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Performance Recovery Update

Public Board Meeting

30th March 2017

Presented for:

Update on position statement presented to January Board for the following standards:

Emergency Care Standard

Cancer Waiting Times

RTT/ 18 weeks

Cancelled Operations not rebooked in 28 days

Presented by:

Professor Suzanne Hinchliffe, Chief Nurse and Deputy Chief Executive

Author(s):

Angie Craig, Assistant Director (Performance)

Sajid Azeb, Assistant Director of Operations (ECS)

Mike Harvey, Assistant Director of Operations (Cancer)

Clare Smith, Assistant Director of Operations (RTT and Diagnostics)

Previous Committees :

None

Key points

1. To provide the Board with an updated position of LTHT’s current performance for the Emergency Care, Cancer, RTT, Diagnostics and Cancelled Operations national operational standards

For Information

2. To provide an update on the action plans and their progress towards achieving recovery of those standards.

For Information

3. To highlight risks to LTHT’s performance. For Discussion

Trust Goals

The best for patient safety, quality and experience

The best place to work

A centre for excellence for research, education and innovation

Seamless integrated care across organisational boundaries

Financial sustainability

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Index

Section Page number

1. Performance summary 2

1.1 Emergency Care 3

1.2 Referral to Treatment 3

1.3 Cancer Waiting Times 3

1.4 Cancelled Operations not rebooked in 28 days 4

2. Publication Under Freedom of Information 4

3. Recommendation 4

4. Authors 4

5. Appendices: A - Performance overview B - Emergency Care detailed report C - Referral to Treatment detailed report D - Cancer Waiting Times detailed report E - Cancelled Operations not rebooked in 28 days detailed report

5 5 6

10 12 15

1. PERFORMANCE SUMMARY

Performing Non-Performing

Responsive • Diagnostic Test Waiting Times • 31 Day Subsequent Radiotherapy and

Chemotherapy Cancer Waiting Times • Outpatient Measures

• Emergency Care Standard • Referral to Treatment • 62 Day Cancer Waiting Times • 31 Day Subsequent Surgery Cancer Waiting

Times • 2 Week Cancer Waiting Times (January) • 31 Day Cancer Waiting Times - First treatment,

(January) • Cancelled Operations • Delayed Transfer of Care and Repatriations • Ambulance Handover

Safe • Incidence of CDI • Venous Thromboembolism (VTE) Risk

Assessments • Incidents

• Incidence of MRSA • Electronic Discharge Advice Notes (eDANs) -

reporting re-instated from Jan 2017

Effective • Mortality Indicator Reporting • 30 Day Emergency Readmission Rates • Harm Free Care

Caring • Complaints

Well-Led • Patient Satisfaction: Friends and Family Test

• People

Other • Length of Stay • CQUIN delivery

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1.1 Emergency Care Standard Performance Compliance with the 95% ECS standard was last achieved in September 2015. Performance for the 2016/17 financial year is as follows:

WYAZ trajectory is to achieve 90% for the month of March 2017.

The Trust successfully achieved the required STF trajectory for Q1.

For Q2 the STF trajectory was achieved only when considered against the Accelerator Zone actions.

In Q3 the continued significant pressure upon non elective services resulted in deterioration in performance.

The January position saw an improved performance and has further improved in February.

The Q4 STF trajectory is currently being achieved when considered against the accelerator zone.

It is anticipated to achieve the March in WYAZ trajectory For more detail, please see Appendix B.

1.2 Referral to treatment Standard (RTT/ 18 weeks) Peformance

The Trust successfully delivered the required STF trajectory for Q1.

For Q2 and Q3 the STF trajectory has not been and will not be achieved for Q4.

