018/19 and beyond.

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b. The potential for further financial flexibility is being further scrutinised to move towards the delivery of a balanced position for the year. Risks continue at this time but there is a degree of cautious optimism that the December results and assumptions underpinning the year end forecast are an indication that a breakeven position may be achievable. Members of the Committee and NHS Board should note that the December Financial Monitoring Return to the Scottish Government Health & Social Care Directorates will set out a break even forecast, with supporting narrative on the key issues from this report. There remain a number of variables under review which may impact positively or negatively on the position:

Identification of qualifying expenditure which can be met from additional DEL funding (beyond the £4.1m total we are currently forecasting)

Further review of all balance sheet accruals to ensure their validity and test their likely crystallisation

A temperature check to our holiday pay accrual is under consideration given there has been a clear direction from the Chief Executive that there should be no carry forward of annual leave from leave year 2017 into 2018, unless there are exceptional circumstances

Assessment of the Integration Joint Board year end risk sharing arrangement with Fife Council.

Ongoing review of operational run rate particularly in relation to winter pressures across both acute services and health & social care service

9. Recommendation

9.1 Members are invited to approach the Director of Finance or Chief Executive for any points of clarity on the position reported and are asked to:

Note the reported overspend of £3.680m to 31 December 2017: of which £1.256m underspend is attributable to the Health Board; and £4.936m overspend to the Integration Joint Board.

Note the forecast year end outturn position ranges between break even (best case) and an overspend of £4.039m (prudent position), with a ’mid range’ forecast of £1.188m overspend, based on the month 9 results and an updated estimate of financial flexibility.

Note the December Financial Performance Return to Scottish Government Health & Social Care Directorates will be based on the best case forecast of a break even position for 2017/18.

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Resources

Section B:3 Staff Governance Summary

Executive SummarySickness Absence target: We will achieve and sustain a sickness absence rate of no more than 4%, measured on a rolling 12-month basis (note: we measure performance on an annual basis to eliminate monthly/seasonal variations, however supporting text focuses on month to month performance)

The sickness absence rate in November was 5.69%. The sickness absence rate for the 2016/17 financial year was 5.02% and the SWISS average sickness absence rate for 2017/18 to date is 5.42%.

Assessment: The Acute Services Division trend has fluctuated over the last six months, reducing to 5.31% in June, 5.14% in July, 4.98% in August, 4.81% in September, increasing to 5.15% in October and decreasing to 5.11% in November.

Despite being the only area in the 4% range in June, the Corporate Directorates rate has increased to 5.01% in July, 5.68% in August, 6.13% in September 6.49% in October and 6.52% in November.

Within the Health & Social Care Partnership, the rate has also fluctuated over the last six months reducing to 5.44% in June, increasing to 5.47% in July, reducing to 5.24% in August, increasing to 5.41% in September, 5.61% in October and 5.94% in November.

The main focus going forward continues to be implementing the actions from the staff and managerial surveys which were run in June 2017.

iMatter Update

The iMatter implementation programme has completed phase 1, providing all staff with the opportunity to participate in the staff engagement monitoring process. All members of NHS Fife staff and the Fife Council Staff working in the Health and Social Care Partnership have now commenced iMatter. There are currently 815 teams established within the iMatter system representing in excess of 10,000 staff. The current Board report for 2017 is representative of the teams which have gone through their anniversary cycles this year to date and represents the views of 6,008 out of 9,552 staff.

KSF Update

KSF performance is regularly reported to EDG and APF and Staff Governance Committee. The completion figure for the 12-month period ending 31 December was 61%, an 11% improvement compared to the position at 31 March 2017 and 13% higher than at 31 December 2016.

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Performance Summary


Previous Period



Sta

ff G

over

nanc

e

RE

D

Sickness Absence Clinically Effective 4.50% 12 months to Nov 2017 5.42% 12 months to

Oct 2017 5.39% ↓ 5.39%

Sec

tion

RA

G

Only published annually: NHS Fife was joint 7th for FY 2016-17 (Fife performance 5.11%, Scotland performance 5.20%)



Performance Data

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Performance Assessment MethodologyThe Scottish Government requires all Health Boards to attain a defined level of performance against a number of measures (known as Standards) which are included in the Local Delivery Plan (LDP). In addition, NHS Fife scrutinises its performance relating to complaints.




