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Paper 13

Ayrshire and Arran NHS Board Monday 29 August 2016

Planned Care Performance Report Author: Fraser Doris, Performance Information Analyst

Sponsoring Director: Liz Moore, Director for Acute Services

Date: 9 August 2016

Recommendation The Board is asked to:

review performance against the national waiting times and access targets at the end of June 2016; and

approve the proposed actions for the sustainable delivery of the patient access goals.

Summary This paper reports on progress towards achieving waiting time and other access targets set by the Scottish Government as well as progress on local targets set by the Board. Latest available information is reported for the following targets and measures:

Treatment Time Guarantee

18 Weeks Referral to Treatment

Stage of Treatment Targets

Unavailability of patients

Cancer waiting times

Patients awaiting discharge

Mental Health Services

AHP MSK waiting times targets A summary scorecard is at Appendix 1. Key Messages:

At the end of June 2016 there were 334 patients who had waited over 84 days for treatment, 2 more than the trajectory agreed with Scottish Government.

18 week Referral to Treatment performance did not meet target in June 2016 with performance of 74.7%.

6175 outpatients had waited in excess of the 12 week Stage of Treatment standard at the end of June 2016, lower than the trajectory of 6591 agreed with Scottish Government.

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223 Endoscopy patients had waited in excess of 6 weeks for diagnostic tests at the end of June 2016, lower than the trajectory of 370 agreed with Scottish Government.

476 Endoscopy patients had waited in excess of 6 weeks for diagnostic tests at the end of June 2016, lower than the trajectory of 230 agreed with Scottish Government.

The 31 day Cancer target was achieved in May 2016, with performance of 100%.

The 62 day Cancer target was not achieved in May 2016, with performance of 90.3%.

There were 39 delayed discharges of more than 14 days in June 2016, all of which were in South Ayrshire.

The majority of the performance information within this report relates to performance in June 2016. A verbal update will be given at the NHS Board meeting of any subsequent updates.

Glossary of Terms A&E AHP AHP MSK CAMHS ENT GPSI ICES IP/DC ISD LDP MRI MSK QuEST RTT SGHSCD TTG UH

Accident and Emergency Allied Health Professional Allied Health Professional Musculoskeletal Child and Adolescent Mental Health Services Ear, Nose and Throat General Practitioner with Special Interest Integrated Care and Emergency Services Inpatient and Day Case Information Services Division Local Delivery Plan Magnetic Resonance Imaging Musculoskeletal Quality and Efficiency Support Team Referral to Treatment Scottish Government Health and Social Care Directorates Treatment Time Guarantee University Hospital

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1. Treatment Time Guarantee Target: The TTG for patients added to the list from 1 October 2012 places a legal responsibility on NHS Boards to deliver treatment to all day case/inpatients within 12 weeks of the patient agreeing to treatment. Performance: At the end of June 2016 a total of 334 patients had waited over 84 days for treatment, the majority in Orthopaedics. This meant that the trajectory agreed with Scottish Government, 332 patients waiting less than 84 days at the end of June 2016, was narrowly missed. There were 201 patients whose wait exceeded 84 days in the month of June. The initial backlog was due to the cancellation of elective activity during the winter of 2014/15 with similar issues, though to a much lesser extent, last winter.

Mar 16

Apr 16

May 16

Jun 16

Patients who have waited more than 84 days for treatment at the end of the month

400 425 377 334

Percentage of patients at the month end who have waited less that 84 days for treatment

86.7% 85.9% 87.2% 88.9%

Patients who breached the TTG during the calendar month

263 235 237 201

Patients who were treated after their TTG during the calendar month

165 278 228 226

Monthly Audit of Waiting Times Recording

Target Mar 15 Apr 16 May 16 Jun 16

TTG audit performance 95% 99.1% 98.7% 99.1% 99.3%

Audit results are provided to service managers who develop improvement plans, which are reviewed and monitored by the Director of Acute Services.