Mitigated in respect of performance have been submitted to NHSI

1.3 Cancer Waiting Times Performance

2016/17

Site April May June July August September October November December January February Q1 Q2 Q3 Q4 YTD

Formally Reported 90.25% 90.36% 87.24% 86.83% 91.53% 89.92% 85.58% 81.13% 78.08% 81.82% 84.25% 89.29% 89.36% 81.69% 82.48% 86.10%

LGI & SJUH - CCG

Reporting89.13% 89.19% 85.71% 85.18% 90.50% 88.66% 83.96% 79.15% 75.93% 79.79% 82.60% 88.02% 88.04% 79.76% 80.58% 84.50%

LGI 91.10% 90.91% 89.09% 88.68% 92.87% 89.58% 88.27% 85.27% 84.90% 88.52% 88.93% 90.37% 90.28% 86.20% 88.80% 88.91%

SJH 86.50% 86.78% 81.15% 80.52% 87.62% 87.41% 77.99% 70.92% 64.51% 68.65% 72.78% 84.82% 85.12% 71.16% 69.78% 78.63%

WGH 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 99.95% 99.98% 100.00% 100.00% 100.00% 100.00% 100.00% 99.98% 100.00% 99.99%

Formally Reported 90.25% 90.36% 87.24% 86.83% 91.53% 89.92% 85.58% 81.13% 78.08% 81.82% 84.25% 89.29% 89.36% 81.69% 82.48% 86.10%

Trust + All MIU's 92.22% 92.43% 89.98% 89.55% 93.15% 91.81% 88.31% 84.73% 82.30% 85.64% 87.54% 91.55% 91.44% 85.19% 86.13% 88.89%

Accelerator Zone 93.66% 93.72% 91.84% 91.40% 94.45% 93.38% 90.52% 87.60% 85.52% 88.26% 89.80% 93.07% 93.03% 87.94% 88.66% 90.92%

NHSI STF trajectory 85.00% 87.00% 88.36% 90.18% 91.28% 93.00% 91.00% 90.00% 88.00% 85.00% 86.00% 86.81% 91.47% 89.71% 87.03% 88.76%

Within 1% of NHS STF trajectory

MONTHLY

(national

reporting

period)

2016/17 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Q1 Q2 Q3

Trust Performance 91.30% 91.30% 90.51% 89.88% 89.15% 88.62% 88.62% 88.66% 87.25% 87.55% 88.09% 91.03% 89.22% 88.64%

Trust Performance minus Restorative Dentistry 92.32% 92.32% 91.66% 90.99% 90.29% 89.56% 89.35% 89.09% 87.58% 87.81% 88.13%

Trust Performance minus agreed NHSE Specialties 92.97% 92.96% 92.46% 92.34% 91.92% 91.70% 91.34% 91.18% 89.63% 89.75% 89.78%

Trust Performance for Leeds CCGs only 93.32% 93.31% 92.73% 92.91% 92.58% 92.30% 92.11% 92.12% 90.71% 90.97% 91.06%

NHSI STP Trajectory 91.00% 90.77% 91.17% 91.40% 91.74% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 90.98% 91.71% 92.00%

Within 1% of NHSI STP Trajectory

62 days 2w w

referral to

Treatment

Actual

Performance

Internal and

by day 38

performance

NHSI STF

Trajectory85.14%85.05% 82.27% 83.43% 84.56% 83.23% 85.15%

75.10%

87.90% 84.84% 86.29%

Nov

78.70%

84.80%

85.19%

86.30%

81.20% 75.81%

Q1 Q2Jan

76.50%

84.50%

85.16%

86.07% 80.56% 77.81% 81.17%

Oct

73.63%

Sep

83.60% 80.40% 80.15% 79.40% 74.18%

Apr May Jun Jul Aug Q3

76.80%

83.60%

85.12%

Dec

76.90%

84.30%

85.03% 83.54% 84.35%

81.26%

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LTHT has not achieved the STF trajectory for overall performance against the 62 day standard this financial year to date.

Although LTHT has not achieved the internal and referrals received by day 38 standard since August, from the low point of 77.81% in September, the Trust has delivered a marked improvement in performance from November, which was sustained in December and January 2017.

Whilst LTHT continued to perform well against the majority of the CWT targets, including the 14 day urgent referral (2ww) standard, we have not achieved the 31 day subsequent surgery target since September. This remains attributable to on-going pressures on surgical capacity across the Trust. For more detail, please see Appendix D.

1.4 Cancelled Operations not rebooked in 28 days

This is a zero tolerance NHS contract standard. Following good progress in reducing levels of cancelled operations breaches not rebooked within 28 days, the position deteriorated in 2016/17.

