THE SCOTTISH PATIENT SAFETY PROGRAMME (SPSP)admin.fifedirect.org.uk/weborgs/nhs/uploadfiles/... ·...

Delivering for QualityIntegrated Performance Report

October 2015

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Contents Page(s)

Executive Summary 3 - 4

Section A – LDP Standards Performance Summary 5 - 7

Targets on Track Short Report 8

Chief Executive’s Performance Escalation

Cancer 62-Day RTT 9 - 10

18 Weeks RTT 11

Patient TTG 12

Outpatient Waiting Times 13 - 14

A&E 4-Hour Waits 15

HAI Sabs / HAI Report 16 - 24

Sickness Absence 25 - 27

Dementia 28 - 29

Delayed Discharge 30 - 31

Smoking Cessation 32

Alcohol Brief Interventions 33

CAMHS Waiting Times 34 - 35

Psychological Therapies Waiting Times 36 - 37

Section B - Capital Programme 39 - 45

Section C - Financial Position 46 - 51

Section D- Scottish Patient Safety Programme 52 - 61

Section E - FOI 62

Section F - Complaints 63 - 65

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EXECUTIVE SUMMARYOBJECTIVE OF THE REPORT

The object of the Integrated Performance Report (IPR) is to provide assurance to the Board on the overall performance of NHS Fife against the corporate aims relating to National Standards (as described in the Local Delivery Plan), local priorities and significant risks.

OVERVIEW

A new style report was introduced to the Board for the first time in June as part of a series of changes to improve the Board’s Integrated Performance Management arrangements.

Within section A, LDP Standards Performance Summary, the report format and content were modified to focus on those areas where improved performance was required (i.e. those areas with an AMBER or RED RAG status). Our traditional Action Plan has changed, to focus on identification of recovery actions with clear accountabilities and timescales which correlate to improvement trajectories and accurate forecasting of achievement of the performance level required.

The rigour of monitoring progress against plans has increased through frequent, focused meetings of a group tasked specifically to concentrate on delivery of the required levels of performance. The Executive Directors established a platform to review Finance and Performance on a weekly and monthly basis. The structure is detailed below.

The above structure supports delivery on the ground and provides assurance to the Finance & Resources (F&R) Committee and to the Board that systems and processes are being rigorously reviewed through the Executive Directors Group (EDG).

In parallel, the Acute Services Division (ASD) has established a revised method of performance reporting and has introduced monthly Directorate Performance Reviews to improve the rigour of performance management across its Directorates.

Performance Packs within Health & Social Care Services have also now been developed, in a similar format to those of ASD.

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RECENT CHANGES AND CHANGE PROPOSALS

Two significant changes have been implemented in November:

Due to performance falling below expectations, the report on Alcohol Brief Interventions (ABI) has been moved from the ‘Short’ section of the report to the ‘Escalation’ section, under Health & Social Care. A Recovery Plan has been produced, along with a summary of Key Risks and Concerns.

Following approval of the revised Improvement Trajectories for the 18 Weeks RTT and Patient TTG targets at the October Board Meeting, the new figures are reflected in the LDP Standards Performance Summary

The previous intention to add a section to the report covering the Programme Management Initiatives is not yet included, although a separate paper on this topic is being presented at the meeting.

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SECTION A: LDP STANDARDS PERFORMANCE SUMMARYThe NHS Fife Board receives performance data in the IPR. The source of data varies and can be derived from validated published sources, official government returns and databases, and local management information from a variety of internal sources. It is important to note that whilst local management information provides a more up to date position, data validation processes may not have been completed and this information may therefore be subject to change.

The shading used in the tables below reflects the performance figures in relation to their 'planned' value (or 'standard' value if no 'planned' value is specified); a figure which is no more than 5% behind is shaded Amber.

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TARGETS ON TRACKNHS Fife continues to meet or perform ahead of the following National Targets and Standards:

Antenatal Access: at least 80% of pregnant women in each SIMD quintile will book for antenatal care by the 12th week of gestationLocal management information shows that NHS Fife has continued to record a performance level of over 80% in all SIMD quintiles. The lowest-performing quintile for the 3-month period ending July was Quintile 4 (Quintile 1 is most-deprived, Quintile 5 is least-deprived), with a figure of 87.8%. The highest-performing quintile was Quintile 5 (92.5%), while the overall NHS Fife figure was 90.0%.

HAI: we will achieve a maximum rate of C diff infection in the over 15s of 0.32Local management data for the 12-month period ending October indicates a C difficile rate of 0.23. This is the lowest infection rate reported since the 12-month period ending May 2014.

IVF: no eligible patient will wait longer than 12 months for screening following referral from Secondary CareAll NHS Fife patients continue to be screened within 12 months, via the service run by NHS Tayside. The latest management information (for the month of September) also confirms that no patient currently waiting for screening has waited beyond 12 months.

Cancer Waiting Times - we will treat any cancer patient within 31 days of decision to treatLocal management information shows that NHS Fife has exceeded the 95% standard in every month of 2015-16 to date, the most recent monthly figures being 96.3% (August) and 96.8% (September).