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TTG breaches during the calendar month Month end TTG breaches (still waiting)

Patients treated in the month who exceeded their TTG

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2. 18 Weeks Referral to Treatment Targets: the target for 18 weeks RTT is to deliver 90% combined admitted/non admitted performance; to deliver 90% of patients with a total pathway which is linked; and to deliver 90% of completed forms at the end of each clinic outlining the outcome of the consultation. Performance:

Target Feb 16 Mar 16 Apr 16 May 16 Jun 16

18 wk RTT performance 90% 74.2% 75.0% 74.1% 75.8% 74.7%

Clinic Outcomes 90% 89.3% 88.7% 88.6% 88.8% 89.1%

18 week RTT performance remains below target, with performance linked to the issues with stage of treatment performance, including recruitment difficulties. The lowest performing specialties in June 2016 were Pain Service at 5.26%, Oral & Maxillofacial Surgery at 26.32% and Gastroenterology at 26.92%. 3. Stage of Treatment Targets Targets: In addition to the TTG and 18 weeks RTT, NHS Boards are also required to report on stage of treatment waits for inpatient and day cases (9 weeks), outpatients (12 weeks) and diagnostics (6 weeks). Performance:

Feb 16 Mar 16 Apr 16 May 16 Jun 16

Inpatient & day case patients exceeding 9 weeks

74.8% (763)

77.1% (690)

77.8% (667)

78.3% (640)

80.2% (556)

Outpatient patients exceeding 12 weeks

74.6% (5655)

76.6% (5257)

75.5% (5695)

74.6% (6140)

74.6% (6175)

Diagnostic patients exceeding 6 weeks

86.6% (771)

86.8% (757)

87.0% (687)

91.4% (479)

88.2% (699)

Performance is shown as a percentage of the patients seen within the target period, with the number of patients exceeding the standard in brackets.

70%

75%

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90%

95%

100%

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18 wk RTT performance Outcome recording

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Scottish Government’s approach to providing funding aligned to month end trajectories for the number of patients waiting longer than target is being extended to the end of September. Trajectories have been developed by service management teams and the trajectory of no more than 6591 outpatients waiting over 12 weeks at the end of June 2016 was achieved. Weekly progress reporting to Scottish Government is in place and the latest report is shown at Appendix 3.

Inpatients and day cases 556 inpatient & day case patients’ waits exceeded 9 weeks at the end of June 2016, a decrease of 84 from the previous month. Increased demand for emergency care during winter caused cancellations of elective procedures, particularly in Orthopaedics, and increased the number of elective patients waiting longer than 9 weeks for treatment. The main specialties which recorded breaches in June 2016 were:

Trauma & Orthopaedic Surgery with 378 patients

Oral & Maxillofacial Surgery with 49 patients

Vascular Surgery with 37 patients; and

General Surgery with 36 patients. In addition there were 29 Ophthalmology patients who waited in excess of 9 weeks but they are within the local 12 week waiting time for these procedures and Scottish Government is aware of this local issue. Outpatients 6175 outpatients’ waits exceeded 12 weeks at the end of June 2016, an increase of 35 patients from the previous month. Demand, particularly ‘urgent’ and ‘urgent, cancer is suspected’ referrals, is up for a number of specialties resulting in capacity shortfalls. Recruitment problems remain a major issue, with expensive short term arrangements in place while permanent recruitment continues. The number of patients waiting more than 16 weeks increased by three to 3877 in June 2016, with 84.0% of patients having waited less than 16 weeks. The specialties with high numbers of patients waiting over 12 weeks in June 2016 are listed below, with a brief overview of the issues affecting performance and improvement actions.