Early signs of improvement have been seen in March 2017 For more detail, please see Appendix E.

2. PUBLICATION UNDER THE FREEDOM OF INFORMATION ACT

This paper will be made available under the Freedom of Information Act 2000.

3. RECCOMMENDATION

The Board is asked to receive this report of Performance within LTHT.

4. NAME OF AUTHOR(S):

Angie Craig, Assistant Director (Performance)

Sajid Azeb, Assistant Director of Operations (ECS)

Mike Harvey, Assistant Director of Operations (Cancer)

Clare Smith, Assistant Director of Operations (RTT and Diagnostics)

Date of paper: 23/03/2017

Performance Measures Target Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17

Cancer: 62 Day: GP/Dentist Referrals >=85 86.19 86.38 83.50 80.18 80.05 79.57 74.53 73.60 75.10 78.70 76.90 76.5

Cancer: 62 Day: Screening >=90 94.29 94.83 91.49 91.49 100.00 91.67 93.94 95.77 96.70 97.78 93.33 98.1

Cancer: 31 Day: 1st Treatment >=96 97.68 97.31 97.22 97.80 97.74 97.39 97.58 96.54 96.93 96.99 97.15 94.8

Cancer: 31 Day: Subsequent Surgery >=94 96.39 89.93 96.05 87.94 93.63 98.52 95.68 97.53 91.84 91.06 90.91 89.6

Cancer: 31 Day: Subsequent Drug >=98 100.00 100.00 100.00 99.53 99.67 100.00 100.00 100.00 100.00 100.00 100.00 100

Cancer: 31 Day: Sub Radiotherapy >=94 100.00 100.00 100.00 100.00 99.73 99.45 99.75 100.00 99.73 100.00 100.00 99.8

Cancer: 14 Day: Urgent GP Referrals >=93 93.20 93.87 92.89 94.38 93.28 94.28 92.19 93.76 95.54 95.45 96.55 92.3

Cancer: 14 Day: Breast Symptoms >=93 98.10 95.37 97.12 96.71 96.57 96.45 94.74 95.05 97.17 95.60 98.27 96.1

2014/2015 2015/2016 Apr-16 May-16 Jun-16Q1

16/17Jul-16 Aug 16 Sep-16

Q2

16/17Oct-16 Nov-16 Dec-16

Q3

16/17Jan-17 Feb-17 Mar-17

Q4

16/17

Cancelled

Ops not

rebooked

in 28 days

132 82 16 13 10 39 14 21 21 56 31 21 31 83 51 28 16 95

Patients whose operations is

cancelled on or after the day

of admission should be

offered another binding date

within 28 days (at LTHT or

funded at a provider of the

patient's choice)

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5. APPENDICES

A. PERFORMANCE OVERVIEW Pressures Peformance in 2016/17 has continued to be significantly affected by the pressure on beds, flow and capacity, with non elective pressures continuing in Q4 at increased levels when compared to previous quarters and a particularly acute period in the first two weeks of January followed by a series of difficult Mondays in February. The previously notified growth in elective demand has not stemmed and has continued to be exacerbated by external service challenges (Q2 pressures were mainly in Head and Neck which have now been joined by Paediatric Urology, Paediatric ENT and Paediatric Dentistry). This, alongside continued rising demand in areas where we have insufficient (but difficult to address) capacity in key large volume areas (Restorative Dentistry, ENT and Spines), as well as our non elective bed pressures, has continued to significantly reduce our elective capacity and throughput and therefore our Cancer and RTT performance. Service review discussions continue with NHSE and local Commissioners to find appropriate solutions, although there remain concerns regarding the pace at which alternative options can be sourced. Impact on Activity Despite these pressures, LTHT activity is significantly above plan YTD overall and above the activity levels for 2015/16 in the order of:

