governing board board papers… · summary finance performance..... 5. strategic objectives..... 6....

GOVERNING BOARD

Date of Meeting 21 September 2016 Agenda Item No

5

Title Integrated Performance Report

Purpose of Paper

The Integrated Performance Report provides the Governing Board with a high level overview of: • Progress against the delivery of the CCG’s strategic priorities

and plans • Overall CCG performance that defines an effective

commissioner

The Integrated Performance Report is presented in the agreed new format which provides a more concise document, with a high-level Executive Summary at the front, presenting the key information under each priority area. A further level of detail can still be found within the appendices.

Recommendations/ Actions Requested

The Governing Board is asked to:

• Accept the contents of the Performance Report.

Potential Conflicts of Interests for Board Members

None.

Author Michael Drake Director of Planning and Performance

Sponsoring Member

Michelle Spandley Chief Finance Officer

Date of Paper 13 September 2016

Portsmouth CCG Governing Board Meeting

21st September 2016

Integrated Performance Report

Improving health services…

Report Contents

Executive Summary ...................................................................................... 3 Finance Summary .......................................................................................... 4 Summary Finance Performance ................................................................................. 5 Strategic Objectives ..................................................................................... 6 Priority 1 ..................................................................................................................... 6 Priority 2 ..................................................................................................................... 9 Priority 3 ................................................................................................................... 11 Priority 4 ................................................................................................................... 12 Annex 1 Quality Report (Provider) ........................................................................... 14 Annex 2: NHS Constitution – Rights and Pledges .................................................... 18 Annex 3: Friends and Family Test Percentage Recommended – June 2016 ........... 19 Annex 4 – 2016/17 Quality Premium - July Estimate ............................................... 20 Annex 5 – Detailed Finance Performance ................................................................ 21 Annex 6 – Financial Risk Rating .............................................................................. 22 Annex 7: IAF - Baseline assessment of six clinical priority areas ............................. 23 Annex 8 - Glossary ................................................................................................... 24

The table below provides a key of the symbols used throughout the document.

Strategic Priority Projects KPIs

On track to deliver expected outcomes May not deliver expected outcomes Very unlikely to deliver expected outcomes

3

Executive Summary Current Delivery of Strategic Priority

Priority 1 Priority 2 Priority 3 Priority 4

Finance Summary

Indicator Target Actual Variance % RAG Plan – year to date surplus (£m) (£1.3m) (£1.3m) 0% Plan - full year forecast surplus (£m) (£3.10m) (£3.10m) 0% QIPP – year to date (£m) £3.2m £3.2m 0% QIPP - full year forecast (£m) £9.37m £9.37m 0%

Programme and Projects

• Overall, the majority of projects that have been signed off by the CCG are on track to deliver the expected outcomes (62, 7 projects are RAG rated amber as having risks relating to delivery of planned outcomes).

• There is a specific risk within the Urgent Care Programme; the programme lead has changed roles. The Commissioning team are reviewing work programmes. This will mean that there will be no ‘Urgent Care’ programme any longer; the schemes within the old programme are being shared amongst other programmes and senior commissioners, this poses a risk to delivery of the associated projects.

• The 7 schemes at risk of delivering outcomes are within all four objectives; 3 within Objective 1, 2 in Objective 2 and 1 each in Objectives 3 and 4. There are actions underway for each project to mitigate these risks; these are articulated within the body of the report.

• A number of projects (18) are under development as part of the agreed planning process.

Expected Delivery of all Projects

Performance

• The CCG underperformed YTD against two cancer targets (2 weeks breast, and 62 days First Definitive Treatment)

• South Central Ambulance Services (SCAS) have failed to achieve all three national standards in July; this is the fourth consecutive month that the Trust has not achieved the national standards.

• A&E 4 hours – Overall, PHT achieved the agreed improvement trajectory for April, May and June but has missed the target set for July and August. To achieve September’s improvement trajectory of 85%, the Trust needs to maintain an average daily breach tolerance of 55. As at 09/09/2016, PHT are averaging 64 breaches per day. The risk of not achieving September’s target is very high.

• Improvement and Assessment Framework (IAF) – NHS England has published its baseline assessment of six clinical priority areas relating to the CCGs IAF. Each area is assessed on a four point scale ranging from top performing, performing well, needs improvement and greatest need for improvement. This is the first assessment and the CCG has concerns about some of the data quality informing the assessment. However, this assessment shows that the CCG achieved one “Top performing”, four areas “Need improvement” and one area “Greatest need for improvement”. Details of the assessment can be seen in Annex 7.