Drug and Alcohol Waiting Times: at least 90% of clients will wait no longer than 3 weeks from referral to treatmentThe September ISD publication, covering the second quarter of 2015, showed that 99.1% of patients were seen within 3 weeks of referral for treatment between April and June. This is the highest quarterly performance ever reported by NHS Fife, and the figure was only exceeded by one other Health Board. Given that performance has risen consistently against a 10% increase in referrals during the last 12 months, this is particularly noteworthy.

Diagnostics Waiting Times: No patient will wait more than 6 weeks to receive one of the 8 key diagnostic tests - barium studies, non-obstetric ultrasound, CT, MRI, upper endoscopy, lower endoscopy, colonoscopy, cystoscopyThe number of patients waiting more than 6 weeks for a test fell slightly at the end of September, continuing the improvement seen over the second quarter of 2015-16. The total number of patients on the list at month end was 3,435, with 7 patients waiting more than 6 weeks for a non-Obstetric Ultrasound and 5 patients waiting more than 6 weeks for one of the ‘scopes’.Detect Cancer Early: at least 29% of cancer patients will be diagnosed and treated in the first stage of breast, colorectal and lung cancerThe measure for this target covers a rolling 2-year period, and the NHS Fife target of 29% covers 2014 and 2015. Local management information for the 2-year period ending June 2015 shows that we remained slightly behind plan, though continuing to improve in both Colorectal and Lung specialties. The Stage 1 Detection Rate for Breast Cancer has scarcely deviated from around 42.5% over the last two years.

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CHIEF EXECUTIVE’S PERFORMANCE ESCALATIONACUTE SERVICESCLINICAL ACCESS & SUPPORTCANCER 62 DAY REFERRAL TO TREATMENT

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

Key Concerns & Risks

As described in previous reports there are a number of areas of risk in achieving this target, namely around Urology and Lung Cancer, including recruitment, liaison with tertiary providers and diagnostics and visiting oncology capacity.

Performance against the 62-day target remains a challenge however the actions taken have prevented any further deterioration.

Recovery Trajectory

Situational Analysis

In the recovery plan for this target there are 7 actions which have a Red or Amber RAG status. The timescales for completion of these have been extended, as shown by light amber colouring. One additional action (2.9) has been added.

Waits for urology oncology appointments are a challenge. A review of outpatient capacity is underway to find ways to increase capacity to meet the demand.

Challenges with vacancies continue to be difficult to resolve with primacy, rightly being given to on-call and ward cover. Targeted additional activity is being undertaken wherever possible and funding from the Scottish Government has been provided to assist with this. These actions have resulted in steady improvement. There is continued effort to recruit.

There are concerns that waits for Fife patients requiring prostate surgery in Lothian will deteriorate due to the unexpected absence of a surgeon. Alternative solutions are being explored with NHS Lothian.

A review of administrative processes and those for review of investigations in urology patients has been completed and it is expected that actions to deliver improvements in the 62-day pathway will be completed by the end of December.

The Inter-Hospital Transfer Policy has been finalised and is awaiting final sign off from NHS Lothian. This has currently stalled due to workforce issues in Lothian however, ahead of sign off, the principles within the policy are being followed. It is anticipated that this action will turn to green in November.

The Standard Operating Procedure alluded to in measure 4.3 is finalised and is being implemented thus completing this action.

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Recovery Plan

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18 WEEKS REFERRAL TO TREATMENT

At least 90% of planned/elective patients will commence treatment within 18 weeks of referral

Following three successive months when performance was above trajectory, we slipped behind plan in August.


The key specialties at risk of not meeting 18 weeks RTT are Urology, Oral Surgery, Neurology and Vascular Surgery. This is driven by vacancies, increasing demand and a demand-capacity gap as described at the recent Board development session.

NHS Fife continues to meet with Scottish Government regarding resilience around this target and discussion is live regarding resourcing of the demand-capacity gap. Plans are being implemented to outsource activity, undertake local waiting times initiatives and increase local provision.

Recovery Trajectory

Recovery Plan

The Recovery Plan for 18 Weeks RTT is covered by the delivery of the Patient Treatment Time Guarantee and Outpatient Waiting Times Recovery Plans shown in the relevant sections on the following pages.

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PATIENT TREATMENT TIME GUARANTEE

We will ensure that all eligible patients receive inpatient or day case treatment within 12 weeks of such treatment being agreed

Performance in this area continues to improve and is currently ahead of trajectory.


At risk specialties for Inpatients and Day Cases are Orthopaedics, Oral Surgery, General Surgery, Urology and Ophthalmology. Whilst an internal mitigation continues to be delivery of additional activity, this is not as resilient as we would wish due to issues such as the availability of anaesthetic cover, use of locums and availability of Operating Department Practitioner (ODP) staff. Agreement is in place with a neighbouring Board to assist in the treatment of a small number of specialised ophthalmology cases. The additional activity being undertaken in outpatients may adversely impact on inpatient and day case waiting times.

Recovery Trajectory

Recovery Plan


There are 3 actions which have a Red or Amber RAG status. Where a revised completion date is known, this is shown by light amber colouring.

Active recruitment to a number of consultant posts is underway as potential candidates have been identified.