2016/17 (April-Jan inclusive) Plan YTD Actual YTD Over / undertrade

Electives 24,295 22,097 -2,198

Non-Electives 72,202 76,905 4,703

Outpatients 924,571 934,999 10,428

Daycase and Regular Day attenders 86,815 89,886 3,071

Total 1,107,883 1,123,887 16,004

The Trust has continued to mitigate the impact of the increased non-elective activity and its impact on elective capacity through increased outpatient and daycase activity this is at a detriment to the Trust overall financial position (£7.7 million undertrade in elective activity and a net impact of £1.6 million on non elective activity once 70% marginal tariff rules and readmission penalties are factored in). Mitigation NHSI Sustainability and Transformation Plan funding (STF) for 2016/17 is released on the achievement of our submitted STF and supporting performance trajectories, unless mitigated, and therefore standard NHS contract fines against specialty level / non achievement of the four key national operational standard (ECS, RTT, 6ww Diagnostics and 62 day Cancer) will not be levied. A mitigation appeal against Q2 performance trajectories was successful with a further appeal for Q3 performance submitted on 16th February 2017 to NHSI.

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B. EMERGENCY CARE

B.1 Comparative national position

LTHT has the second highest ED attendance rate for Type 1 within this peer group at 17,366 attendances and is 17th largest A&E service nationally. All 6 organisations performing better than LTHT in the above peer comparison (January data) have much lower levels of A&E Type 1 attendances when compared to LTHT.

We have also undertaken a comparison of the LTHT position relative to those A&E departments that have the largest type 1 attendance levels. This is measured against all hospitals within the country irrespective of the types of services e.g. Major Trauma / tertiary provider designation. The table below demonstrates LTHT position in relation to Type 1 A&E departments with the highest attendances. This shows that LTHT rank 4th out of the top 10 in regard to performance when viewed against levels of attendances, which is an improving position.

January 2017 Benchmark Data

A&E attendances

Name Type 1

Departments -

Major A&E

Type 2

Departments -

Single

Specialty

Type 3

Departments -

Other

A&E/Minor

Injury Unit

Total

attendances

Type 1

Departments -

Major A&E

Type 2

Departments -

Single

Specialty

Type 3

Departments -

Other

A&E/Minor

Injury Unit

Total

Attendances

> 4 hours

Percentage

in 4 hours

or less

(type 1)

Frimley Health NHS Foundation Trust 19,458 0 0 19,458 2,980 0 0 2,980 84.7%

Chelsea And Westminster Hospital NHS

Foundation Trust 16,920 0 7,349 24,269 3,141 0 73 3,214 81.4%

Royal Free London NHS Foundation Trust 18,559 0 3,151 21,710 3,690 0 1 3,691 80.1%

Leeds Teaching Hospitals NHS Trust 17,366 0 1,932 19,298 3,508 0 0 3,508 79.8%

Mid Yorkshire Hospitals NHS Trust 19,422 0 0 19,422 4,444 0 0 4,444 77.1%

Lewisham And Greenwich NHS Trust 17,998 0 5,481 23,479 4,454 0 164 4,618 75.3%

Barking, Havering And Redbridge

University Hospitals NHS Trust 20,430 632 3,227 24,289 5,247 7 19 5,273 74.3%

Barts Health NHS Trust 28,420 598 11,699 40,717 7,426 34 168 7,628 73.9%

Heart Of England NHS Foundation Trust 18,898 0 3,317 22,215 5,019 0 59 5,078 73.4%

Pennine Acute Hospitals NHS Trust 21,943 0 4,227 26,170 6,004 0 86 6,090 72.6%

A&E attendances > 4 hours from arrival to admission, transfer or

discharge

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When compared to all organisations reporting against the Daily winter sitrep position our performance is presented within the graph below:

B.2 Underlying Issues Despite a reduction in A&E attendances there is continued pressure on LTHT flow and systems due to the following competing pressures:

Demand for IP beds outstripping capacity due to medical outlier and medically optimised patients

Increased staffing pressures within community nursing services resulting in delays in patients being accepted for out of hospital support.

Reduced community bed provision.

A&E Attendances Whilst overall attendances are up by 4% YTD April-January in comparison to the previous year for SJUH and LGI which equates to additional 8156 attendances for the period April 2016 - January 2017 (approximately 741 additional patients per month or 24 per day), for the month of February this has seen a marked reduction.