Year to Date Delivery of all KPIs

2 7 19

4

Quality

• Portsmouth Hospital Trust: o Subject to Care Quality Commission (CQC) enforcement action following unannounced

inspection. o Contract Performance Notice (CPN) issued to the Trust on 15/06/16 for quality and safety in the

emergency department. • Partnering Health Ltd (formally Portsmouth Health Ltd): GP Out of Hours (OOH)

o Concerns remain about the service’s ability to effectively manage patient risk in relation to service delays

GBAF Risks

Risk matrix of all GBAF risks

The top risk for the CCG is a risk to patient safety and experience due to increased pressure on the urgent care system. A number of key controls are in place to mitigate these risks including:

• A contract performance notice (CPN) issued 15 June 2016 and associated requirement for remedial action plan in place

• An NHS England risk summit process in progress since December 2015, the last meeting was held on 20th June 2016.

• Unscheduled Care Improvement Plan under review to include actions identified by CQC and actions for CPN

• Monitoring of the delivery of actions required following the CQC enforcement notice

Finance Summary CCG Finance

Finance Key Issues As at M5 reporting the CCG remains on track to meet its 2016/17 target surplus of £3.1m with a YTD surplus of £1.3m. Activity across the acute sector has flattened in month leading to a reduction in the financial yearend forecast. The CCG continues to lobby nationally for the release of funding to cover the announced 16/17 increase in fees relating to Funded Nursing Care. The closing cash position for M5 has achieved the national target of less than 1.25%. The CCG is continuing to work with its partners to clear the debtors over 90 days old

5

Summary Finance Performance

6

Strategic Objectives

Priority 1 We want everyone to be able to access the right health services, in the right place, as and when they need them.

Delivery of Strategic Priority 1

0 3 34Projects

0 5 2KPIs (YTD)

5 0 0GBAF Risks

Project Delivery

Project Priority Headline Commentary Progress

• Of the 37 projects assigned to this priority, 23 are on track with 11 projects having been completed. • Hampshire Fire and Rescue, Wessex Strategic Clinical Pathways and Developing Pathways within

Health Visiting Teams are new Hampshire wide schemes, these were agreed at the August meeting of CSC.

• Completed projects fall within the Primary Care and Planned Care & Long Term Conditions programmes.

Challenges

• In addition to the count of 37 projects assigned to this priority, there are 6 projects under development (within the Integrated Commissioning Unit, Planned Care & LTC and Primary Care programmes).

o Action: Planning team working with project leads to move schemes through required governance.

• Risk that commissioners and providers have a difference in opinion for Ambulatory Care services is still live.

o Action: Pathways under review for formal ‘relaunch’ to ensure they are followed. • Model for Urgent Care Centre (UCC)/Prime Hub not yet determined.

o Action: Meetings taking place between senior representation from CCGs and the providers, including clinical leads.

• Combined GI Service is at risk due to lack of engagement from the provider. o Action: Meeting arrangement between the CCG and the provider for September to expedite

the workstream.

Performance

In Year KPIs Indicating Delivery Direction Status (YTD) Period

A&E Waits (NHS Portsmouth CCG) July 16

Calls answered within 60 seconds (NHS 111) July 16

(Red 19) Ambulance Response (SCAS) July 16

(Red 1) 8 Minute Ambulance Response (SCAS) July 16

(Red 2) 8 Minute Ambulance Response (SCAS) July 16

Diagnostic Test Waiting Times (NHS Portsmouth CCG) July 16

RTT: Incomplete (NHS Portsmouth CCG) July 16

Performance Priority Headline Commentary Challenges

• A&E – Achievement of the A&E Standard remains under pressure. As forecast in the previous month’s report, the Trust achieved 80.25% for July against an improvement trajectory of 85%. PHT are also set to fail the improvement trajectory of 85% for August. The outlook remains challenging and there remains a high risk that the improvement trajectory of 85% will not be achieved September. The Trust needs to maintain an average daily number of 55 breaches and are currently averaging 64 breaches

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per day as at 09/09/2016. o Action: Continued implementation of the improvement plan, a revised A&E Escalation Policy

revised and approved by the Operational Group for A&E Delivery (formally System Resilience Group)

• RTT - PHT have reported one breach of the 52 week standard in Gastroenterology. Patient was identified through validation process and has now subsequently been seen and placed onto active monitoring. PHT believes that no harm has been suffered by the patient as a result of this delay. A full investigation is being conducted to determine the cause of the breach to mitigate further breaches.

• RTT - The CCG did not achieve the RTT standard in July, recording 91.1% against the 92% standard. This is the second consecutive month that standard has not been met. The CCG’s position was mainly driven by performance at PHT who missed the standard at trust level, recording 91.2% in July. The specialties contributing to PHT’s underperformance include General Surgery, Oral Surgery, Gastroenterology, Urology and Ophthalmology.

• 999 Ambulance Response - SCAS have failed the Red1, Red 2 and Red 19 National Standards for July; 68.4% for Red1 (target 75%) 70.8% for Red 2 (target 75%) 93.0% for Red 19 (target 95%)

o Action: Commissioners have not accepted the Recovery Action Plan (RAP) submitted by SCAS on the 25/08/2016 as it does not deliver the Red 1 standards until February 2017. A meeting has scheduled in to agree a revised RAP prior to the next CRM scheduled for the 5th October.