The Day Surgery clinical group continues to meet monthly with the aim of improving usage of the Day Surgery Unit in QMH and improvements are planned in terms of theatre utilisation, pre-assessment and procedure selection. It is anticipated that this action will move this measure from Amber to Green RAG.

The action to transfer Phase 2 to Phase 3 theatres is being explored via a review of theatres as part of the Optimising Surgical Efficiencies project.

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OUTPATIENT WAITING TIMES

At least 95% of patients (stretch target of 100%) will have their first outpatient appointment within 12 weeks of referral. Additionally, we must eradicate waits over 16 weeks.


Performance in outpatients continues to be a significant challenge although the actions taken have prevented further deterioration.

The at-risk specialties are Urology, Dermatology, Neurology, Gastroenterology, Cardiology, Respiratory Medicine, Orthopaedics and Oral Surgery. Recruitment into Consultant vacancies in key specialties is particularly challenging.

Discussions continue with the Scottish Government to consider resources to clear the backlog in outpatients waiting over 12 weeks as well as sustainable solutions to meet the ongoing gap in outpatient capacity identified through the capacity and demand exercise.

Plans are in place to outsource activity and undertake local waiting times initiatives in all of the at-risk specialties. Given the size of the challenge the timescale for delivery of improvement is likely to extend until March 2016.

Recovery Trajectory

Recovery Plan


The recovery plan shows that 5 actions are rated as Red or Amber for delivery. Where a revised completion date is known, or an additional action is in place this is shown by light amber colouring.

The focus is on recovery of the current backlog in outpatients waiting over 12 weeks. Significant effort is being put into delivering additional activity to clear this, but this is highly dependent on the availability of skilled workforce across a number of specialties and departments.

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Work by directorates to identify solutions to meet the gap in outpatient capacity continues but consultant vacancies in a number of key specialities makes planning for this a significant challenge reflecting the continued Amber status.

An action highlighting the need to recruit to vacant consultant posts has been added. There are difficulties in recruiting to Gastroenterology, Cardiology, Respiratory and Neurology, reflected in the Red status for this action.

There is an active programme of work in place to redesign the urology DTC. The number of patients waiting over 12 weeks and the challenges to develop and sustain the appropriately skilled workforce to deliver the improvements means that the timescale for delivery has been extended to March 2016.

The outpatient redesign work is a three year programme. Project Management resource is being put in place to support the development and delivery of this work. This will move this action to Green.

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EMERGENCY CAREA&E 4-HOUR WAITING TIME

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

For 6 successive months performance has been ahead of trajectory and is on target to achieve the year end required performance.


A number of risks remain in the system including recruitment to vacant medical posts across the Directorate, admission numbers, flexibility of the ambulance service response to same day discharge and a significant increase in the number of patients in delay.

Recovery Trajectory

Note that the ‘Actual Performance’ figures shown are 12-month averages, not figures for the individual months.

The performance figure for all Fife for the single month of October was 97.3%, with the ED at VHK itself recording a performance of 96.1%. Monthly performance has exceeded 95% in every month of FY 2015-16 to date.

A weekly review of ED breaches to help improve performance further is in place.

An additional discharge ambulance started on 1st October, for a six month period, while an internal transport option will start from 26th October. Strategic and operational ambulance meetings have been reinstated and will commence in November.

A new assessment model in AU1 was introduced on 19th October, and Capacity within Ambulatory Care (ECAS) increased from the same date.

Recovery Plan

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BOARD WIDEHAI SABS

We will achieve a maximum rate of staphylococcus aureas bacteraemia (including MRSA) of 0.24


The actions described will ensure that reductions already achieved in preventable (hospital acquired) SAB numbers are maintained and increased. Infections related to invasive devices such as peripheral venous cannulae (PVC) and urinary catheters constitute the single biggest preventable cause and are a particular area of focus.

Hospital SABs made up 29% of the total in the last twelve months (28 of 97), with the remainder arising spontaneously in the community. There is a risk that community case numbers may negate gains made through hospital improvement programmes.

Recovery Trajectory

Recovery Plan


Even though all of the actions specified above are being executed, there has been no significant reduction in the infection rate during the first half of 2015-16. As the target is measured over a 12-month period, we know that we have already had more cases this FY (74) than could see us achieve a rate of 0.24 by March 2016. The challenge now is to see a sustained reduction over the second half of the year.

A test of change using revised PVC documentation is taking place in a single Acute Hospital ward, with a roll-out to other wards starting when sustained improvement is evident.

Within the community, collaborative work with Addition Services is underway, to investigate if early intervention in needle exchange schemes can identify localised infection and offer treatment to prevent invasive infection in the intravenous drug user population in Fife.

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Healthcare Associated Infection Reporting Template (HAIRT) Update

1. Key Healthcare Associated Infection Headlines for October 2015

1.1 Achievements

C difficile infection rates continue to be below target and below national average.

1.2 Challenges

SAB case rates have started to rise (primarily from community sources). In the first 7 months of the year, there were 74 cases (against 60 for the corresponding 7 months of 2014-15).

PVC related SABs were virtually eliminated in 2014, but reappeared in 2015. This trend must be reversed if the 2016 target is to be met.

CDI case numbers must be reduced by an average 4% per year to offset the decrease in TOBD denominator for the rate calculation.

