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SUTTON HORIZON CONSORTIUM board... · 2017-07-10 · February 2017. Initial figures for May...
Transcript of SUTTON HORIZON CONSORTIUM board... · 2017-07-10 · February 2017. Initial figures for May...
1. Sutton CCG
This section reports all providers for Sutton patients
Quality Performance standards
Sutton CCG has been assured across all quality domains including Patient and
public involvement, Continuing Health Care and Safeguarding.
The Sutton Homes of Care Vanguard is now being rolled out across South
West London as a priority and is being used nationally to improve the care of
residents in care homes.
Most recent month available
Target/ Threshold
Performance Achieved in month (Y/N)
Month Performance %
Feb Mar
Referral to Treatment (RTT) Patients on non-emergency pathways wait no more than 18 weeks
Apr 92% Yes 92.90% 93.10% 93.30%
Commentary Actions being taken
Sutton CCG achieved the incomplete standard in April with an outcome of 92.91%. However, it should be noted this figure does not include data from St George’s who ceased reporting of RTT data in June 2016 to improve data quality and Accuracy of the PTL. There is a significant risk that when St. Georges begin reporting again, Sutton CCG's performance will be adversely affected. This risk has been highlighted to NHSE though the Quarter 1 Integrated Assurance Framework submission.
Actions are in place within the ESHT and across the ESHT economy (Sutton CCG, Merton CCG, Surrey Downs CCG and ESHT), these are outlined in the ESHT section of this report.
62-day cancer waiting standard From urgent GP referral
Most recent month available
Target/ Threshold
Performance Achieved in month (Y/N)
Month Performance %
Feb Mar
Apr 93% Yes 95.10% 99.00% 99.50%
Commentary Actions being taken
for suspected cancer to first treatment
Sutton CCG has met six of the eight cancer waiting time Standards for April (M1) 2017/18, including the 62-day cancer standard. The CCG did not achieve the 31 day subsequent surgery standard with 92.9% due to one breach at RMH out of 14 pathways nor the 62-day screening standard with 85.7% due to one breach at SGH out of 7 pathways. There was one 100+ day patient breach for Sutton CCG in April (M1) 2017/18 shared between ESTH and RMH
To address late referrals/ ITTs, System Leadership Forum (SLF) are monitoring trusts’ referrals to the treating trust by day 38. Weekly calls are in place between trusts to agree referral/ITT dates are being undertaken. 38-day performance is being monitored on weekly performance calls with the CSU Trusts are also developing reports to show 38-day breach reasons. Three trust pathways are being monitored through SLF and NHSE London are collating data on Three trust pathways The Head & Neck pathway for SW London is being reviewed by TCST.
Diagnostic waits Patients waiting less than 6 weeks
Most recent month available
Target/ Threshold
Performance Achieved in month (Y/N)
Month Performance %
Feb Mar
Apr 99% Yes 99.50% 99.50% 99.70%
Commentary Actions being taken
Performance consistently exceeds the target.
52 week breaches Referral to treatment (RTT) incomplete pathways greater than 52 weeks
Most recent month available
Target/ Threshold
Performance Achieved in month (Y/N)
Month Performance %
Feb Mar
Apr 0 Yes 0 1 1
Commentary Actions being taken
There have been no 52 week breaches this month.
Dementia diagnosis rate
Most recent month available
Target/ Threshold
Performance Achieved in month (Y/N)
Month Performance %
Feb Mar
Apr 67% Yes 73.00% 68.50% 68.30%
2. Epsom and St. Helier
Quality ( May 2017) Performance standards
Item / issue: Dementia screening below 40% should be 90%
Impact: Impact on patient not being diagnosed
Action(s): Trust have been written to and asked for a recovery plan and to present this plan
at the August CQRG
Risk Owner: Medical director Trust
Item / issue: C.diff ceiling target for 17/18 will remain at 39. In April, only one trust apportioned
case against the trajectory of 5 was reported.
Impact: Patient safety
Action(s): Continue to implement Infection prevention and control improvement plan
Risk Owner: Chief Nurse Trust
Item / issue: VTE assessments have remained steady at 94.6%, but still remains just below
target of 95% .
Impact: Patient safety
Action(s): Maintained focus in VTE by directorate
Continue to implement Infection prevention and control improvement plan
Risk Owner: Medical director
Item / issue: Clinical workforce level is maintained over the target level, and overall Nursing
workforce showed net positive change in April.
Trust agency spend remains below the financial trajectory.
Sickness absence level dropped below ceiling target, lowest level in the last 13
months.
Turnover and vacancy rate remains high.