Primary Care Metrics The following metrics are intended to provide an indication of the relevant issues within primary care.

Indicator Current Period Current Target Current Value Status NHS England

Influenza Uptake (65+) September -

January 2016

75% 73% 71.8%*

Influenza Uptake (At Risk Groups)

September - January

2016 53% 45.7% 46.4%*

Prescribing costs/ASTRO-PU

March 2016 (12 months) N/A £43,669 £42,024

Antibacterial Items per STAR PU

March 2016 (12 months) 1.184 1.111 1.072

Antibacterial Items Prescribed as 3C

March 2016 (12 months) 11.3% 9.3% 9.7%

GP Friends & Family Test April 2016 N/A 80% 88%

Prescribing EPS Items March 2016 60% 44.1% 38.0%

Repeat Dispensing Items April 2016 N/A 16.7% 8.5%

Dementia Diagnosis Rate April 2016 72.3% 70.6% N/A

Avoidable Emergency Admissions

January 2015

(forecast <1458 714 N/A

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Governing Board Assurance Framework Risks

Risk Matrix Ref Risk Description Score

PHT.05

There is a risk to patient safety and experience due to increased pressure on the urgent care system. This has an impact on the timeliness of assessment and management of patients requiring emergency department intervention. There is overcrowding in the department, queuing and 12 hour trolley breaches. There are a high number of red and black alerts and ambulance diverts which impacts on other system partners. This demonstrates a continued deteriorating position which is reflected in the quality severity rating of 25 (highest risk) and escalation to Risk Summit and the CQC intention to take enforcement action under Section 31 of the Health and Social Care Act (2013).

25

Fin.P.19

IF the QIPP/Savings and pace of change are not identified and then delivered, THEN this will impact on the ability of the CCG to deliver its planned position.

20

Perf1

Main concerns are for the following areas: • A&E - failure to achieve the Sustainability and

Transformation Fund Improvement Trajectory. • RTT - failure to achieve the incomplete standard at

aggregate and specialty level, and achievement of the Sustainability and Transformation Fund Improvement Trajectory.

• Cancer - failure to achieve all 9 standards, and achievement of the Sustainability and Transformation Fund Improvement Trajectory.

• Ambulance response - failure to achieve the Red 1, Red 2 and Red 19 standards, and achievement of the Sustainability and Transformation Fund Improvement Trajectory.

20

Fin.P.01

IF cuts in Public Health and Adult Social Care Funding are made, THEN there would be an impact on service delivery and outcomes for patients, together with potential financial consequences for the CCG

16

Fin.P.29

IF health partners within the system are under extreme financial pressures, THEN there might be an impact on the CCG within the overall context of system sustainability.

16

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Priority 2 We want to ensure that when people receive health services they are treated with compassion, respect and dignity and that health services are safe, effective and excellent quality.


0 2 9Projects

2 0 0GBAF Risks

Project Delivery Project Priority Headline Commentary Progress

• Of the 11 projects assigned to this priority, 9 are on track. • Work is progressing well with the Continuing Healthcare programme, the majority of the schemes are

moving forward as planned. • The RightCare development plan was approved at the August meeting of Clinical Strategy Committee. Work

is ongoing to review and analyse the focus packs to identify local opportunities to inform project plans. Challenges

• In addition to the count of 11 projects assigned to this priority, there are 4 projects under development (within the Integrated Commissioning Unit and Quality programmes).

o Action: Planning team working with project leads to move schemes through required governance. • Patient Transport Services (PTS) – Renal project is amber, gaining traction with joint comms work with

West Hampshire CCG remains challenging. o Action: Work is progressing with the local Comms lead meeting with the Kidney Dialysis Association

in July to discuss use of transport. The Association agreed to include a questionnaire in the next publication of their magazine to support the engagement process.

• Pharmacy Repeat Urgent Medicine this project is now amber due to the delay in NHS England with IT procurement. Due to this delay the service will not go live in August as planned.

o Action: Work is continuing in liaison with partners to work towards a go live date of 1st October. Performance In Year KPIs Indicating Delivery Direction Status (YTD) Period

Incidents of C.diff (NHS Portsmouth CCG) July16

Friends & Family Test Combined Response Rate (Portsmouth Hospitals NHS Trust)

June16

Mixed Sex Accommodation breaches (NHS Portsmouth CCG) July16

Incidents of MRSA (NHS Portsmouth CCG) July16

Never Events (Portsmouth Hospitals NHS Trust) June16

Venous Thromboembolism (VTE) Risk Assessment (Portsmouth Hospitals NHS Trust)

June 16

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• HCAI - There were four C.diff cases reported in July against a threshold of four taking the year-to-date to 11 reported cases against a threshold of 16.

o Action: The CCG is working collaboratively to ensure sharing of information on themes and trends and lessons learnt as well as using expertise to proactively guide strategies to mitigate the number of infections.