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Overall admissions are up by 640 admissions YTD which is a 2.0% increase in the number of admitted patients (April - January). The conversion rate from ED attendance to inpatient admissions continues to be below that of the previous year due to the improvement work being undertaken within LTHT, with April 2016-Jan 2017 YTD position 21.7% against 22.3% for the same period in 2015/16. If this improvement had not been delivered and based on current attendance numbers into ED this would have resulted in a further 1182 admissions into the bed base. During the same period of time the Non-elective length of stay has continued to be below the same period last year (0.2 day reduction for the period April – February). Continuing pressures in outflow from ED have led to the significant increase in number of patients on trollies in ED, and the extended length of time they are awaiting a bed:

In January 2016 there were a total of 6,630 bed requests with 420 patients waiting more than 4 hours in the department from the decision to admit. In comparison, for January 2017 there were less bed requests (6,081) with an increase in number of patients waiting more than 4 hours in the department from decision to admit to 833, a 98.3% increase. However, this is showing an improved position continuing into March. Since the transfer of the JAMA to A&E on 16th January focus has been maintained in the performance of the minor injury & GP stream which can be shown in the graph below:

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Delayed Transfers of Care / Medically Fit for Discharge (MFFD) Based on a spot check audit conducted on the 30th January 2017 we had a total of 180 patients classified as MFFD across SJUH and LGI of which 40 were assigned as a DTOC. An emerging issue relating to the closure of community beds (nursing, EMI, residential) across the Leeds economy, coupled with and led to the escalation of Leeds Community Health to Silver Command (due to acute staffing issues in community nursing teams) led to further delays.

*The “patient or family choice” category includes patients whose families are choosing homes or waiting for home managers to assess patients.

Repatriations The Trust continues to share repatriation delays with A&E Delivery Group chairs and neighbouring acute Trusts. During April - January 2017, LTHT have lost an equivalent of 12 beds per day for patients where their transfer was delayed beyond the agreed 48 hour transfer window following acceptance. This continues to be the focus of the strategy / operations monthly Directors meetings and continues to be escalated to NHSE/ NHSI.

B.3 LTHT Recovery Actions

The Trust has continued to enact its full capacity plan since beginning of October 2016, and has continued to be at REAP level 4 and above together with Silver Command for considerable periods of time during Q3 and early Q4.

Further actions include:

Strengthened ED medical rota’s through recruitment of 11 substantive doctors reducing the reliance on agency / locum staff allowing for better shift fill rates achieved in August 2016.

Positive nurse recruitment to the ED

‘Green Stream’ in place at both ED sites to allow streaming of the less complex patients in ED.

Continuation of the Joint Acute Medical Assessment (JAMA) pilot improvements through the creation of a dedicated assessment area (6 trolleys) to avoid inpatient admissions into the bed base. A frailty pilot has also been completed and has now

February comparative positions

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progressed to the development of an enhanced ambulatory care model based on collaboration between Urgent Care and Acute Medicine CSU, which has included increasing capacity in ED through movement of minor injuries unit to accommodate JAMA in the ED.

GPs and patient advisor in ED at both sides of the city from early November to date.

LTHT have an agreed set of West Yorkshire Accelerator Zone actions with partners with action in place and reporting against funding provided on 17th November 2016.

Introduction of SAFER bundle and Red & Green days as well as a review of all patients by HRG above the national LoS average. ECIP workshop on the SAFER care bundle was held on 30/11/2016 roll out plans by CSU are being developed.

From 3rd January, additional Winter capacity (9 beds) has been created by the move of J16 to J11.

Additional 2 beds will be created from the conversion of 2 treatment rooms on J20 at the end of March.

Weekly report and escalation of repatriation delays to Acute Trusts across West Yorkshire.

Continued work with partners to roll out and fully establish and the Integrated Discharge Service and Trusted Assessor model across 8 medical wards.

Additional step down capacity created (Bilberry Unit, 26 beds) at Wharfedale and 6 beds made available at Chapel Allerton to ease congestion at both sites. A second ward (Heather) was also opened in March.