Impact: Patient care and safety
Action(s): Detailed monitoring regularly reported to CQRG monthly, expectation that vacancy
Most recent month available
Target/ Threshold
Performance Achieved in month (Y/N)
Month Performance %
Feb Mar
Access standards for A&E Patients wait no more than four hours
Apr 95% Yes 95.20% 95.20% 96.40%
Commentary Actions being taken
ESTH achieved the A&E standard with a trust-wide outcome of 95.2% in April, down from 96.38% in March. The Trust has achieved the target every month since February 2017. Initial figures for May indicate the Trust will achieve 95.70% for All Types and 95.55% for Type1 attendances. Individual site level performance at Epsom was 95.55%. St. Helier site level performance was 95.80% for All type and 95.55% for Type 1. The Trust have raised concerns regarding their reduced ability to redirect patients to the Out of Hours Service (OOH) since the service was retendered as part of 111/OOH, suggesting that this presents a missed opportunity to maximise performance in A&E.
A task and finish group is being established to look at the issue of redirection of patients who can be seen outside of A&E. This group will be overseen by the ESHT QIPP and CIP Transformation Board who will ensure that there are members from the full spectrum of potential contributors to the solution.
Referral to Treatment (RTT) Patients on non-emergency pathways
Most recent month available
Target/ Threshold
Performance Achieved in month (Y/N)
Month Performance %
Feb Mar
Apr 92% Yes 95.20% 95.20% 96.40%
Commentary Actions being taken
rate will improve over next few months
Risk Owner: Director of HR
Item / issue: C Section rates
PPH
Impact: Patient safety
Action(s): Trust wide performance 28.8% for April below national/London average 27%.
Emergency CS 20.4%. The trust has recently agreed to use carbetocin for
emergency CS deliveries in addition to planned.
Post Partum Haemorrhage: 3.97% Trust wide performance for April. The LW lead
consultants and midwives are aware of the ongoing PPH focus. A self-nominated
PPH midwife champion has already created a poster to raise awareness on
preventative measures in PPH which has been shared cross-site. The major
association with significant PPH is assisted vaginal deliveries. Trainees have been
instructed to obtain consultant supervision during instrumental deliveries (when
they are on site) and to respond and escalate early during a PPH. Consultants
have also been reminded of the need to supervise trainees. Continuous audits are
in progress
Risk Owner: Chief Nurse and Head of Midwifery
wait no more than 18 weeks
ESTH achieved the RTT standard during April, however the Trust have suggested that this has been with some difficulty. There are a number of specialties where the Trust is experiencing significant pressures including gynaecology where referral rate increases have caused considerable pressures. The Trust have also noted that achievement of RTT is impacted severely when there are non elective pressures at the Trust as this diverts resources away from planned activity. It has also been suggested that historical methods of addressing back logs have involved putting on of additional clinics for example at weekends are costly and therefore not an option available in the current financial climate.
The ESHT QIPP and CIP Transformation Board has agreed to focus attention on those areas where performance reporting and the Trust themselves have identified as an issue in terms of RTT (both those where performance is not achieving the standard and those where the Trust is experiencing significant pressures in delivering a compliant performance, including gynaecology, dermatology and urology. We are currently in a scoping phase (further detail is available in the Exec papers of 14th June). ESHT report that they are working on the gynaecology admitted pathway, previously the Trust had relied on the private sector to decrease the backlog which is an expensive solution to the issue. Theatre allocation has according to the Trust been reviewed across both sites and an action plan has been put in place.
62-day cancer waiting standard From urgent GP referral for suspected cancer to first treatment
Most recent month available
Target/ Threshold
Performance Achieved in month (Y/N)
Month Performance %
Feb Mar
Apr 85% Yes 92.60% 93.20%
Commentary Actions being taken
ESHT's performance for all patients was 91.24% (2,346 breaches) in April. Whilst this represents a reduction in performance compared with March 2017 when the Trust achieved the target, this performance is in line with the Trust operating plan submission of 91.20% for April-17. Overall, the majority of breaches continue to occur in T&O (416) and Gynaecology (332). In comparison to the previous month however, whilst Gynaecology saw an increase of 61 breaches (a rise of 22.5%), T&O performance was more stable with an extra 13 breaches (a rise of 3.2%). The Trust report that demand has increased by 8% compared with the same period last year.
Performance for Sutton CCG patients was achieved at Epsom and St Helier with an outcome of 92.57%, down from 93.22% in March.
Most recent month available
Target/ Threshold
Performance Achieved in month (Y/N)
Month Performance %
Feb Mar
Diagnostic waits Patients waiting less than 6 weeks
Apr 99% Yes 99.70%
The Trust report that Urodynamics and Cystoscopy did not meet the standard, however, urodynamics performance improved with 2 breaches for 118 waits. The Trust suggests that performance has been affected by: - Bank holidays - Lack of capacity - Issues around Rectal and Liver MRIs
The Trust has reported that radiology has a good plan in place for speciality scans.
3. St. George’s
Quality May 2017 Performance standards
St George’s continues to be monitored closely by NHSE and Wandsworth CCG as the
host CCG following the last CQC report.