• Never Event – One reported case in June involving an incorrect use of device for insulin administration. o PHT has reported that the incident has been thoroughly investigated and there was no harm to the

patient and lessons learnt from the investigation have been implemented. Governing Board Assurance Framework Risks


R.Ports.QUA.11

PHL: HDOCS: failure to meet assessment and home visit timeframe targets Failure to meet assessment and home visit timeframe targets has resulted in poorly timed care and negative patient experience. IF this continues or deteriorates further THEN more harm may occur to patients.

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R.Ports.QUA.05

Solent NHS Trust: potential impact on the ability to provide patient care by the Portsmouth Community Nursing team Solent has recently experienced a high number of registered nursing vacancies within the community nursing team and has undergone a significant recruitment process. This is ongoing and there remains (to date) 11.0 WTE vacancy rate across the area. IF these posts are not recruited to effectively and efficiently, with the additional impact of a high number of new staff in post, THEN the quality of patient care delivered maybe compromised with the potential for care to be prioritised reactively as opposed to proactively.

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Priority 3 We want health and social care services joined up so that people only have to tell their story once. People should not have unnecessary assessments of their needs, or go to hospital when they can be safely cared for at home or stay in hospital longer than they need to.


0 1 13Projects


• Of the 14 projects assigned to this priority, 1 project is currently off track, a further 11 on track and 2 projects have now been completed.

• The organisation’s Better Care Fund plan has been recommended for full approval, the CCG has received formal notification to this effect.

• The Acute Visiting Service continues to perform well, review recommendations will be implemented from September.

• Funding for Safe Space for the remainder of 16/17 was approved at the August Clinical Strategy Committee. • The completed projects are within the Primary Care and Better Care Fund programmes.

Challenges

• In addition to the count of 14 projects assigned to this priority, there are 3 projects under development (within the Primary Care programme) and the Health and Care Portsmouth Transformation Programme (Blueprint).

o Action: Planning team working with project leads to move schemes through required governance. • Although funding for 16/17 for Safe Space was agreed, the recurrent funding request was denied.

o Project lead to work with Portsmouth University and Hampshire Constabulary in regards to securing match funding for 17/18 and beyond.

Performance Performance Priority Headline Commentary KPI Commentary Recently released data reveals that the 2014/15 annual position for Reducing avoidable emergency admissions has been achieved. The BCF programme of work is continuing into 2016/17, projects have been planned to run beyond just 2015/16. Governing Board Assurance Framework Risks


GB04

IF providers do not achieve required cultural changes and service reform THEN the implementation of the Portsmouth Blueprint may be compromised.

12

Fin.P.02

IF there is lack of coherent IT solutions to support the integrated care agenda, THEN there could be an impact on the pace of change.

9

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Priority 4 With our partners, we will tackle the biggest causes of ill health and early death and promote wellbeing and positive mental health.


0 1 6Projects

1 2 12KPIs (YTD)

0 0 0GBAF Risks


• Of the 7 projects assigned to this priority, 6 are on track. • The specification for a Young People’s Emotional Health and Wellbeing service, as part of Future in Mind,

has been completed. The service is now out to tender. • Evaluation of tenders for ADHD services continues as planned.

Challenges

• In addition to the count of 7 projects assigned to this priority, there are 4 projects under development (within the Integrated Commissioning Unit programme).

o Action: Planning team working with project leads to move schemes through required governance. • The CAT Pilot project is currently RAG rated as amber as early indicators suggest the original planned

savings values are not being realised due to confusion amongst prescribers in regards to mattress availability and costing.

o Action: meetings are being arranged between the CAT Authoriser and team manager on how to progress.

Performance In Year KPIs Indicating Delivery Direction Status (YTD) Period

Cancer Patients - 2 Week Waits (NHS Portsmouth CCG) July 16

Cancer Patients - 2 Week Waits (Breast Symptoms) (NHS Portsmouth CCG)

July 16

Cancer Waits - 31 Days (All Cancers) (NHS Portsmouth CCG) July 16

Cancer Waits - 31 Days (Drugs) (NHS Portsmouth CCG) July 16

Cancer Waits - 31 Days (Radiotherapy) (NHS Portsmouth CCG) July 16

Cancer Waits - 31 Days (Surgery) (NHS Portsmouth CCG) July 16

Cancer Waits - 62 Days (Decision to Upgrade) (NHS Portsmouth CCG) July 16

Cancer Waits - 62 Days (GP Referral) (NHS Portsmouth CCG) July 16

Cancer Waits - 62 Days (Screening Service) (NHS Portsmouth CCG) July 16

CPA 7 Day Follow Up (NHS Portsmouth CCG) July 16

Dementia Diagnosis Rate (NHS Portsmouth CCG) June 16

Hospital Standardised Mortality Ratio (Portsmouth Hospitals NHS Trust) June 16

IAPT: People Moving to Recovery (NHS Portsmouth CCG) April 16

IAPT: People Entering Treatment (NHS Portsmouth CCG) April 16

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In Year KPIs Indicating Delivery Direction Status (YTD) Period