2. Staphylococcus aureus (including MRSA)

2.1 Trends

SABs

Commentary on quarterly epidemiological data in Scotland: Q2 2015 (April to June)

Fife had 30 cases in the quarter (up from 16 the previous quarter and 27 in the same period in 2014) which equates to 0.42 cases/kAOBD for the quarter.

This is RED against the HEAT trajectory (0.24) however the target is for the annual rate (which was 0.30 - still RED);

NHS Fife is above the national average (0.33) for the quarter, and below national average (0.31) for annual rates;

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The change in quarterly rate was exaggerated by a fall in our Acute Occupied Bed Days from 72,230 the previous quarter to 67,311 in this quarter;

Community cases remain consistent around 60% of the total;

In Q2 2015 the position achieved for NHS Fife SABs slipped back from the positive one in Q1 and case numbers for Q3 (to be published Jan 2016) are 10% higher still, and

On this basis there is a high risk that the Mar 2016 LDP Standard will not be met (though we may remain better than national average).

2.2 National MRSA screening programme

NHS Fife remains well ahead of the target 90%, and well ahead of national average.

2.3 NHS Fife local targets for SAB reduction

By end 2015 in NHS Fife Jan-Oct 15

MRSA to be ≤ 5% of total SABs. 6.67% 6 of 90 Behind plan ↑

Vascular access device SAB to be ≤35% of hospital SAB 50% 13 of 26 Behind plan ↓

PVC related SABs to be halved compared with 2013 11 Plan = 6 Behind plan ↓

2.4 Current initiatives

Continued focus on reducing and eliminating vascular access device related SABs

Fife-wide Collaborative Improvement Initiatives:

Review every SAB to establish source of infection;

Every PVC SAB entered on Datix and subject to SAER, with a time-limited action plan;

Monthly SAB reports to directorates highlighting sources of infection and actions to be taken. Reports will celebrate areas of good practice as well as challenges and improvements required;

SPSP PVC audits reported monthly to wards and directorates, and

Urinary catheter insertion and maintenance bundles to be rolled out to acute and community wards throughout NHS Fife. Areas where bundle embedded and showing sustained improvement to share areas of good practice with peers; tests of change continue.

Acute Directorate Improvements Initiatives:

Tests of change using revised PVC documentation continue in one ward; roll out will commence when sustained improvement is maintained in the test ward.

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Community Improvement Initiatives:

Collaborative work with addition services: community based research project commissioned to investigate if early intervention in needle exchange schemes can identify localised infection and offer treatment to prevent invasive infection in the intravenous drug user population in Fife.

Collaborative work with other health boards to address SAB risk within the intravenous drug user population.

Reduce Other Hospital Acquired SABs:

Continue joint action planning with Health Protection Scotland and other Scottish health boards to identify other areas for intervention.

Reinforce blood samples guidance to junior doctors to reduce contaminated samples.

Target IP&C training based on SAB reports, SAERs and PVC audits.

3. Clostridium difficile

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3.1 Trends

Commentary on quarterly epidemiological data in Scotland: Q2 2015 (April to June)

Age 15+, Fife had 16 cases in the quarter (vs. 13 the previous quarter and 23 in the same period 2014). This equates to 0.24 cases/kTOBD.

This quarter is GREEN against the LDP Standard (0.32) and the 12 month rate of 0.27 was also GREEN;

NHS Fife is below national average (0.32) for the quarter and below national average (0.33) for the year;

As with SABs, community cases average 60% of the total during 2015;

Case numbers for Q3 were similar to Q2, so the current GREEN position vs. the target should be maintained when data to Sep15 is published in Jan 2016, and

CDI data for Apr-Jun 2015 showed NHS Fife annual rate (age 15+) fell to 0.27 per 1000 Total Occupied Bed Days (TOBD). This is below the Scottish average of 0. Current management data indicates a rate of 0.23 to Oct 2015 which is well on track to meet the LDP Standard of 0.32.

3.2 Current initiatives

Continued follow up of all hospital and community cases.

3.3 Risks

The denominator for CDI rate calculations is still based on Total Occupied Bed Days (acute plus community) in Boards, despite the majority of cases arising outside hospital. TOBD in Fife has been falling since 2009 at an average 4% per year. To maintain the current rate, which meets the LDP Standard, case numbers must reduce by a corresponding 4% per year.

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4. Outbreaks

4.1 Norovirus

Preparations are underway for the 2015-16 season

5. Assessment

SAB numbers continue to fluctuate from quarter to quarter, but the fall in cases has not been maintained and further work is needed if the LDP Standard is to be achieved by March 2016.

Continuing low levels of C difficile indicate that the initiatives in place to reduce infection rates are working long-term.