Assurance has been provided on improvements in End of Life Care,
recruitment and retention as areas highlighted by the CQC Report for urgent
action.
The Trust has exceeded both their C Diff Target and MRSA year to date.
Further assurance has been requested by commissioners on their infection
prevention and control strategy.
GPs from a number of CCGs continue to raise concern around outpatient
access times; as a result of this Sutton CCG has invited a representative from
the Trust to attend a Quality Committee to describe in detail the actions that
are taking place to address some of our membership concerns.
The Trust has made considerable progress towards the new arrangements set
out in the Elective Care Recovery Programme and have shared this progress
with commissioners.
Most recent month available
Target/ Threshold
Performance Achieved in month (Y/N)
Month Performance %
Feb Mar
Access standards for A&E Patients wait no more than four hours
Apr 95% No 90.50% 90.60% 88.60%
Commentary / Actions being taken
St. Georges achieved an outcome of 90.5% in April up from 88.6% in March. This is above the operating plan target of 89.4% for April. The provisional figure for May’s performance is 89.68% against an operating plan target of 91.03% for the month. The standard was met on three days in April but performance became sustainably better, routinely exceeding 90%. The trust reported on the daily calls with the surge hub that breaches were due to; o High acuity presentations o Surges of patients in week one and two of the month, particularly early evening o An increased volume of patients In week two o The third week saw the Trust achieve target on two days, however there was high take and high volumes of patients o The fourth week of May was affected by high attendances, bed availability and some infection control issues
Referral to Treatment (RTT) Patients on non-emergency pathways wait no more than 18 weeks
Data Currently not being reported
Commentary / Actions being taken
ENT and dermatology will be subject to an initial pilot to undertake a waiting list review and redirect appropriate patients. The Trust has been asked to identify further specialities and estimated volumes that could be removed from the SGH hospital for treatment elsewhere and provide an update to commissioners There was a suggestions that CQRG review the feasibility of extending the deadline beyond 10 days for some categories of letter. Trust paper being developed to set out options to prevent letters backlog from reoccurring.
62-day cancer waiting standard
Most recent month available
Target/ Threshold
Performance Achieved in month (Y/N)
Month Performance %
Feb Mar
Apr 85% No 84.70%
Commentary Actions being taken
Vacancies in MDT Coordinator roles have now been addressed however there are now 4 vacancies (out of a total of 6) in the 2ww booking office
The Trust has been asked to revisit and recirculate the cancer action plan
Diagnostic waits Patients waiting less than 6 weeks
Most recent month available
Target/ Threshold
Performance Achieved in month (Y/N)
Month Performance %
Feb Mar
Apr 99% No 95.90%
4. South West London and St. Georges Mental Health Trust / IAPT
Quality February 2017 Performance standards
Item / issue: Serious Incidents
February 2017
• 7 new SIs reported, 0 never events • 2 suspected suicide • 3 unexpected deaths • 1 attempted suicide
• Incidents show an increase in reported self harm
Impact: There is a risk of patient safety if the Trust fails to manage SI processes within
required timescales with effective delivery and learning from action plans.
Action(s): • SI management process • Quarterly learning report
Risk Owner: Trust
Item / issue: Restrictive practice
• The level of restrictive practice reporting has increased in February - increases in; • Prone restraint • Seclusion • Rapid tranquilisation
Impact: Risk to patient safety
Risk to patient experience
Action(s): • New seclusion policy • Internal audit of practice against policy in Q1 2017/18 • All instances reviewed by Head of Nursing
Risk Owner: Trust
Item / issue: Patient Story – South West London Recovery College
• UK’s first mental health recovery study and training facility providing a range of courses and resources for service users, families, friends, carers and staff.
• Courses run at 5 sites (5 boroughs) • 750 + sessions per year
April May
IAPT Access
First treatment numbers required to deliver 4.2% (rolling quarter)
303 303
Number of people entered treatment 350 373
Commentary Actions being Taken
Sutton are on target to meet the National trajectory of 4.2% for Q1 17/18, currently meeting 3.3%.
Continued marketing and outreach to a range of community groups. Well-being team able to do this work. Introduction of Silver Cloud a new on-line provision. Focus on engaging those with low symptoms by providing one off well-being workshops. Introduction of new Step 3 group programme, successful in Richmond.
IAPT Recovery
April May
Recovery rate delivered (%) 56.50% 56.00%
Commentary Actions being Taken
Sutton has met the National target (50%) for the first time in both April & May 17/18.