System wide recovery actions LTHT have an agreed a set of West Yorkshire Accelerator Zone actions with partners for which funding confirmation has been received to support:

Commissioning of 24 transitional convalescence / awaiting further care beds at Wharfedale in partnership with Villa Care (Heather Unit).

Weekly report and escalation of repatriation delays to acute trusts across West Yorkshire continues.

Continued work with partners to roll out and fully establish the Integrated Discharge Service and Trusted Assessor model across 8 medical wards.

Extraordinary SRG Summit meeting held with partners to identify further system actions that can be taken, with a further follow-up meetings held via SRAB. This work identified 10 areas of which the following have been actioned to date:

o Expanding ward J31 o Commissioner investment in equipment pool o Skills supervisor to be attached to IDS Team o Additional hospital social workers

C. REFERRAL TO TREATMENT

The number of reporting specialties failing the 92% incomplete standard in both October and November was eight; this has improved to seven in December, January and February. Furthermore, there is a slight improved position in the number of patients waiting over 18 weeks.

C.1 National Comparative Position

When compared to other units nationally, LTHT remains static in its nationally ranked position. The key areas of risk to improvement are primarily bed pressures across the Trust and the continued rising demand in some of our already pressured specialties.

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C.2 Underlying Issues The submitted RTT trajectory was based on a 5% growth in demand and activity above 2015/16 levels at Trust level, in line with our plans agreed with commissioners. Specialties that are non-compliant with RTT in the main continue to reflect the areas where demand is significantly outweighing available capacity or non-elective bed pressures are a major factor. In Q2 the most significant of those specialty issues was in Leeds Dental Institute, however, actions agreed with NHSE and taken internally have resulted in an improved position with our biggest pressures in Q3 and Q4 now related to increased IP demand in Paediatric Urology and Paediatric ENT alongside well known significant capacity constraints in Adult Spines. There are also emerging short term issues in Paediatric Dentistry.

There are 12 specialties with above 10% IP growth - Gastroenterology, Neurology, Foot & Ankle, Hip & Knee, Upper Limb, Interventional Radiology, Dermatology, Paediatric Gastroenterology, Paediatric Immunology and Paediatric Rheumatology, of which the biggest concerns are for Paediatric Urology and Paediatric ENT due to limited in house surgical capacity to address.

This growth equates to an additional 202 IP waiting list additions across the Trust each week

There are 12 specialties with more than 5% OP growth (or non-reduction) against their agreed contractual levels (with subsequent IP conversion).

This equates to an additional 116 referrals across the Trust each week

Referrals per week

CSU / Business Unit

Expected

Growth

Plan

2016-17

Baseline

Average

Referrals

2015-16

2016-17

YTD Average

Referrals

2016-17

YTD Growth

over 2015-16

304 - Clinical Physiology (CPH) +37.4% 22 26 +18.0%

306 - Adult Hepatology -13.2% 63 64 +0.7%

340 - Thoracic Medicine (THOR) -0.8% 140 146 +3.9%

400 - Neurology (NEUR) +15.8% 157 193 +22.6%

110 - Foot & Ankle +11.4% 67 83 +24.5%

110 - Hip & Knee +10.0% 163 190 +16.8%

257 - Paediatric Dermatology (PDER) -12.6% 30 33 +10.4%

103 - Breast Surgery (BREA) +2.9% 194 209 +7.6%

173 - Thoracic Surgery (THOS) +1.1% 32 34 +7.5%

143 - Orthodontics (ODON) -13.0% 28 26 -6.7%

811 - Interventional Radiology (IRAD) -34.8% 92 98 +6.2%

107 - Vascular Surgery (VAS) -4.6% 88 90 +3.2%

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C.3 Recovery Actions All CSUs and specialties with significant backlogs of patients over 18 Weeks have had their recovery plans assessed and refreshed, recognising on-going constraints with workforce and bed capacity. With current plans in place, the number of patients waiting over 18 weeks on a non-admitted / Outpatient pathway reduced from end of December to end of February by 812 patients. It is anticipated that if activity continues as per CSU trajectories and plans this would remove a further 200 patients by the end of March 2017, which it is hoped will improve the Trusts RTT position further. Actions to improve non elective activity include:

Ward J43 ring-fenced to support surgical capacity at the SJUH site from 16th January (timed to coincide with the opening of the Bilberry Unit to minimise any resulting site pressures).