Christina CoulombeInfection Control Manager9th November 2015

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Section 2 – Healthcare Associated Infection Report Cards

NHS FIFE REPORT CARD

Staphylococcus aureus bacteraemia (SAB) monthly case numbers

Nov 2014

Dec 201

4

Jan201

5

Feb 201

5

Mar2015

Apr 201

5

May2015

Jun201

5

Jul201

5

Aug2015

Sep201

5

Oct 201

5MRSA 2 0 1 0 0 1 1 0 1 2 0 0MSSA 1 4 7 1 7 8 14 6 11 10 13 7Total SABS 3 4 8 1 7 9 15 6 12 12 13 7

Clostridium difficile infection (CDI) monthly case numbers

Nov 201

4

Dec 201

4

Jan201

5

Feb 2015

Mar201

5

Apr 2015

May201

5

Jun201

5

Jul201

5

Aug2015

Sep201

5

Oct 2015

Ages 15-64 1 2 1 0 0 0 1 1 2 0 4 3Ages > 65 2 4 1 6 5 2 4 8 2 7 2 6Total 15

plus3 6 2 6 5 2 5 9 4 7 6 9

VICTORIA HOSPITAL, KIRKCALDY REPORT CARD


Nov 2014

Dec 201

4

Jan201

5

Feb 201

5

Mar2015

Apr 201

5

May2015

Jun201

5

Jul201

5

Aug2015

Sep201

5

Oct 201



Nov 201

4

Dec 201

4

Jan201

5

Feb 2015

Mar201

5

Apr 2015

May201

5

Jun201

5

Jul201

5

Aug2015

Sep201

5

Oct2015

Ages 15-64 1 0 1 0 0 0 0 0 0 0 2 1Ages > 65 2 3 0 2 3 0 1 1 1 0 0 1Total 15 plus

3 3 1 2 3 0 1 1 1 0 2 2

QUEEN MARGARET HOSPITAL, DUNFERMLINE REPORT CARD


Nov 2014

Dec 201

4

Jan201

5

Feb 201

5

Mar2015

Apr 201

5

May2015

Jun201

5

Jul201

5

Aug2015

Sep201

5

Oct201

5MRSA 0 0 0 0 0 1 0 0 0 0 0 0MSSA 0 0 0 0 0 0 0 0 0 0 0 2

Total SABS 0 0 0 0 0 1 0 0 0 0 0 2

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Nov 201

4

Dec 201

4

Jan201

5

Feb 2015

Mar201

5

Apr 2015

May201

5

Jun201

5

Jul201

5

Aug2015

Sep201

5

Oct2015

Ages 15-64 0 0 0 0 0 0 0 0 0 0 0 0Ages > 65 0 0 0 0 0 0 0 0 0 0 0 0Total 15 plus

0 0 0 0 0 0 0 0 0 0 0 0

NHS FIFE COMMUNITY HOSPITALS REPORT CARD

The community hospitals covered in this report card are: QMH - Queen Margaret Hospital wards 1-4 LH - Lynebank Hospital WBH - Whyteman's Brae Hospital RWH - Randolph Wemyss Hospital CH - Cameron Hospital GH - Glenrothes Hospital SH - Stratheden Hospital AH - Adamson Hospital SAC- St Andrews Community Hospital QH - QMH Ward 16 Hospice VH - Victoria Hospital Hospice

Staphylococcus aureus bacteraemia (SAB) monthly case numbersNov 2014

Dec 201

4

Jan201

5

Feb 201

5

Mar2015

Apr 201

5

May2015

Jun201

5

Jul201

5

Aug2015

Sep201

5

Oct201


Clostridium difficile infection (CDI) monthly case numbersNov 2014

Dec 201

4

Jan201

5

Feb 201

5

Mar201

5

Apr 201

5

May201

5

Jun201

5

Jul201

5

Aug201

5

Sep201

5

Oct2015

Ages 15-64 0 0 0 0 0 0 0 0 1 0 0 0Ages > 65 0 0 0 0 0 1 0 2 1 0 1 0

Total 15 plus 0 0 0 0 0 1 0 2 2 0 1 0

OUT OF HOSPITAL INFECTIONS REPORT CARD

Staphylococcus aureus bacteraemia (SAB) monthly case numbersNov 2014

Dec 201

4

Jan201

5

Feb 201

5

Mar2015

Apr 201

5

May2015

Jun201

5

Jul201

5

Aug2015

Sep201

5

Oct201

5MRSA 1 0 1 0 0 0 0 0 0 1 0 0MSSA 1 3 7 1 4 6 10 4 8 6 9 4

Total SABS 2 3 8 1 4 6 10 4 8 7 9 4

Clostridium difficile infection (CDI) monthly case numbers of 66

Nov 2014

Dec 201

4

Jan201

5

Feb 201

5

Mar2015

Apr 201

5

May2015

Jun201

5

Jul201

5

Aug201

5

Sep201

5

Oct201

5Ages 15-64 0 2 0 0 0 0 1 1 1 0 2 2Ages > 65 0 1 0 4 2 1 3 5 0 7 1 5

Total 15 plus 0 3 1 4 2 1 4 6 1 7 3 7

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National StatisticsNational surveillance data for C difficile and for SABs (including data for MRSA) has been published by Health Protection Scotland (HPS) for the period to Jun 15

For C difficile, the NHS Fife quarterly rate was 0.24 cases per 1000 Total Occupied Bed Days (TOBD). This is below the Scottish quarterly average of 0.32

For all SABs the NHS Fife quarterly rate rose to 0.45 cases per 1000 Acute Occupied Bed Days (AOBD) – above the Scottish quarterly average of 0.33

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C difficile (over 65) Apr-Jun 15NHS Fife is shown as FF

(below the centre line)

MRSA SAB Apr-Jun 15NHS Fife is shown as FF

(just above the centre line).