Symptom reviews each treatment session following a further training session with the team Reviewing non-recovered clients in supervision toward the end of treatment and adjust treatment where recovery may be met Improve Mental health cluster allocation via triage supervision and training Administration of PHQ9 and GAD7 questionnaires to spontaneous remitters reporting no longer
Themes from Service users;
• Fantastic • Truly supportive …. My use of this service has enabled me to relinquish
medication, to grow as a person and feel stronger • There is hope and recovery is possible • It would be helpful if there was a course that includes some kind of
physical exercise
Impact: Patient Experience
Recovery & Treatment
Action(s): • Forensic Recovery College • Bespoke courses • Recovery Peer Trainers • Recovery Support Workers
• Develop stronger links with Kingston University on research • New courses
• Understanding anxiety and panic • Understanding hoarding • How to keep yourself safe (safeguarding)
Risk Owner: Chief Nurse
Item / issue: Q3 Safeguarding report – Adults
• 242 allegations of abuse or neglect reported in Q3 • 84 physical abuse • 40 psychological/ emotional abuse • 30 sexual abuse • 24 Domestic Violence
• PREVENT – 2 Train the Trainers appointed • Safeguarding adult Reviews – 2 cases open to SAR process • Level 1 training – 90.2% compliance
Impact: Risk to patient safety
Action(s): • Participate in ‘Making Safeguarding Personal’ (MSP) group • Recovery College to launch ‘Keeping Yourself Safe’ in May 2017
Risk Owner: Chief Nurse
Item / issue: Q3 Safeguarding report – Children
• Contributed to Richmond LSCB S11 audit in December 2016 • S11 Challenge Review in Merton in October 2016 – highlighted
improved knowledge and understanding in adult mental health services with regards to child safeguarding and potential effects of parental mental illness
require the service
IAPT Waiting times
% who received their first treatment appointment within 6 weeks of referral
98.50% 98.50%
% who received their first treatment appointment within 8 weeks of referral
100% 100%
Commentary Actions being Taken
Sutton is meeting the 6 and 18 weeks waiting time standard. However, there are ‘hidden waits' that occurred between first and second appointments. The increase in numbers entering the service and the work to improve recovery will have an impact of WTs.
Close monitoring Implementation of Silver cloud
• 2 Serious Case Reviews (SCR) in progress – 1 Merton, 1 Wandsworth • 1 SI in November 2016 relating to a child (assault by a minor on his
mother) • 50 child safeguarding referrals in Q3 – 1 severe harm (November 2016
as above)
Impact: Risk to patient safety
Action(s): • Safeguarding children to be clearly highlighted and recorded as an integral aspect of Clinical Supervision
• Increase representation of adult mental health at LSCB meetings and learning events
Risk Owner:
5. Sutton Community Health Services
Quality Performance standards
Item / issue: Staffing levels
Impact: Risk to patient safety
Risk to patient experience
Action(s): Continues focus on staffing which is improving slowly, a
number of newly qualified nurses will hopefully be taking up
post in September.
CQC action plan due early July
Risk Owner: Divisional Director RMH
There are three red-rated KPIs in April 2017, which has reduced from 15 in March 2017. Of these, one indicator has been identified as a longer-term issue in children services due to reduced staff capacity. A demand and capacity modelling analysis is ongoing. Red KPIs KPI 17b: Number of routine therapy referrals offered an assessment within 30 working days of acceptance. Actual: 39.7% Target: 75.0% Underperforming service Mar performance Children’s Dietetics, Children’s OT Health Children’s Physio Children’s SALT Children’s Services: Reduced staff capacity due to staff sickness, maternity leave and partial cover across Children’s Services is impacting on the availability of appointments. Actions: In response to the reduced staff capacity, a demand and capacity modelling exercise is ongoing to understand the requisite level to keep a pace with demand following disaggregation. RMCS will feedback results to Sutton CCG following analysis in July. Recruitment is also on-going to cover maternity posts. KPI 18: Referrer/ GP notified of non-acceptance within 24 hours. Actual: 74.5% Target: 90% Underperforming services Adult dietetics
Adult SALT Children’s SALT MSK This KPI is measured against all services with five services currently underperforming against the 90% target. However, underperformance in these areas is considered to be a data quality issue. Action: This is currently being addressed internally and improvement should be seen in May reporting. KPI 1N: Percentage of urgent referrals seen within 10 working days of acceptance of referral Actual: 69.5% Target: 90% Underperforming service MSK – 69.5% New KPI in April In April, 131 referrals were triaged under the “priority” pathway and 40 of these were not seen within the target 10 days from acceptance of referral. Review of these cases is ongoing with the Service Lead and the findings will be discussed at Contract Monitoring Meeting. Of note, the MSK service does not have an “urgent” referral pathway and patients requiring early review are categorised under the “priority” pathway. RMCS would like to request the KPI definition is amended to state “priority.
6. 111 & Out of Hours
Quality April 2017 Performance standards
Item / issue: • No new SI’s reported for April 2017 • No Never Events • 2 SI’s remain open (Croydon & Wandsworth) • 2 SI’s completed (Merton & Croydon)
Impact: There is a risk of patient safety if the Vocare fails to manage SI processes within
required timescales with effective delivery and learning from action plans.