The Heather Unit opened at Wharfedale Hospital on 6th March 2017 to support acute and elective flow at the SJUH site.

Limited overnight stay capacity at Wharfedale Hospital opened in February 2017 for trial period, providing additional inpatient operating capacity for five CSUs with 18 week pressures in their admitted patient waits. The outcome of this trial will be reviewed and recommendations made as to future use of this option.

D. CANCER WAITING TIMES Although LTHT has not achieved the internal and referrals received by day 38 standard since August, the Trust has delivered a marked improvement in performance from November, which was sustained in December and January 2017. Whilst LTHT continued to perform well against the majority of the CWT targets, including the 14 day urgent referral (2ww) standard, we have not achieved the 31 day subsequent surgery target since September. From October to December this was attributable to on-going pressures on surgical capacity across the Trust and particularly within the TRS CSU which were highlighted in the January Board paper. Non delivery of the 2ww standard in January is attributable to a significant number of patients choosing to decline an appointment over the Christmas period alongside capacity challenges in Lower and Upper GI. LTHT will meet this standard in February and is expected to be maintained in March. D.1 National Comparative Position Although LTHT continues to perform under the required standard for 62 days overall, the graph below shows that internal performance was higher than the overall performance for England in November, December and January:

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*December data latest nationally available for cancer

D.2 Underlying Issues

Internal Performance Although internal performance has improved in Q3 and January, it remains below the 90% level required to support the achievement of the overall standard by providing a buffer for late referrals from other organisations.

Demand The continued increase in 2ww demand (406 additional patients in Q3 compared with the same period in the previous year) continues to place additional pressure on the diagnostic, outpatient and surgical investigation services. The increased diagnostic demand makes it more challenging to ensure that patients who do have cancer receive a diagnosis as early in the pathway as possible, allowing adequate time to arrange appropriate treatment within the 62 day standard.

Continued risks for February and March Due to a significant number of patients who chose to decline appointments over the Christmas period, alongside capacity challenges in key surgical specialties due to the impact of non- elective flows as previously described, there remain risks throughout Q4. With actions in place the 31 day 1st treatment standard is expected to recover in March, however as 62 day and 31 subsequent surgery standards require the clearance of surgical backlogs, progress against these standards is expected to take longer with internal 62 day performance not expected to recover until September 2017 in line with submitted CSU trajectories.

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Inter Provider Transfers (IPTs) LTHT continues to receive approximately 50% of its IPTs after day 38, which provides very little time for LTHT to avoid a breach. Work is on-going, as described below to ensure the breach allocation rules implemented acknowledge these difficulties and reward performance fairly and equitably across the whole pathway.

D.3 Recovery Actions The pathway review programme led by the Lead Cancer team in conjunction with key CSUs has continued to progress with good levels of clinical and administrative engagement. This work is focused on reducing waste in the pathways and removing steps which do not add value in the following key pathways

Lung

Urology

Head and Neck

Gynaecology

These pathways remain the most challenged pathways in terms of timeliness and any improvement in this regard should have a significant impact on overall and internal 62 day performance. It is prudent to note that on-going site pressures have the potential to limit the impact of this work on performance in the short term.

The ring fencing of J43 on the SJUH site, coinciding with the opening of the Bilberry Unit have demonstrated tangible benefits in terms of surgical throughput in the latter half of

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January which has continued into February and March as the SJUH site has become less congested.

Work is on-going to optimise the use of available theatre sessions and some additional internal theatre capacity has been identified which will be allocated accordingly to our most challenged areas.

External

Work continues (Sponsored by WYAAT) across the Cancer Alliance group of organisations to agree a process and understand the impact of the introduction of Breach Allocation within the system. LTHT is likely to be a net beneficiary in performance terms through the introduction of the system. Agreement in principle should be reached by the Chief Operating Officers Group by the end of March 2017 for introduction from April 2017.