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Diag 6wks IP 9wks OP 12wks

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Oral & Maxillofacial Surgery (936 patients) There has been a consultant vacancy for over a year, to which there has been no success in recruiting. Two specialty doctors are now in post to undertake outpatient clinics to support the service. The consultant team has also been undertaking additional clinic sessions to supplement core capacity. Patient pathways are being reviewed. ENT (774 patients) Staff turnover over the last eighteen months has resulted in a succession of vacancies, with one consultant post currently vacant. All capacity is being utilised but the position remains challenging despite the consultant team undertaking additional sessions to supplement core capacity. There has also been an increase in Urgent and Urgent Suspect Cancer referrals which has had a knock-on impact on routine waiting times. General Surgery (723 patients) The high number of patients waiting beyond 12 weeks was generated as a result of consultant vacancies and unplanned leave. This was further exacerbated through increased Urgent Suspect Cancer referrals lengthening the wait for patients requiring routine appointments. The waiting list position has now stabilised but reducing the backlog of patients has been challenging. Consultants have moved around their programmed activities to assist and additional clinics have been organised with the expectation of sustained improvement. Ophthalmology (642 patients) With high numbers of patients referred to the service, the waiting list and waiting times increase rapidly whenever there are clinician vacancies and/or unplanned leave. Both have occurred over recent months, but recent successful optometrist recruitment and the ongoing use of additional clinics, where possible, will help maintain the current position. Clearing the backlog remains a challenge, with pressure on clinic space and nursing support an additional factor. Anaesthetics/Pain Service (583 patients) The high number of patients waiting beyond 12 weeks is as a result of the inability to recruit to a consultant vacancy for more than a year. A further consultant has resigned from the pain service in the past year. To bridge the capacity gap an associate specialist commenced in the service in May 2016 and a further consultant will provide two sessions each week from October 2016. However this will not cover the capacity gap entirely and further recruitment is required to provide more clinical sessions. Discussions regarding redesign of the service model are also ongoing to improve waiting times for patients. Endocrinology & Diabetes (546 patients) Two new consultants have been appointed, with the first due to commence at end of August, and additional sessions have been arranged to reduce patient waiting times. Improvement work is underway to standardise processes across the two hospitals. Respiratory Medicine (471 patients) The service is continuing to experience high demand for urgent and urgent cancer suspected appointments, impacting on routine appointment availability and waiting times. Additional consultant led community clinics are being held on a weekly basis. Medinet support has been confirmed for the next few months. Gastroenterology (402 patients) High numbers of urgent referrals continue to impact on routine clinic slot availability. Additional consultant posts have been advertised with an Ayrshire wide remit, but it is proving very challenging to recruit to these posts. A high number of additional clinics have been booked and the service is awaiting confirmation of Medinet support.

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Diagnostic tests Of the total of 223 patients waiting over 6 weeks for Endoscopy investigations at the end of June 2016, 130 were for Upper Gastrointestinal, 23 were for Lower Endoscopy and 70 were for Colonoscopies. This is below the trajectory of 370 agreed with Scottish Government. Work is ongoing to ensure all Endoscopy cancelled sessions are backfilled and capacity is being maximised at both sites. Additional sessions are being used wherever possible, including at weekends. Patient focussed booking continues for all nurse endoscopist lists. Of the 476 patients waiting over 6 weeks for Radiology Imaging investigations at the end of June 2016, 73 were for MRI, 104 were for CT and 299 were for Non Obstetric Ultrasound. This is above the trajectory of 230 agreed with Scottish Government. The increase in ultrasound is due to maternity leave, which the service has been unable to backfill, and unexpected leave. Agency ultrasonographers are being used to support the service but capacity is limited. Attempts to recruit to permanent posts continue. 4. Unavailability of Patients and Full Waiting List Size The number of patients waiting for Inpatient and Day Case treatments or Outpatient appointments is shown below.

Total waiting list size Feb 16 Mar 16 Apr 16 May 16 Jun 16

Inpatient and Day Cases 3029 3012 3007 2946 2805

Outpatients 22265 22417 23283 24194 24294

Unavailability of patients is monitored closely based on “reasonable offers” being made to patients for access to outpatient, inpatient and day case services. The overall position is detailed below, with the percentage against the total waiting list shown in brackets.

Patients unavailable Jan 16 Feb 16 Mar 16 Apr 16 May 16 Jun 16

Inpatient and Day Cases 423 (11.8%)

437 (12.6%)

474 (13.6%)

470 (15.6%)

499 (20.6%)

557 (19.9%)

Outpatients 172 (0.79%)

192 (0.85%)

188 (0.83%)

227 (0.97%)

218 (0.90%)

297 (1.22%)

397 of the 557 inpatient and 292 of the 297 outpatient unavailable episodes were patient advised in June 2016. 5. Cancer Waiting Times Targets: 95% of all eligible patients should wait no longer than 62 days or 31 days. A 5% tolerance level is applied to these targets as for some patients it may not be clinically appropriate for treatment to begin within target. The 62 day urgent referral to treatment target includes screened positive patients and all patients referred urgently with a suspicion of cancer. The 31 day target includes all patients diagnosed with cancer, whatever their route of referral, from decision to treat to treatment.