IAPT: Referral to Treatment within 6 weeks (NHS Portsmouth CCG) April 16

IAPT: Referral to Treatment within 18 weeks (NHS Portsmouth CCG) April 16


• Cancer - The CCG achieved seven of the nine cancer standards (YTD) in July, failing 2 weeks Breast symptoms and 62 days First Diagnosis to Treatment'. CCG’s underperformance was mainly driven by PHT who achieved seven out of the nine standards in July, failing 62 day first definitive treatment (FDT) and 62 Day Consultant Upgrade. Failure of 62 Day FDT target at PHT was mainly due to underperformance in the following tumour sites, Gynaecology, Haematology, Head & Neck, Lower Gastrointestinal, Respiratory and Urology. Breast Symptoms target was achieved by provider in July although failure to achieve standard in Q1 2016/17 has had an adverse impact of the CCG’s YTD position.

o Action: Delivery of PHT’s improvement plan in place and monitored at Cancer Steering Group. o Working to address the underlying clinical capacity shortfall in Urology with additional lists, patient by

patient management and pathway reviews. o Weekly review of patients 14 days to breach on an individual basis to ensure treatment plan in place

and delays mitigated where possible. • Hospital Standardised Mortality Ratio (HSMR) - There was a reported increase in Hospital Standardised

Mortality Ratio (HSMR) at PHT in June. The rate increased from 100.06 in April to 108.11 in June. However this remains within the tolerance. The factors contributing to the increase are being investigated by the Clinical Effectiveness and Mortality Steering Group (CEMSG).

Governing Board Assurance Framework Risks No GBAF risks have been identified for priority 4.

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Annex 1 Quality Report (Provider) PARTNERING HEALTH LTD (formally Portsmouth Health Ltd): GP OOHs Current CQC Rating: Good (Feb 16)

Is the provider subject to current contractual action? Yes • A performance rectification action plan (RAP) was

requested by commissioners and has been in place since September 2014

• A quality rectification action plan (RAP) was requested by commissioners and has been in place since November 2014

Plans have had various incarnations & were combined in Jan 16.

Activity & Performance 11,905 cases were received system-wide for the month of June. Demand was 91% against the baseline contracted activity levels (last year’s actual) and 75.7% against HDOCS forecasted demand. The service staffed 90.8% of its planned hours. Agency use was 8.1% of the overall clinical resource. Portsmouth compact area (PSEH) PSEH performed better than system wide in 6 out of 8 active KPIs and showed improvement in 7 out of 8. However, activity this month was lower than contracted and significantly lower than HDOCS forecasted. The same 4 indicators (assessment and routine home visits) remain non-compliant. Urgent assessments (HCP calls) have moved into compliance now that the target has changed from 15 minutes to 30 minutes.

Key Risk: Failure to meet assessment and home visit timeframe targets has resulted in poorly timed care and negative patient experience.

Current & planned actions to mitigate risk: • Weekly checkpoint commissioner conference calls to continue • Quality Leads & PHL’s Director of Operations & Lead Nurse to meet at the end of August for a

learning review of complaints • Quality leads to attend PHL’s internal monthly governance meeting • Ongoing monthly discussions between the 5 CCGs about future commissioning intentions PSEH commissioners have agreed to a request from PHL to fix income for 16/17 with the following requirements; 1. PHL to deliver their obligations as detailed in the Quality Schedule and confirm acceptance that any

variance to the quality schedule agreed by quality managers will be time limited to support improved focus on key areas of quality assurance or risk.

2. PHL to provide a clear plan and trajectory to support, embed and sustain recent improvement in reporting on both operational and quality requirements.

3. PHL to provide clear proposals including an implementation plan to deliver additional support capacity across the quality assurance activities currently expected of their Lead Nurse.

4. PHL to deliver robust assurance against outstanding quality and risk concerns; accompanied by an action plan and timely trajectory, particularly in relation to clinical co-ordination and management of definitive clinical assessment (DCA). Whilst all parties expect and will support this being delivered within the framework of the pilot for an integrated urgent care call centre (IUCCC), PHL are required to confirm they understand this will remain an expectation of quality managers independent of the progress of the IUCCC pilot.