E. CANCELLED OPERATIONS NOT REBOOKED WITHIN 28 DAYS E.1 Current Performance

The Trust has consistently found the delivery of the Cancelled Operations not rebooked within 28 days zero tolerance standard challenging. The LTHT quarterly performance and the national rating since April 2014 are shown below (Quarter 4 16/17 position is based on January and February data only):

If the cancellations due to the Telepath IT system outage in September are discounted then the number of operations cancelled for Q2 16/17 would be reduced to 419. A summary of cancellation reason for the 16/17 financial year is shown below:

Qtr Performance

Number of last

minute elective

operations

cancelled for non

clinical reasons

Number of

patients not

treated within 28

days of last

minute elective

cancellation

National

Ranking

Quarter 1, 2014-15 (April to June 2014) 4.84% 310 15 120

Quarter 2, 2014-15 (July to September 2014) 4.25% 353 15 114

Quarter 3, 2014-15 (October to December 2014) 10.00% 410 41 138

Quarter 4, 2014-15 (January to March 2015) 19.03% 310 59 147

Quarter 1, 2015-16 (April to June 2015) 7.47% 308 23 115

Quarter 2, 2015-16 (July to September 2015) 3.26% 307 10 99

Quarter 3, 2015-16 (October to December 2015) 3.65% 356 13 102

Quarter 4, 2015-16 (January to March 2016) 8.62% 429 37 120

Quarter 1, 2016-17 (April to June 2016) 8.88% 439 39 114

Quarter 2, 2016-17 (July to September 2016) 9.91% 565 56 131

Quarter 3, 2016-17 (October to December 2016) 15.13% 542 83 144

Quarter 4, 2016-17 (January to March 2017) 26.78% 295 79

Quarter 1

Total Quarter 2

Quarter 2

Total Quarter 3

Quarter 3

Total Grand Total

Cancelation Reasons Oct-16 Nov-16 Dec-16 Jan-17

CRITICAL CARE CAPACITY 59 15 25 12 52 18 18 129

FAILURE OF EQUIPMENT 27 3 3 2 8 7 7 42

NO ANAESTHETIST 11 1 1 12

NO OPERATOR 10 15 3 5 23 9 9 42

NOT KNOWN 62 22 18 18 58 16 16 136

RAN OUT OF THEATRE TIME 124 32 44 20 96 21 21 241

SCHEDULING 50 22 19 22 63 22 22 135

THEATRES 18 4 8 4 16 34

WARD BED CAPACITY 204 70 76 79 225 68 68 497

Grand Total 565 183 196 163 542 161 161 1268

Agenda Item 12.2

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The above graph shows the good progress LTHT made in reducing all cancellations in 2015/16 (reportable 28 day breaches and last minute cancellations) which have unfortunately been lost in 2016/17 due to continued bed and flow pressures, although this is an improving position from November to date.

E.2 National comparative position

In comparison to other units nationally, LTHT is currently ranked 144th, a continued deterioration since Q1 this financial year.

Agenda Item 12.2

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E.4 Recovery Actions Whilst current bed pressures remain achievement of this performance standard will continue to be challenging.

To mitigate these pressures we have:

Ring-fenced elective capacity on J43 from Monday 16th January.

We continue to identify suitable patients that would normally be treated as IP to move to day case to try to further reduce patients subject to cancellations

Wharfedale limited overnight stay surgical capacity opened in February for those IP who can be treated with a 23 hour stay.

The below table demonstrates the impact on improved cancellation rates in the AMS CSU of the above actions from 2nd January to 6th February 2017:

Week Commencing

Total Ops

planned

Ops done

Ops done %

Ops cancelled

on day

Ops cancelled on day %

Ops cancelled day before

Ops cancelled

day before %

02/01/2017 92 34 36.96% 22 23.91% 36 39.13%

09/01/2017 105 56 53.33% 9 8.57% 40 38.10%

16/01/2017 97 90 92.78% 1 1.03% 6 6.19%

23/01/2017 82 77 93.90% 2 2.44% 3 3.66%

30/01/2017 99 89 89.90% 9 9.09% 1 1.01%

06/02/2017 109 93 85.32% 10 9.17% 6 5.50%

*cases cancelled for non-bed reasons have been excluded.