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Performance:

Dec 16 Jan 16 Feb 16 Mar 16 Apr 16 May 16

62 days 93.2% 91.8% 92.5% 89.9% 93.6% 90.3%

31 days 100% 97.8% 97.9% 95.6% 95.9% 100%

In May 2016, 65 out of 72 patients (90.3%) were treated for cancer within 62 days of referral with suspicion of cancer. The specialties below target were Urology at 75% (2 of 8 patients), Lung at 84.6% (2 of 13 patients), Colorectal at 88.2% (2 of 14 patients) and Breast at 94.7% (1 of 19 patients). Urology Patients require a number of diagnostic tests before their diagnosis can be confirmed. The introduction of artemis biopsy techniques at UH Ayr is a welcome service development for patients. The pathway has been reviewed by the cancer team and an improvement in 62 day performance is expected from August 2016 in light of this. Lung Lung cancer public health campaigns have meant that the Respiratory service has received a significant increase in referrals, which now exceed the service’s capacity. This has created an ongoing challenge in offering appointments for outpatient clinics within two weeks of referral. Colorectal The primary pressure within this service is the time taken for patients to receive colonoscopy, which is required to make a diagnosis and inform future treatment. The surgical teams at both hospitals are continuously reviewing pathways and vetting processes to ensure that all UCS scopes performed are within 2 weeks of referral, as often as possible. Other factors included waiting times for first outpatient appointments, pre-operative appointments and radiotherapy treatment. Breast Patients required a number of diagnostic tests before their diagnosis and care could be discussed by the multi-disciplinary team (MDT). All patients’ care pathways must be discussed at MDT sessions. There has been a recent improvement in consultant surgical staffing numbers although there still remain challenges in both Medical Imaging and Pathology, both of which support this service. 6. Patients Awaiting Discharge Targets: The current target is that no-one will wait more than 14 days to be discharged from hospital into a more appropriate care setting once treatment is complete. Performance:

Jan 16 Feb 16 Mar 16 Apr 16 May 16 Jun 16

14 day delayed discharges 15 17 20 21 38 39

All those who waited more than 14 days over the last three months were in South Ayrshire.

7. Mental Health Services – National Targets Targets:

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1. The national standard is that 90% of clients will wait no longer than 3 weeks from referral received to an appropriate drug or alcohol treatment that supports their recovery, and no-one will wait more than 6 weeks.

2. Deliver 18 weeks referral to treatment for specialist Child and Adolescent Mental Health Services (CAMHS).

3. Deliver 18 weeks referral to treatment for Psychological Therapies. Performance: 1. Drug or Alcohol Treatment performance was 94.5% in June 2016 against the target of

90%. 2. CAMHS 18 week performance, based on adjusted waits, was 95.89% in May 2016

against the target of 90%. 3. Psychological Therapies 18 week performance, based on adjusted waits, was 73.22%

for May 2016 against the target of 90%. Psychological Therapies Psychological therapies are delivered by a number of professions across mental health and physical health services, which leads to complexities and challenges in delivering this target. The target is being met in some services and a significant amount of work continues towards achieving this target over all services. 8. MSK pathway waiting times measurement Target: The target is that no patient aged 16 years or older will wait more than 4 weeks from referral to treatment. Performance:

Feb 16 Mar 16 Apr 16 May 16 Jun 16

Patients waiting less than 4 weeks for MSK services

31.9% 27.3% 27.3% 25.4% 25.0%

Waiting times improved during 2014 through the use of additional staff resources. Since then the waiting list for MSK patients has been increasing by around 500 patients per month, with a corresponding increase in the number of patients waiting over target.

Service and process redesign options are being explored to progress towards the 4 week target.

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Monitoring Form

Policy/Strategy Implications

The Patients’ Rights Act and the Treatment Time Guarantee have a profound effect on waiting times management and monitoring.

Workforce Implications

Workforce implications identified –

Recruitment of permanent staff or retention of locum staff where currently being utilised

Availability of staff to hold additional clinics

Financial Implications

There is continuing growth in referrals across a number of specialties in Acute Services. This, along with current financial challenges, has led to bids for Waiting List Initiatives and ongoing service enhancements being reviewed and resubmitted, where appropriate, by service managers.