76

N/A for Staff Governance this month

N/A for Staff Governance this month






77

NHS Fife Strategic Overview

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Staff Governance

Area Dec 2016

%

Jan 2017

%

Feb 2017

%

Mar 2017

%

April 2017

%

May 2017

%Acute Services 5.55 5.75 4.79 5.31 5.00 5.51Health & Social Care Partnership 5.34 5.90 4.69 5.55 5.04 6.09Corporate Directorates 6.23 6.96 5.12 5.78 5.11 5.69NHS Fife 5.58 6.02 4.80 5.49 5.03 5.78

Area June 2017

%

July 2017

%

Aug 2017

%

Sept 2017

%

Oct 2017

%

Nov 2017

%Acute Services 5.31 5.14 4.98 4.81 5.15 5.11Health & Social Care Partnership 5.44 5.47 5.24 5.41 5.61 5.94Corporate Directorates 4.94 5.01 5.68 6.13 6.49 6.52NHS Fife 5.30 5.25 5.21 5.28 5.57 5.69

NHS Fife Sickness Absence

The NHS Fife sickness absence rate increased from 5.57% in October to 5.69% in November, with increases within the Health and Social Care Partnership and Corporate Directorates and a slight decrease within the Acute Services Division:

The Acute Services Division sickness absence rate decreased from 5.15% to 5.11% The Health & Social Care Partnership sickness absence rate increased from 5.61% to

5.94% The Corporate Directorates sickness absence rate increased slightly from 6.49% to

6.52%

Additional Points to Note:

There were 1,372 occasions of sickness absence in November, 32 more than October 26.07% of all hours lost due were due to Anxiety / Stress / Depression, an increase of

2.19% from October; and 11.59% were due to Other Musculoskeletal problems, a decrease of 1.11% from October

Staff in the 50-54 age group (18.62% of the total workforce) lost the most hours, 23.68% of the total hours lost, and accounted for the greatest proportion of absence

Long-term sickness absence equated to 60.85% of the hours lost and short-term absence equated to 39.15% of the hours lost. This has changed slightly from the October position of 58.88% and 41.12% hours lost, respectively.

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Rolling 12 Month Absence Analysis (up to end November 2017)

80

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

NHS Fife Sickness Absence Data by Operational Unit

December 2016 to November 2017

Next Steps – Well at Work

The key themes for progress during 2017/2018 are as follows:

The Action Plan in respect of the Management of Attendance / Well at Work Survey Results has been developed and is being progressed via the respective services and the Well at Work, Management of Attendance, Health Promoting Health Service Groups, along with the Survey Leads

We are currently awaiting feedback on an Endowment Bid to progress the Culture of Kindness work within NHS Fife

The Healthy Harmonies Choir had another successful Winter Concert on 10 December, a great night was had by all who attended

Alcohol and Drugs in the Workplace training is available for Line Managers and Supervisors. The next session is due to take place on 14 February

As part of their campaign to raise awareness of the signs and symptoms of celiac disease to increase diagnosis rates, the charity Coeliac UK is offering short awareness sessions in the workplace, which local Well at Work Leads are arranging.

The local Well at Work Groups are continuing to support different workshops, themes and events throughout the year to promote staff health and wellbeing

The Board’s recovery plans continue to build on the following points:

Review & Improvement Panel meetings continue to take place to review short and long term absence cases. Recent panels have been held within H&SCP East and West Divisions, with further dates scheduled for 2018 for all operational units.

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Staff Governance

Identification and analysis of the core reasons for sickness absence within Divisions and Directorates, along with themes and trends and what supportive steps can be implemented to minimise absences occurring in future

Attendance Management training dates for 2018 have been arranged and will be available via the Intranet

All previously reported actions continue to be implemented within NHS Fife

iMatter Update

The iMatter implementation programme has completed phase 1, providing all staff with the opportunity to participate in the staff engagement monitoring process. All members of NHS Fife staff and the Fife Council Staff working in the Health and Social Care Partnership have now commenced iMatter. There are currently 815 teams established within the iMatter system representing in excess of 10,000 staff. The current Board report for 2017 is representative of the teams which have gone through their anniversary cycles this year to date and represents the views of 6,008 out of 9,552 staff.

The current Board report details a 63% response rate from staff and an Employee Engagement Index score of 76%. This remains very positive in relation to the previous National staff survey and the current NHS Scotland report. The current report represents the views of staff in 729 teams. Of these, 436 teams are in the green Employee Engagement Index threshold of scoring (67%-100%) and 41 teams are in the yellow EEI threshold of scoring (51%-66%). There are two amber teams in the 34% - 50% scoring range and there are no red teams currently reporting in 2017.

The Health and Social Care Partnership has published its reports and has achieved a 63% response rate and a 77% EEI score which for the first experience of iMatter is very positive.