Action(s): SI and Never Events reviewed monthly at CQRG
Risk Owner: London Regional Manager
Item / issue: KPI for answering calls within 60 seconds not met for 111.
88% against 95% target.
Low abandonment rate
Impact: Potential risk to patients or patients seek alternative urgent care (999 or ED)
Action(s): Recruitment strategy following a rostering realignment to meet service demand
Risk Owner: London Regional Manager
Item / issue: 111 Audit – outstanding call Audits not completed by provider for March/April 2017
Impact: Risk to patient safety as call advisors and handlers may not being given feedback
and training
Action(s): Vocare are allocating additional resource to complete
Risk Owner: Clinical Manager –SWL IUC
Item / issue: Safeguarding Arrangements
Training compliance : for both adults and children - improved
Governance Arrangements – named professional not in place
Quality and Performance Indicators
Quality and Performance Indicator(s) Mar Apr May
Patient Safety Patient's registered GP to receive report of all frequent users (who present for treatment more than 8 times a month) by 08:00 the next working day following 8th visit
100% 100% 100%
Time taken for call back to HCP
Calls to be returned to an HCP caller must commence within 20 minutes of the call being received
90.08% 87.27% 94.35%
Telephone Clinical Assessment (20 mins)
Clinical assessment by telephone advice for urgent calls must commence within 20 minutes of the Initial call from HCP being completed or the case being received from a 111service. Note that where a case has been received from a 111 service commissioners consider that Initial Definitive Clinical Assessment as defined in NQR 8 has taken place.
95.16% 93.24% 93.53%
Telephone Clinical Assessment (60 Mins)
Clinical assessment by telephone advice for routine call backs must commence within 60 minutes of the initial call from HCP being completed or the case being received from a 111 service. Note that where a case has been received from a 111 service commissioners consider that Initial Definitive Clinical Assessment as defined in NQR 8 has taken place for all dispositions mapped to 1 hour.
86.45% 87.59% 95.04%
Telephone Clinical Assessment (120 Mins)
Clinical assessment by telephone advice for routine call backs must commence within 60 minutes of the initial call being received from a 111 service for all dispositions mapped to 2 hour
91.23% 92.93% 95.98%
Telephone Clinical Assessment (240 Mins)
Clinical assessment by telephone advice for non-routine call backs must commence within 240 minutes of the initial call being received from a 111 service for all dispositions mapped to 4 hour.
90.00% 95.45% 96.55%
Service provision
All primary care base sessions appropriately and adequately clinically and non clinically staffed and all sessions for the measurement period are completed
100% 100% 100%
Supervision not in place
Safer recruitment – policies needed to be revised
Impact: Risk to Patient Safety
Staff not adequately trained and supported
Action(s): Vocare have a recovery plan that is due to be completed by end of July 2017.
Plan progressing and governance arrangements being implemented
Assurance Template to be completed in July 2017 with new Head of Safeguarding
Risk Owner: London Region Manager/Director of Nursing Vocare
7. London Ambulance Service
Quality Performance standards
Along with colleagues in SWL Sutton has plans in place to reduce
demand on LAS and as a result improve performance. Sutton’s current
schemes are outlined below
Initiative Description Total Activity Reduction
Sutton Vanguard
Sutton homes of Care Vanguard Programme continues into 2017/18 with increasing spread of good practice across all Sutton CCG care homes. Through the Vanguard Programme there is a sustained reduction in conveyance from nursing homes and it is anticipated a 5% reduction in conveyance will be achieved in 2017/18 with the roll out of the programme to residential homes in 2017/18. This is within the context of anticipated growth with additional care homes opening in 2017 increasing care home bed capacity within Sutton
678
GP Education programme re LAS HCP guidance with Audit on Guidance adherence
To improve awareness of LAS Guidance on HCP calls 2% reduction identified
136
Sutton Health and Care
Focus on creating an integrated, multi-disciplinary service delivered in the
136
Most recent month available
Target Month Performance %
Performance Achieved in month (Y/N)
Feb Mar Apr
Ambulance Red 1 (8-minute response)
May 75% 73.1% No 76.0% 78.8% 78.1%
Ambulance Red 2 (8-minute response)
May 75% 79.4% No 77.5% 80.9% 80.2%
Cat A 8-minute response
May 95% 96.8% No 95.2% 96.9% 96.8%
:
home and the community to prevent hospital admissions and reduce conveyances by LAS.