CCG Assurance Statement: Concerns remain about the service’s ability to effectively manage patient risk in relation to service delays. Increased involvement with service operations from the CCGs’ quality leads and PHL’s current willingness to engage are encouraging. The service is now delivering monthly incident reports and where long waits have taken place exception reports. From August Quality Leads will meet with PHL lead staff monthly to work together on deep dives in key areas of concern. With these sessions in place, there is potential for this risk to be reduced but it recommended that the risk score remain high until PHL can begin to evidence learning and improvement.

Risk History (rolling 12 months)

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PORTSMOUTH HOSPITAL TRUST Current CQC Rating: Requires Improvement for MAU and Inadequate for ED: Overall Requires Improvement (Jun 16).

Is the provider subject to current contractual action? 1. CPN issued to the Trust on 15/6/16 for

quality and safety in ED Review date August 2016 in CQRM

Other risks and concerns closely monitored: 1. Responsible Clinician arrangements; risk score 16 2. Low staffing; risk score 12 3. Compliance of spinal services with national standards; risk score 12 4. Safety on discharge 5. Variation in cancer standards affecting quality of care & patient outcomes 6. Compliance with national stroke standards

Key Risk: Timeliness of assessment and management of patients in the emergency impacting patient safety and experience. This risk affects the delivery of the NHS Constitution Target of 95% 4 hour wait Risk Score 25 since Nov 15 Current & planned actions to mitigate risk: Actions the Trust is taking: • Revised ED escalation policy has been implemented resulting in decreased ambulance handover delays. • Urgent care improvement plan is delivering improvements in reducing queues, outliers and closing escalation areas • CQC Enforcement Action and weekly CQC metrics provided. • Detailed turnaround plan developed with 8 work streams – feeding into System Resilience Group (SRG)structures • Full capacity policy reviewed and ED escalation policy • Short stay pathway operational • New medical take model operational • Frailty Intervention Team in ED • New front door minor process will go live by 3rd week of August. Workforce • Rolling advert for the recruitment of 5 ED nurses and medical workforce • Medical workforce – rota flexibility used to fill gaps on night shifts with twilight SHOs being moved onto night shifts, locums sought, internal locums used and recently

consultants now filling SHO shifts. • Streaming of patients to AMU ambulatory clinic (8am – 6pm -suitable patients rage from 7 – 14 per day). However rota gaps on AMU impacts on capacity within

Ambulatory clinic daily. • Business case to be written to support extra nurses in AMU and ED • Key risks on appraisals, staffing and MHT access on divisional risk register. Actions the CCG is taking • Engagement with the risk summit and monitoring of delivery. 4 x meetings undertaken and the next risk summit review is 27th September 2016. • Weekly monitoring of CQC quality metrics – fed into SRG • Daily exception reporting to the CQC for patient safety issues • SRG and CCG support to community partners for a wide range of out of hospital capacity releasing initiatives e.g. Frailty Intervention Team (FIT) • Further assurance sought on actions to mitigate medical workforce gaps in ED – this will be fed into SRG quality report CCG Assurance Statement: The June performance data shows there is improved performance against national targets. The quality analysis data indicates a positive achievement with Friends & Family Test positive ratings and response rates. There are similar levels of complaints being reported (emergency services division) with a proportion graded as “moderate” and patient safety incidents graded moderate. There are significant workforce challenges within the emergency service CSC, including both

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nursing and medical, with mitigation actions with partial effectivity and evidence of impact on patient assessment, management, experience and negative impact on operational management. The impact of the workforce is also evident from sickness rates and inability to undertake appraisals. In addition the CSC risk register highlights a risk of access to mental health teams; however, further clarification on this issue is required. The quality issues, as part of the contract performance notice will be reviewed at the August CQRM. Further consideration of the workforce challenges will be presented in the System Resilience Group on 11th August. There are signs that all initiatives are yielding the desired improvements and the focus is now on sustainability. Further quality analysis will be required on the level of moderate complaints, patient safety incidents and workforce challenges being reported.

SOLENT NHS TRUST Current CQC Rating: Good (Jun 14). Awaiting outcome of June 16 inspection

Is the provider subject to current contractual action? 1. Contract Performance Notice issued Aug 15 for Podiatric

Surgery due to long waits. Solent has subsequently given the CCG 12 mths notice.