C difficile (age 15-64) Apr-Jun 15NHS Fife is shown as FF(on the bottom curve)

Total SAB Apr-Jun 15NHS Fife is shown as FF(above the centre line).

SICKNESS ABSENCE

We will achieve and sustain a sickness absence rate of no more than 4%


Each of the operational parts of the systems are developing action plans in partnership, and at a time of significant change this is more difficult to manage and monitor for services in the community.

The three biggest risks to sustaining the planned reductions are:

Management and HR capacity Any community outbreak of illness (e.g. norovirus) which can impact on short term

absence Increased pressure on the system in terms of patient numbers which in turn

increases pressure on staff capacity and can result in increased absence

Recovery Trajectory

NOTE – the figures quoted are 12-month rolling absence rates, not those for the individual month. This is a better way of demonstrating an improvement trend.

As previously reported, resources have been committed to implement a series of improvement works aimed at reducing the levels of sickness absence. These works include a renewed commitment to delivering attendance management training sessions. During 2015, approximately 270 Managers / Supervisors have been trained to date. The reintroduction of Review & Improvement Attendance Management Panels within the Acute Services Division, Estates, Facilities and Capital Service and the Health and Social Care Directorates, have concentrated on management of short term absence. Following the revision of the Live Positive Stress Toolkit, a Health and Well-being Strategy for the Board has been developed.

The levels of sickness absence level for NHS Fife reduced to 4.58% in August, which was an improvement from the July position of 5.29%, however, there was a slight increase to 4.82% in September.

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Further analysis of the September sickness absence data indicates that this deterioration is due to increases in the levels of both long term and short term sickness absence, with the breakdown for the Board indicating that just over 3000 more hours were lost due to long term sickness absence in September and short term hours lost increasing by 440, when compared with the August position.

In addition, the analysis of the September data for the Nursing & Midwifery staff group has shown that the sickness absence rate per age bracket is proportionate to the breakdown of the nursing and midwifery workforce by age. The September data shows that the age groups with the highest concentration of absence are within the age 45 to 59 groupings, which amounts to 63.37% of the nursing workforce and 21,973.3 hours of the total 34673.5 hours lost.

The top five reasons for absence for these age groups in September are detailed below, broken into long term and short term absences. Further work is on-going to assess what support can be provided to improve attendance in these categories and for staff generally, as part of Well at Work Project.

Similar analysis will be undertaken for other staff groups in future reports, to build up a more informed position of the areas of concern and potential solutions.

16-19 20-24 24-25 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+-5%0%5%

10%15%20%25%30%

Nursing & Midwifery Sickness Absence September 2015

% breakdown of sickness absence within N&M by age

% breakdown of sickness absence by age% breakdown of N&M workforce by age

16-24 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+-5%0%5%

10%15%20%25%30%

Nursing & Midwifery Sickness Absence September 2015

% breakdown of N&M by age group - long and short term absence

N&M Long Term %N&M Short Term %

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Nursing & Midwifery Long Term Absence for Age Groups 45 – 59 (September 2015)

Absence Reason %Anxiety / stress / depression / other psychiatric illnesses 18.99Other musculoskeletal problems 11.21Back problems 4.11Injury, fracture 3.94Genitourinary & gynaecological disorders 3.88

Nursing & Midwifery Short Term Absence for Age Groups 45 – 59 (September 2015)

Absence Reason %Unknown causes / not specified 8.13Anxiety / stress / depression / other psychiatric illnesses 5.72Other known causes 5.47Other musculoskeletal problems 3.78Cold, cough, flu - influenza 3.18

Recovery Plan

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HEALTH & SOCIAL CARE INTEGRATIONThe Chief Officer (Director of Health and Social Care) reports to the Chief Executive, NHS Fife and the Chief Executive, Fife Council. Joint performance review meetings involving both Chief Executives and the Director of Health and Social Care take place on a regular basis in accordance with each organisation’s normal performance management arrangements. The Director of Health & Social Care has overall responsibility for the delivery of the Standards reported in this section and for determining further activity, commissioning and performance data for measuring progress in delivering the aims and objectives of the partnership.

DEMENTIA REGISTRATION AND POST-DIAGNOSIS SUPPORT

We will have a QOF-registered proportion of diagnosed dementia patients consistent with the European measure of prevalence, all of whom will have a minimum of a year’s post-diagnosis support and a person centred support plan

Post-Diagnosis Support Background

The offer of Dementia Post-Diagnosis Support (PDS) which meets the Alzheimer’s Scotland (5 Pillars) standard is relatively new and is in direct response to the national standard having been set. It is in addition to other support/care/treatment which would have been taking place as a matter of routine work.

The current workforce identified for the task comprises a mixture of mental health, psychology, Alzheimer’s Scotland and other resources operating from three geographically based hubs. There has been success in clearly articulating and streamlining pathways to diagnosis and to PDS. This success has now left us with the challenge of managing high referral volumes.

In order to future proof the offer of Dementia PDS in Fife we need to do two things:

Identify additional resources (from within our existing workforce/budgets) Devise a management arrangement which provides a functional level of coordination,

standardisation and quality assurance

Identifying additional resource is currently proving challenging but recent clarification of responsibilities for the Dementia target should make the second action easier to achieve.