Appendix 1: CCG Performance Dashboard
Feb-17 Mar-17 Apr-17
Summary EAS04 MRSA - Incidence of HCAI YTD 0 0 0 0 (YTD) Apr-17 1 0 0 ►
Summary EAS05 C. difficile - Incidence of HCAI YTD - (2017-18 Target = 41) 4 (YTD) 0 0 0 (YTD) Apr-17 1 4 0 ►
NHS Constitution
Scorecard EB001 RTT admitted 90% 75.4% 75.4% 186 Apr-17 76.6% 74.8% 75.4% ▼
Scorecard EB002 RTT non-admitted 95% 93.5% 93.5% 229 Apr-17 89.3% 91.4% 93.5% ►
Summary EE001 RTT incomplete 92% 92.9% 92.9% 899 Apr-17 93.1% 93.3% 92.9% ▲
Summary EBS04(3) RTT 52+ week waiters 0 0 0 0 Apr-17 1 1 0 ►
Summary RTTBL RTT Admitted Backlog 301 301 Apr-17 302 329 301 ►
Summary EE004 Diagnostics Diagnostics - 6 weeks + 99% 99.5% 99.5% 17 Apr-17 99.5% 99.7% 99.5% ▲
Summary EB006 2 week wait 93% 95.1% 95.1% 19 Apr-17 99.0% 95.5% 95.1% ►
Scorecard EB007 Breast symptoms 2 week wait 93% 93.2% 93.2% 5 Apr-17 97.7% 93.5% 93.2% ►
Summary EB008 31 day first definitive treatment 96% 100.0% 100.0% 0 Apr-17 98.5% 100.0% 100.0% ►
Scorecard EB009 31 day subsequent treatment surgery 94% 92.9% 92.9% 1 Apr-17 100.0% 100.0% 92.9% ►
Scorecard EB010 31 day subsequent treatment drug 98% 100.0% 100.0% 0 Apr-17 100.0% 94.7% 100.0% ►
Scorecard EB011 31 day subsequent treatment radiotherapy 94% 100.0% 100.0% 0 Apr-17 93.8% 88.5% 100.0% ►
Summary EB012 62 day standard 85% 90.0% 90.0% 3 Apr-17 88.9% 90.9% 90.0% ▲
Scorecard EB013 62 day screening 90% 85.7% 85.7% 1 Apr-17 100.0% 100.0% 85.7% ►
Scorecard EB014 62 day upgrade 90% 50.0% 50.0% 3 Apr-17 100.0% 100.0% 50.0% ►
Scorecard EBS01 Mixed-sex accommodation breaches 0 0 0 0 May-17 0 0 0 ►
Scorecard Local9 Total number of Delayed Transfers of Care 0 379 31 31 Mar-17 37 31 ►
CCG EBS03 CPA follow up within 7 days 95% 96.8% 100.0% 0 Mar-17 100.0% ▲
CCG EH01 IAPT 6 week target 75% 96.4% 97.4% 10 Mar-17 98.1% 97.4% ►
CCG EH02 IAPT 18 week target 95% 99.3% 100.0% 0 Mar-17 100.0% 100.0% ►
CCG EH03 IAPT in recovery 50% 46.1% 45.2% 85 Mar-17 47.4% 45.2% ►
CCG EH04 Early Intervention Psychosis 2 week target 50% 100.0% 60.0% 2 Mar-17 87.5% 60.0% ►
CCG EAS01 Dementia 67% 73.1% 73.0% 518 May-17 68.5% 68.3% 73.2% ▲
Activity & Efficiency
CCG EC001 G and A elective FFCEs 367 367 Apr-17 338 390 367 ►
CCG EC002 G and A daycase FFCEs 1440 1440 Apr-17 1681 1692 1440 ►
CCG EC003 G and A total FFCEs 1807 1807 Apr-17 2019 2082 1807 ►
CCG EC004 Non elective FFCEs 1662 1662 Apr-17 1515 1627 1662 ►
CCG EC005 All first outpatient attendances 3662 3662 Apr-17 4115 4425 3662 ►
CCG EC009 GP written referrals (G and A) 3210 3210 Apr-17 3632 4114 3210 ►
CCG EC010 Other referrals (G and A) 637 637 Apr-17 707 755 637 ►
CCG EC011 Total referrals 3847 3847 Apr-17 4339 4869 3847 ►
CCG EC012 First outpatient attendances following GP referral 2525 2525 Apr-17 2926 3139 2525 ►
A&E 4 Hour Waits
Summary EB005 % within 4 hours EPSOM AND ST HELIER UNIVERSITY HOSPITALS NHS TRUST 95% 95.2% 95.2% 599 Apr-17 95.2% 96.4% 95.2% ►
Summary EB005 % within 4 hours ST GEORGE'S UNIVERSITY HOSPITALS NHS FOUNDATION TRUST 95% 90.5% 90.5% 1353 Apr-17 90.6% 88.6% 90.5% ▼
Do Not Show A&EEB005 % within 4 hours
Do Not Show A&EEB005 % within 4 hours
Do Not Show A&EEB005 % within 4 hours
Summary EBS05 Trolley Waits >12Hrs EPSOM AND ST HELIER UNIVERSITY HOSPITALS NHS TRUST 0 0 0 0 Apr-17 0 1 0 ►
Summary EBS05 Trolley Waits >12Hrs ST GEORGE'S UNIVERSITY HOSPITALS NHS FOUNDATION TRUST 0 0 0 0 Apr-17 1 0 0 ►
Do Not Show A&EEBS05 Trolley Waits >12Hrs 0
Do Not Show A&EEBS05 Trolley Waits >12Hrs 0
Do Not Show A&EEBS05 Trolley Waits >12Hrs 0
Ambulance
Do Not Show EB015(1)S Red 1 - SECAmb 75% 68.1% May-17 65.6% 67.3% 70.8%
Do Not Show EB015(2)S Red 2 - SECAmb 75% 52.4% May-17 49.8% 49.6% 56.2%