Key Concerns: 1. Staffing & capacity in PRRT to support PHT discharge and step up; CCG & Solent have agreed metrics

for enhanced weekly monitoring wef 1/6/16 – no obvious concerns being highlighted 2. Podiatric Surgery backlog. In July there was an unexpected increase in the waiting list. This was due to

administrative data quality issues at the point of referral assessment. A thorough check has been made and Solent is confident no further patients will be added to the list. Contract with Spire now signed and trajectory to treat all patients by 31/3/17 should be met

Key Risk: If Solent make the decision to close the 136 suite there will be a detrimental impact on care pathways for individuals and wider system issues affecting other health, LA organisations and the Police NEW RISK: Score 12 opened 8/8/16 Solent sub-contract the management of the 136 suite to Medisec and are having difficulty gaining assurance about particular aspects of service delivery. This was picked up by CQC at their recent inspection. In addition Medisec are struggling to respond in a timely way to Police requests for the 136 suite to be used due to capacity issues. This has resulted in a number of recent incidents which is causing Solent to question whether the suite can remain open with the current operational arrangements due to risk and safety issues. Current & planned actions to mitigate risk: CCG 1. Hampshire Constabulary risk summit on 15/8 will be attended by all partners 2. Ongoing discussions with Solent about alternative short term solutions Solent 1. Solent has reinforced with the Police that they must comply with the current procedures for access to the suite 2. Solent is continuing with contractual enforcement with Medisec

CCG Assurance Statement: This is a new risk and there are a number of actions in train between Solent and the CCG. The risk will be reviewed on a monthly basis SCAS: 999 Current CQC Rating: Jan 15 – no ratings given as part of first wave ambulance service inspections. Awaiting outcome of Inspection May 16

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Is the provider subject to current contractual action? Yes

Key Concerns: 999 Workforce; Commissioners were concerned to that overall performance against plan is 10FTE down and is likely to rise to 15 FTE down by the end of M3. Vacancies against rota establishment are now at 339FTE (19%) and CQRM looks forward to receiving a copy of the SCAS Workforce strategy. The impact of the shortages in recruitment, largely caused by the significant drop in International Paramedics, has been reduced by improvements in staff retention with attrition below plan and last year.

Key Risk: 999 Long waits impacting patient outcomes. Risk Score 20 for last 12 months +

Current & planned actions to mitigate risk: 1. Call prioritisation. 2. Upgrading of calls and welfare checks. Green long waits are reviewed by the Clinical Service Desk (CSD) and welfare checks are carried out. The CSD have the ability

to upgrade a green to a red should the patient’s condition change. Green long waits are routinely welfare checked however when there is a surge in demand this impacts the CSD’s ability to take calls.

3. Community first responders and co-responders, with 1,600 green calls responded to by this group. 4. Planning assumptions made on monthly, weekly and daily basis. 5. Introduction of health care professional (HCP) tier. 6. SCAS have implemented a green frailty vehicle that is protected for this cohort of patients and general feedback from crews is positive. The service is in its early infancy

but is a non-commissioned. 7. The National Ambulance Response Programme (NARP) was introduced in Oct 15 as a pilot. The NARP is a fundamental review of the way ambulance services respond

to patients; time to respond (performance) and categorisation (clinical coding) which determines associated response standards. SCAS are now using 240 seconds to process Red 2 calls. Verbal feedback that this is having a positive impact and supporting clinical decision making on the allocation of the right crews and resources.

8. Monthly CCG analysis of position on long waits, including root causes. 9. SCAS have reviewed the long waits group to expand the terms of reference to include deep dives into the longest waits (addressing the tail end). 10. SCAS review all red incidents resulting in a delay and the daily operational meetings. 11. Investment into resources and development of the CSD to maximise accuracy in call disposition 12. SCAS have conducted end to end review on a cohort of long waits, for example stroke conditions. 13. Work undertaken in call audits to review speed of identifying key words to support correct disposition. 14. HCP process has been rolled out. A review of the changes will be carried out including GP leads. 15. A clinical governance lead has been appointed for 999 services in the North, enabling the South Cluster designated time from the existing lead. 16. Reassurance given at CQRM that there is a positive reporting culture. 17. SCAS engagement in the urgent care board to work with system partners. 18. Improvement in hear and treat performance is maintained & above plan. SCAS will monitor rates of re-contact and if deemed necessary will undertake quality analysis. 19. EOC focus on using clinical triage teams to minimise unnecessary dispatch of ambulance resources. 20. Non-conveyance rate, complaints, hospital handover etc. are reviewed at CQRM. CCG Assurance Statement: Commissioners were expecting to receive the RAP from SCAS by the 31st July in line with the SDIP that was agreed as part of the new 2016/7 contract. SCAS advised that it would be available within 2-3 weeks. It was stated the RAP would be influenced by the Lightfoot Review which was now nearly complete. Commissioners note that demand for June has reduced but is still above plan and last year. Hospital handover delays have decreased and it is positive to note that performance for Red1, Red2 and Red19 all improved, although they all continue to remain below national targets. A reduction in performance is, replicated nationally.