Post-Diagnosis Support Performance

Guidance for measuring and reporting on this target, and the target itself, is now expected to be available in December. It is likely that the focus will be on patients diagnosed with dementia and their initial contact with a link/support worker, rather than the previous focus of having 1-year post-diagnosis support and a support plan. When this is clarified, we expect to be able to provide some local performance information and to then consider what type of recovery/improvement is required.


Dementia Registrations

The main risks to achieving the standard are:

Failure to respond adequately to demands for PDS (as it is the existence of PDS which has been used to incentivise GPs and others to refer early to secondary care for diagnosis)

Failure to keep the profile of dementia and dementia registration high with Primary Care colleagues

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Dementia Post-Diagnosis Support

The main risk to achieving this target is:

Managing demand and capacity

Dementia Registration

Recovery Trajectory

Recovery Plan

Dementia Post-Diagnosis Support

Recovery Trajectory

Not available at present, pending further guidance from the Scottish Government around prevalence and the target.

Recovery Plan


Task 1.3 We have been unable to identify additional capacity within the existing workforce. As of 21st September, there were 177 people waiting for post-diagnosis support. Until additional workers can be found we are focusing on maximising efficiencies.

A short piece of scoping conducted by a Senior Nurse has been concluded. An action plan is being created to establish a Fife-wide Team leader from within current resources, to manage and report performance, and to provide a Fife-wide consistent approach to PDS which enhances flexibility and efficiencies.

.

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DELAYED DISCHARGE

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


The actions described in the recovery plan below are expected to support a working solution to the target that no patient will be delayed in hospital 2 weeks beyond being clinically fit for discharge.

The joint Delayed Discharge Task Group continues to monitor and manage the demand for placements and services across the partnership on a weekly basis. A significant amount of modelling work has been undertaken to try to understand the pressures across the system and in particular the reason people are in delay.

A number of initiatives have been developed and will come on-stream in November, in an attempt to reduce the number of people being admitted to hospital; in addition, once a person is ready for discharge home a care team will wrap services around the person to allow him/her to leave hospital as quickly as possible.

There remains a significant demand for long term care; this is currently a pressure on the system due to the cost implications and the ongoing commitment. Currently demand is outstripping available resources.

As part of the Delayed Discharge Action Plan there will be an increase in STAR facilities over the winter and work is underway to determine the capacity available across Fife. This will ensure people will be supported to return home following a period of reablement.

The delivery plan is closely monitored and every effort will be made to mitigate any risk.

Recovery Trajectory

Note that the ‘Actual Performance’ figures relate to the situation at the monthly census, generally taken around the 15 th of the month – the number in delay will vary from day to day.


The actions listed in the plan on the next page are largely on track.

Task 8.1 has been deferred pending the discharge of the existing patients in Step down beds at which point the charging policy will be further considered.

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Recovery Plan

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SMOKING CESSATION

We will deliver a minimum of 602 post 12 weeks smoking quits in the 40% most deprived areas of Fife


The actions described are expected to ensure that NHS Fife will meet its target of successful quits by March 2016.

There are a number of risks that must be considered:

Pharmacy changes which require a new follow-up model to become embedded The increasing rise of e-cigarettes which are being seen by smokers as a stop

smoking aid

These challenges are addressed at a monthly task meeting and actions are put in place where possible.

Recovery Trajectory

In October, the service completed a mapping exercise based on capacity and community needs as measured by smoking prevalence and SIMD data. Clinic activity has been re-orientated accordingly. In addition six new clinics have been established in the Glenrothes area within GP practices due to additional capacity as a result of the move to the Fife-wide model. The redesign to a Fife wide model with East and West Divisions and a single management structure has been completed, with local co-ordinators for each Division in place.

Recovery Plan

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ALCOHOL BRIEF INTERVENTIONS

We will deliver a minimum of 4,187 interventions, at least 80% of which will be in priority settings


The actions described are to ensure that NHS Fife will deliver the required number of ABI during the year.

There are a number of risks that must be considered:

Embedding of alcohol brief interventions in geographical areas of multiple deprivation No identified ABI training co-ordinator post Funding provided from SG in previous years no longer ring fenced for ABI activity

Recovery Trajectory

Although we are a little behind the target, it is possible that this is due to the late return of information for Q2 of FY 2015-16. Addressing this is part of the Recovery Plan, and any late returns will be added to the Q3 submission (due at the end of January).

Recovery Plan

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CHILD AND ADOLESCENT MENTAL HEALTH SERVICE WAITING TIMES

At least 90% of clients will wait no longer than 18 Weeks from referral received to treatment for specialist child and adolescent mental Health Services (CAMHS)


There was a significant spike in referral numbers earlier this year which had a negative impact on our performance over the summer months. Poor performance against this target is primarily the result of a lack of overall capacity but there are also bottlenecks which are being addressed through pathway redesign.

Current improvement plans have been focused heavily on investing in additional staff. Part of our allocation through the mental health innovation fund will be invested in additional capacity. This will have the greatest impact on therapeutic services for looked after children and in the training of the school nurses. In addition, the Scottish Government are still devising their allocation strategy for the new funding (£85M over 5 years), some of which is specifically to improve access to CAMHS.