Do Not Show EB016S Cat A19 - SECAmb 95% 89.6% May-17 87.6% 88.3% 91.4%
Scorecard EB015(1) Red 1 75% 75.9% 73.1% 7 May-17 76.0% 78.8% 78.1% ▲
Scorecard EB015(2) Red 2 75% 79.8% 79.4% 200 May-17 77.5% 80.9% 80.2% ▲
Scorecard EB016 Cat A19 95% 96.8% 96.8% 32 May-17 95.2% 96.9% 96.8% ▲
Target Breaches 12M Trend
Safe environment and protecting
from avoidable harm
A&E
Mental Health
Cancer - 2 weeks
Cancer - 31 days
Cancer - 62 days
SECAmb
LAS
Trust Measures
RTT
Activity
Previous MonthsPerformance
YTD
Performance
Month
Latest
Data
SEL/SWL/
KentCode Health Outcomes Framework / Every one Counts
Appendix 2: Sutton CCG Mental Health Performance 2016/17 Target Month Change
Re: EBS3 : 7 Day Follow Ups: Proportion of Service Users followed up within 7 calendar days of discharge 95% 94.1% Worse
RTT - Incomplete Pathway: Percentage of patients on an incomplete pathway that have been waiting less than 18 weeks (month in arrears, 2 appointment proxy for community services).
92% 96.6% No Change
Re: EBS4 : Zero Tolerance for RTT waits >52 wks: Number of Service Users waiting over 52 weeks for Treatment (2 appointment proxy, month in arrears)
0 0 No Change
Completion of a valid NHS Number field 99% 99.9% No Change
Completion of Mental Health Minimum Data Set ethnicity coding 90% 99.0% No Change
Duty of Candour Breach 0 0 No Change
Re: EH4 : EIP : Percentage of Service Users experiencing a first episode of psychosis who commenced a NICE Concordant package of care within two weeks of referral
Local Requirements
Access Requirements
Access to services - CMHTs 1: Percentage of patients that were assessed within 28 calendar days of referral. (Non-Urgent Referrals) 80% 88.2% Worse
Access to services - OPCMHTs 1: Percentage of patients that were assessed within 28 calendar days of referral. (Non-Urgent Referrals) 80% 84.5% No Change
Access to services - CMHTs 2: Percentage of patients that were assessed within 7 calendar days of referral. (Urgent Referrals) 90% 100.0% Better
Access to services - OPCMHTs 2 :Percentage of patients that were assessed within 7 calendar days of referral. (Urgent Referrals)
Face to face Gatekeeping: Ratio of all informal admissions to the number which are gate-kept by CR/HT service (face to face contacts only) 95% 100.0% No Change
Delayed transfers of care (DTOCs): DTOCs as a proportion of bed days 3% 8.8% Worse
Cluster Requirements
Clustering Extent:Proportion of patients seen face to face at least once and have a valid cluster 95% 98.4% No Change
Cluster Timeliness:Proportion of clustered service users that have an in-date cluster 95% 93.0% Better
Serious Incidents
Ensuring timely STEIS investigations: (Submission to Merton CCG) Number of STEIS reports that have not been submitted to Merton CCG and are overdue (past their 60 day deadlines).
0 1
Completeness of STEIS Investigations: Percentage of STEIS Reports where Merton CCG has requested further details 30% 0
Crisis Care & Readmissions
The proportion of users on CPA with a collaborative crisis plan in place (R6) 90% 93.5% No Change
% of discharges (excluding respite care : incl adult & older people) subject to unplanned readmission within 30 days 7% 2.8% Worse
DNA
% DNA 1st appointment 14% 9.7% No Change
Follow up after DNA - HTTs: Percentage of HTT clients who have a follow up attempted within 24 hours of DNA 85.0% 100.0% Better
Patient Experience & Carers
% of complaints acknowledged within 3 working days 100% 57.1% Worse
% of complaints responded to within timescale 95% 57.1% Worse
% of people on CPA who have had a care review who brought a friend and/or were given the opportunity to bring a friend, relative or advocate with them.