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Annex 2: NHS Constitution – Rights and Pledges

Indicator July 2016 Q2 2016/17 2016/17

Monthly Trend Target Value Status Short

Trend Value Status Value Status

RTT: Incomplete Pathways <18 Weeks 92% 91.14% 91.14% 91.14%

Patients waiting >52 Weeks 0 1 1 2

Diagnostic Test Waiting Times 99% 99.5% 99.5% 99.5%

A&E 4 Hour Waits 85% 80.25% 81.02% 80.14%

Cancer: 2 Week Waits 93% 96.62% 96.62% 95.92%

Cancer: 2 Week Waits (Breast Symptoms) 93% 93.67% 93.67% 90.44%

Cancer: 31 Days (All Treatment) 96% 100% 100% 98.07%

Cancer: 31 Days (Surgery) 94% 100% 100% 94.59%

Cancer: 31 Days (Drug Therapy) 98% 100% 100% 100%

Cancer: 31 Days (Radiotherapy) 94% 97.96% 97.96% 99.36%

Cancer: 62 Days (GP Referral) 85% 84.21% 84.21% 79.05%

Cancer: 62 Days (Screening Referral) 90% 100% 100% 95.95%

Cancer: 62 Days (Consultant Upgrade) 86% No Activity No Activity No Activity

Red 1 Ambulance Response (SCAS) 75% 68.42% 68.42% 72.69%



Mixed Sex Accommodation (YTD) 0 0 0 0

Legend: Green = > target Amber = < 5% target Red = > 5% away from target

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Annex 3: Friends and Family Test Percentage Recommended – June 2016

A&E Inpatient Maternity - Antenatal Care Maternity - Birth Maternity - Postnatal

Ward Maternity - Postnatal

Community Value Value Value Value Value Value

NHS England Average 86% 96% 95% 97% 94% 98% Frimley Health 92% 97% 99% 98% 92% 100%

Hampshire Hospitals 82% 82% No Activity 98% 96% No Activity Portsmouth Hospitals 95% 96% 100% 98% 99% 97% Royal Surrey County

Hospital 82% 95% 95% 100% 97% 90%

University Hospital Southampton 95% 96% 97% 96% 94% 93%

Western Sussex Hospitals 91% 77% 93% 96% 96% No Activity

Mental Health Community

Value Value Solent NHS Trust 93% 97%

Southern Health NHS Foundation Trust 80% 96% NHS England 87% 95%

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Annex 4 – 2016/17 Quality Premium - July Estimate

Measure Status

% of Quality

Premium Estimated Financial

Value for CCG National Measures

Cancers diagnosed at early stage 20% £223,082

Increase in the proportion of GP referrals made by e-referrals 20% £0

Overall experience of making a GP appointment 20% £223,082

Antimicrobial resistance (AMR) Improving antibiotic prescribing in primary care 10% £111,541

Local Measure

Respiratory -Reported prevalence of COPD on GP registers as % of estimated prevalence 10% £111,541

Maternity - Rate of emergency admissions for respiratory tract infections in infants aged <one 10% £111,541

Mental Health - The number of people on Care Programme Approach 10% £111,541

Sub-Total £892,328

NHS Constitution Reduction (Provider level) Status % of

Quality Premium

Financial Value for CCG

RTT Incomplete - PHT level 25% £0

A&E 4 hours waits - PHT level 25% £0

Cancer – 62 day from urgent GP referral to first definitive treatment 25% £0

Category A Red 1 Ambulance Response - SCAS level 25% £0

Total £0

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Annex 5 – Detailed Finance Performance

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Annex 6 – Financial Risk Rating

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Annex 7: IAF - Baseline assessment of six clinical priority areas

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Annex 8 - Glossary

Glossary of Terms Abbreviation Translation A&E Accident and Emergency Department (Emergency Department) ADHD Attention Deficit Hyperactivity Disorder AMU Acute Medical Unit BCF Better Care Fund CCG Clinical Commissioning Group CPA Care Programme Approach CPN Contract Performance Notice CQC Care Quality Commission CQRM Contract Quality Review Meeting CSD Clinical Service Desk ED Emergency Department (Accident and Emergency Department) EPS Electronic Prescribing Service GBAF Governing Board Assurance Framework HDOCS Hampshire Doctors on Call Service HSMR Hospital Standardised Mortality Ratio IAF Improvement and Assessment Framework IAPT Increase Access Phycology Therapy IPR Integrated Performance Report IUCCC Integrated Urgent Care Call Centre KPI Key Performance Indicator LTC Long Term Condition NARP National Ambulance Response Programme NHS National Health Service OOH Out of Hours PHL Portsmouth Health Limited PHT Portsmouth Hospitals NHS Trust PRRT Portsmouth Rehab and Re-enablement Team PSEH Portsmouth and South Eastern Hampshire PTS Patient Transport Services QIPP Quality, Innovation, Productivity and Prevention RAG Red, Amber, Green RAP Remedial Action Plan RTT Referral To Treatment SCAS South Coast Ambulance Services SHO Senior House Officers SRG System Resilience Group UCC Urgent Care Centre VTE Venous Thromboembolism WTE Whole Time Equivalent YTD Year To Date

governing board board papers… · summary finance performance..... 5. strategic objectives..... 6....

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