Bids for all further investment are reviewed in light of available funding and the implication of levels of investment on waiting times targets. Additional Scottish Government support is being provided.

Consultation (including Professional Committees)

This report is compiled by summarising information from a variety of sources and other NHS Ayrshire & Arran reports.

A Waiting Times report is reviewed monthly by the Corporate Management Team.

Risk Assessment

There is a significant risk to the organisation in failing to improve against the waiting times targets, with action plans in place to ensure safety of patient care is prioritised.

Risks remain that unforeseen circumstances, e.g. ward closures due to illness, could adversely affect any recovery programme. As all internal relevant staff and facilities are already committed to this effort no contingency plans are possible. Risk mitigation is being delivered by close scrutiny and management.

Best Value - Vision and leadership - Effective partnerships - Governance and

accountability - Use of resources - Performance management

Successful management of waiting times requires leadership, and engagement with clinical staff.

The developing Health and Social Care Partnerships have increasing influence on Delayed Discharge performance through patient flow.

Local performance management information is used to provide as up to date a position as possible in this report. Some information may change when the data is quality assured by ISD in readiness for publication.

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Compliance with Corporate Objectives

The achievement of the waiting times targets set out within this paper complies with a number of the corporate objectives: improving health; safety/outcomes; quality of experience; equality; transforming and patient flow; supply and demand.

Single Outcome Agreement (SOA)

The achievement of the targets provides better access to healthcare services and should therefore have a positive effect on the health inequalities priority within local SOAs.

The achievement of the patients awaiting discharge targets will have a positive contribution towards the Outcomes for Older People priority.

Impact Assessment

An Equality and Diversity Impact Assessment is not required for this paper. Service improvement plans referred to within the paper will be assessed as appropriate.

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Appendix 1

Waiting Times scorecard Jul 15 Aug 15 Sep 15 Oct 15 Nov 15 Dec 15 Jan 16 Feb 16 Mar 16 Apr 16 May 16 Jun 16

12wks TTG (IP/DC) 92.4% 94.2% 94.5% 93.5% 93.1% 90.4% 85.8% 86.3% 87.6% 86.1% 87.2% 88.9%

Patients who breached the TTG

during the calendar month

144 125 139 167 177 228 246 128 165 278 228 226

Patients treated in the month who

exceeded their TTG

148 149 130 125 159 134 199 203 263 235 237 201

Access audit scores 99.3% 98.7% 99.6% 97.7% 97.7% 99.1% 96.8% 98.7% 99.1% 98.7% 99.1% 99.3%

18 weeks Referral To Treatment -

Performance

78.96% 78.14% 75.61% 71.02% 75.5% 77.3% 76.26% 74.21% 75% 74.14% 75.76% 74.74%

18 week RTT clinic outcome

recording

91.9% 90.66% 90.38% 88.4% 88.18% 87.5% 88.41% 89.28% 88.7% 88.62% 88.76% 89.07%

New Outpatients: Maximum 12

weeks from Referral (95%)

81.48% 79.09% 77.85% 78.22% 81.03% 78.77% 74.77% 74.6% 76.55% 75.54% 74.62% 74.58%

4388 5105 5240 5138 4210 4561 5478 5655 5257 5695 6140 6175

Inpatients & Day Cases: Maximum

9 weeks

84.7% 85.5% 86.2% 82.6% 83.6% 80.2% 77.3% 74.8% 77.1% 77.8% 78.3% 80.2%

400 406 408 543 491 606 716 763 690 667 640 556

Percentage of diagnostic patients

waiting less than 6 weeks

75.1% 76.5% 81.7% 86.3% 90.3% 87.0% 81.2% 86.6% 86.8% 87.0% 91.4% 88.2%

1,618 1,426 986 806 513 728 1,040 771 757 687 479 699

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Jul 15 Aug 15 Sep 15 Oct 15 Nov 15 Dec 15 Jan 16 Feb 16 Mar 16 Apr 16 May 16 Jun 16

Total Outpatient waiting list size 23,687 24,419 23,654 23,589 22,187 21,479 21,713 22,265 22,417 23,283 24,194 24,294