100% 75.5% Better
Percentage of appointments for patients on CPA that are cancelled by the provider 3% 1.9% No Change
Percentage of carers who have been offered a carers assessment
Learning Difficulties / Autism
% of inpatients where the field to capture learning disability and/or an autistic spectrum disorder (including Asperger's syndrome) is completed
100% 85.2% Better
% of inpatients with an LD/autism ICD10 code have had, at the time of discharge, a CPA (or CTR) within last 26 weeks (or, if not, a date for the review has been agreed).
100% 0
Mental & Physical Health
% of trust caseload with smoking status recorded in electronic record 80% 86.5% No Change
Ensuring Physical Health for Inpatients: All service users to have a Physical Health Assessment attempted within 48 hours of their admission.
98% 85.7% Worse
Ensuring Physical Health for Long Stay Inpatients: All inpatient service users to have a physical health assessment every six months (or more often)
Care Planning
% CPA reviews/care plans sent to GPs within 2 weeks 50% 75.5% Worse
% of patients on CPA with outcome recorded 95% 75.5% Worse
Each person on CPA and seen more than once has had their care plan reviewed within 30 days 95% 89.9% No Change
Safeguarding
% of eligible staff shall receive appropriate (as directed by the provider's policy) Adult safeguarding training across the whole organisation (Level 1)
95% 93.2% Worse
% of eligible staff shall receive appropriate (as directed by the Provider's policy) Children's safeguarding training across the whole organisation (Level 2)
95% 94.1% No Change
% of eligible staff shall receive appropriate (as directed by the Provider's policy) Children's safeguarding training across the whole organisation (Level 3)
Data Quality Incl Review
Patient identity data completeness metrics (from the MHSDS): Average percentage completeness of NHS number, date of birth, postcode, gender, GP and commissioner organisational code
97% 100.0% No Change
Outcome Measure Data Quality: % CPA patients have up to date HoNOS 95% 90.5% Worse
Ensuring a timely review of service users on CPA: Quarterly Snapshot of Current Caseload 98% 96.4% Better
Service Users on the CPA to have two or more recovery outcome goals recorded on RiO (Promoting recovery orientated practice). 75% 86.1% No Change
Pharmacy
Delayed & omitted medicines audit result
Other
Communication with Primary Care at point of Discharge: All service users to have a discharge summary sent to the GP within 24 hours of discharge (IP and Daycase Only)
100% 72.7% Worse
The number of episodes of absence without leave (AWOL) for patients detained under the Mental Health Act 1983 on acute wards on sections 2 and 3
CAMHS & Related Specialised Related Services
Access
Length of wait time for access to Tier 3 CAMHS (average weeks) 8 4.9 Worse
% of young people seen within 8 weeks of referral to Tier 3 CAMHS (first assessment) 80% 87.5% Worse
% of young people seen within 12 weeks of referral to Tier 3 CAMHS (first assessment) 90% 95.8% Worse
% of young people referred to CAMHS for an urgent appointment seen within 5 working days (number and percentage) 95% 100.0% No Change
% of young people referred to CAMHS as an emergency seen within 24 hours (number and percentage) 95% 100.0% No Change
% of Tier 3 triage referrals received by CAMHS from all agencies where the child or young person received a service (defined as one or more face to face/phone contacts)
90% 100.0% No Change
% DNA 1st appointment 14% 4.5% Worse
% DNA follow up appointment 14% 5.0% No Change
Percentage of children referred to the Eating Disorder Service for an urgent appointment who are assessed within 5 working days of referral
95% No Cases
Percentage of children referred to the Eating Disorder Service for an emergency appointment who are assessed within 24 hours of referral 95% No Cases
Percentage of children referred to the CAMHS Tier 3 Eating Disorder Service for a routine appointment who are assessed within 4 weeks of referral
95% 100.0% No Change
Average length of wait time for access to CAMHS Tier 3 Eating Disorder Service (weeks) 4 1 Better
Percentage of young people referred to the ASD/ADHD Service for a routine appointment who are seen within 8 weeks - Wworth CCG
Average wait time for access to CAMHS ASD/ADHD Service (weeks) : average over all CCGs 12 8 Worse
Percentage of young people referred to the ASD/ADHD Service for a routine appointment who are seen within 12 weeks - All CCGs 90% 73.3% Worse
Number of episodes on adult facilities for patients who are 16-17 years old 0 0 Worse
% Paired Measures 90% 91.7% Better
% of children and young people in EET 90% 96.8% Better
% Goals set for those interacting with the service more than once 90% 100.0% No Change
% of service users who have responded within or to their latest course of treatment; including assessments (e.g. CHI-ESQ) 93.8% Worse
Experience and Quality
Patient Experience & Carers
% of patients feeling safe on an in-patient unit 80.0% Worse
% of community patients saying that overall their care in the last 12 months was good, very good or excellent 65.8% No Change
CAMHS : Crisis
Number of children attending A&E due to self harming/attempted suicide/alcohol harm/substance misuse 10 Worse
Number of young people assessed through the 136 Suite