Focus continues to ensure all managers meet with their staff once a year to discuss their iMatter experience, examine their reports and agree the priorities for improvement for the year ahead. The key to iMatter success long term is staff being able to see real change as a consequence of their participation and inclusion in the action planning process. The Board has currently 385 (53%) action plans completed out of a possible 729 in 2017/18, with Emergency Care and Corporate Services cohorts still to complete their action plans in January. H&SC Partnership has achieved a 63% completion rate for action plans to date.

Phase 2 of iMatter will continue in 2018 focusing on the improvements achieved by teams through their annual action planning activities and examining the improvements they are achieving as a consequence. The work to link the staff experience and the experience of patients and clients will continue as the focus of phase 2. Positive examples of teams who have achieved change as a direct result of their iMatter action plan are being sought for publication on Dispatches.

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KSF Performance

KSF performance is regularly reported to EDG and APF and Staff Governance Committee. Table 1 below details overall NHS Fife performance and operating units as at 31 December. It indicates that 73% of staff are actively engaged in the KSF process with 61% of our staff compliant.

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Table 1: KSF performance as at 31 December 2017 (rolling year)

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Staff Governance

CHP/DivisionNumber of

staff

e-KSF Reviews

'activated' %

e-KSF Reviews ready for sign-off %

Number of e-KSF

Reviews %+/- cf

November 2017

Acute Services Division

Total 2986 229 8 104 3 1875 63 -

Corporate Division

Total 1616 31 2 19 1 1131 70 +13%

Fife Wide Divison

Total 1787 222 12 39 2 800 45 -4%

East Divison

Total 531 78 15 18 3 260 49 +8%

West Division

Total 747 73 10 17 2 379 51 +6%Others (No job family shown)

Total 31 7 207

Number of permanent

staff %

Number of e-KSF

Reviews ready for sign-off %

Number of e-KSF

Reviews completed %

Overall total 7667 664 9 204 3 4652 61 +5%

Actions

A number of actions to ensure continuing improvement and achievement of the 80% target in 2017/18 continue to be progressed including:

The Health & Social Care Partnership (H&SCP) Leadership team has agreed a recovery plan and trajectory with KSF leads identified for each of the divisions to progress implementation

EDG has agreed and is implementing an improvement and recovery plan and trajectory for Corporate Services

KSF PDP is a key performance metric considered at the Acute Services Division Directorate monthly performance reviews

KSF PDP performance is a standing agenda item at the ASD Staff Governance Board meetings

The provision of baseline eKSF performance compliance data to the operational units

Regular performance monitoring and reporting to EDG and Staff Governance Committee

Preparation for transition between e-KSF and Turas Appraisal in 2018 is underway with measures in place to facilitate continuing improvement and compliance in KSF PDP performance

Bespoke e-KSF training will be offered according to demand until 31 January

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Sickness AbsenceDrill Down

86

Measure We will achieve and sustain a sickness absence rate of no more than 4% (measured on a rolling 12-month basis)

Current Performance 5.42% for 12-month period to end of November 2017

Scotland Performance 5.20% for 2016/17 (data published annually)

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

4.80%

4.90%

5.00%

5.10%

5.20%

5.30%

5.40%

5.50%

Nov-

16

Dec-

16

Jan-

17

Feb-

17

Mar

-17

Apr-

17

May

-17

Jun-

17

Jul-1

7

Aug-

17

Sep-

17

Oct

-17

Nov-

17

Indi

vidu

al A

rea

%

NHS

Fife

Ave

rage

Ann

ual %

Sickness AbsenceNHS Fife (Annual Average) Standard Emergency Care Planned Care

Clinical Support & Access HSC East HSC West HSC Fife-Wide

Previous 3 Months12 Months to Aug 2017 12 Months to Sep 2017 12 Months to Oct 2017

5.28 % ↓ 5.31% ↓ 5.39 % ↓

Current Issues Increases in the first 8 months of the 2017/18 FY are mainly due to increases in anxiety, stress and depression, other musculoskeletal problems and gastro-intestinal problems

Context Sickness absence was poorer in the first 8 months of 2017/18, when compared with 2016/17

Key Actions for Improvement Planned Benefits Due By StatusCorporate Support Services Sickness Absence Review

Improvement in the rates of sickness absence within Corporate Support Services in 2017/18

Dec 2017 DelayedRevised to Mar 2018

East Division Sickness Absence Review Improvement in the rates of sickness absence within the East Division in 2017/18

Dec 2017 DelayedRevised to Mar 2018

PAUL HAWKINSChief Executive23rd January 2018

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Prepared by:JANN GARDNERDirector of Planning and Strategic Partnerships

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Documents

Overview and Executive SummarySection A: Introductionadmin.fifedirect.org.uk/.../c64_Item16a-IPRJanuary2018.docx · Web view0.05 5.5100000000000003E-2 5.3100000000000001E-2 5.1400000000000001E-2