Unavailable Outpatients on

waiting list 301 256 292 252 273 308 172 192 188 227 218 297

Total Inpatient/Day case waiting

list size 2,622 2,795 2,953 3,119 2,997 3,063 3,153 3,029 3,012 3,007 2,946 2,805

Unavailable Inpatient/day case

patients on waiting list 548 559 581 494 540 606 423 437 474 470 499 557

A&E Waits to be a Maximum of 4

hours

95.6% 95.2% 92.5% 89.7% 91.9% 97.4% 91.0% 90.4% 91.1% 93.7% 95.2% 94.0%

62-Day Cancer: Suspicion-of-

Cancer Referrals (62 days)

89.5% 93.3% 84% 94.4% 92.2% 93.2% 91.8% 92.5% 89.9% 93.6% 90.3%

31-Day Cancer: All Cancer

Treatment (31 days)

97.8% 100% 100% 100% 99.1% 100% 97.8% 97.9% 95.6% 95.9% 100%

T15.1 Delayed Discharges - 2 week

waits

2 7 0 2 7 16 15 17 20 21 38 39

Drug and Alcohol Treatment:

Referral to Treatment

96.6% 97.2% 97.5% 98.1% 98.1% 96% 98.1% 98.1% 96.5% 95.6% 96.8% 94.5%

Faster Access to CAMHS - 18 wks 95.1% 98.55% 98.85% 98.81% 98.97% 100% 96.7% 98.18% 98.02% 100% 95.89%

Faster Access to Psychological

Therapies - 18 wks

77.63% 74.83% 72.74% 68.14% 81.36% 80.53% 76.06% 78.26% 75.25% 73.1% 73.22%

Adult patients waiting less than 4

weeks for MSK services

45.9% 43.4% 39.1% 38.6% 39.3% 27.7% 29.3% 31.9% 27.3% 27.3% 25.4% 25.0%

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Appendix 2

Weekly monitoring by Scottish Government – new outpatients waiting more than 12 weeks

Projected Projected Projected Projected Projected

Position Position Position Position Position

Specialty 30-May End May16 06-Jun 13-Jun 20-Jun 27-Jun End June-16 04-Jul 11-Jul 18-Jul 25-Jul End July-16 01-Aug 08-Aug 15-Aug 22-Aug 29-Aug End Aug-16 End Sep-16

Cardiology 175 290 188 213 204 203 385 223 226 231 262 484 256 583 682

Dermatology 104 100 179 246 289 315 220 368 371 427 430 340 360 460 580

Diabetes/Endocrinology 552 585 554 579 570 557 545 549 562 547 532 528 532 548 568

ENT 758 622 791 818 828 808 740 806 801 838 841 700 849 650 600

Gastroenterology 379 495 406 395 380 379 528 410 387 414 443 441 407 486 531

General Surgery (exc Vascular) 745 800 767 764 778 720 750 716 747 750 762 700 784 650 600

Gynaecology 270 150 298 328 297 297 220 284 319 353 355 180 381 140 100

Neurology 218 270 235 195 200 144 258 163 163 160 154 246 110 286 372

Ophthalmology 836 550 875 853 815 739 500 734 683 624 621 450 592 400 350

Oral & Maxillofacial Surgery 1,041 1,068 1,047 1,021 1,014 999 1,020 968 961 957 929 960 910 900 840

Pain Management/Anaesthetics 571 585 589 569 601 586 600 582 616 631 639 650 656 700 750

Respiratory 398 495 403 434 455 455 630 469 500 572 594 645 604 780 920

Rheumatology 0 0 0 0 0 1 25 2 5 15 17 25 10 25 25

Trauma & Orthopaedics 84 150 123 151 138 99 130 87 104 123 129 130 138 110 90

Urology 8 0 11 6 6 6 0 5 2 3 3 0 0 0 0

Other 25 20 42 41 39 35 40 11 37 39 41 70 60 70 40

6,164 6,180 6,508 6,613 6,614 6,343 6,591 6,377 6,484 6,684 6,591 6,549 6,649 0 0 0 0 6,788 7,048

Week End ActualWeek End ActualWeek End Actual Week End Actual