The current improvement plan and predicted trajectory - which sees us achieving the target by the end of the financial year – has been contingent upon receipt of this new funding. Once the allocation strategy for this new funding has been determined and shared it will be possible to predict more accurately when the target can be achieved. Positive news in relation to our current performance is that NHS Fife’s most recent published average waiting time was 8 weeks and as such is below the national average.

In summary, the main risks to achieving the standard are as follows:

Inadequate capacity to meet demand A sub-optimal distribution of resources and coordination across tiers of service

leading to bottlenecks

The risks are being managed by planned new investment – bidding for Scottish Government mental health innovation fund money and anticipated additional nationally allocated resources; and by a re-design of the existing service to address the distribution issues. In the current absence of the new investment there is now a focus on improving the productivity of the clinical staff working with the high volume low intensity cases.

The service has received confirmation that the innovation funding bid has been successful.

Recovery Trajectory

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Recovery Plan


Task 1.1 In the current absence of any new investment, a new approach is being implemented which focuses on setting and close monitoring of new standards for improved productivity of clinicians working with the high volume low intensity cases. This work has been modelled to produce a month on month improvement and is aimed at matching the previously predicted trajectory.

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PSYCHOLOGICAL THERAPIES WAITING TIMES

At least 90% of clients will wait no longer than 18 weeks from referral received to treatment for psychological therapies


Poor performance against this target is primarily the result of a lack of overall capacity. This assertion has been confirmed by work that was done with Scottish Government QuEST

Current improvement plans are focused heavily on investing in additional therapists utilising the Scottish Government new funding (£85M over 5 years) some of which is specifically to improve access to Psychological Therapies.

The current improvement plan and predicted trajectory - which sees us achieving the target by the end of the financial year – is based on using this funding. More accurate plans can now be determined as to when the target can be achieved. In the meantime strategies are being progressed for:

diverting referrals at an earlier stage towards self help expanding our group work programme (appropriate for a proportion of new referrals

for people with anxiety and depression).

A recent success in relation to self help has been the rollout of computerised CBT ('Beating the Blues') as part of an EU wide programme being organised and supported in Scotland by NHS24. Within Fife over 350 people have been referred to 'Beating the Blues' since it was first made available ten months ago.

The main risks to achieving the standard are as follows:

Inadequate capacity to meet demand An absence of other signposting options for referrers leading to high referral volumes An absence of suitable community venues across Fife

The risks are being managed by bidding for anticipated additional nationally (Scottish Government) allocated resources; and by supporting developments such as an investment in a European wide initiative widening access to computerised CBT as an alternative to referral. Work is about to start to identify the required community venues for therapy.

Recovery Trajectory

The apparent improvement may not continue due to the temporary absence through the holiday period of a disproportionate number of staff who, in previous months, targeted the high number of patients waiting. Due to the way performance is measured as a percentage of all newly seen patients who are seen within target, this can lead to anomalies.

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Recovery Plan


Task 1.4 Although clinic space has been identified, the completion of this task is contingent on aligning staff to run the therapeutic group work. This ties in therefore with task 1.5.

Task 1.7 Progress has been made with this task. The main problem area for under-provision is Levenmouth, and work is ongoing to attempt to resolve this. The Psychological Therapies Development Lead has joined an H&SC group set up to allocate accommodation across the partnership.

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RECOMMENDATION

The Finance & Resources Committee is asked to:

Note the key items of information highlighted within the Integrated Performance Report

Note the inclusion of revised improvement trajectories in the LDP Standards Summary

CHRIS BOWRINGDirector of Finance24 November 2015

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SECTION BCAPITAL PROGRAMME 2015/16

1. INTRODUCTION

1.1 This report provides an update on the 2015/16 Capital Programme as approved by the Board at its meeting on 24 February 2015.

1.2 The report provides information on the following:

Expenditure to 31 October 2015;

Changes to the Board’s Capital Resource Limit (CRL);

Details of changes in Planned Expenditure;

Estimated Capital Expenditure outturn; and

Capital Receipts

2. EXPENDITURE TO DATE

2.1 The expenditure position shown is for the period to 31 October 2015. Appendix A provides details of the current expenditure.

2.2 For 2015/16 each of the Project Leads have provided an estimated spend profile against which actual expenditure is being monitored.

2.3 The estimated spend profile for the period to 31 October 2015 is £6.119m (46.4% of the total allocation).

2.4 The expenditure to date amounts to £5.155m. This represents 39.0% of the estimated annual expenditure (Appendix B). The main areas where expenditure has been incurred since the previous report to the Board are as follows:

Statutory Compliance/Backlog Maintenance £0.601m Stratheden IPCU £0.258m General Hospitals & Maternity Services £0.117m

2.5 Total expenditure to date is £0.964m behind the profiled trajectory and this is primarily due to the Statutory Compliance/Backlog Maintenance and Minor Capital Works schemes slipping from their projected timescales.

3. CHANGES TO CAPITAL RESOURCE LIMIT

3.1 Since the approval of the Capital Programme for 2015/16 by the Board, no changes have been made or are expected to be made to the available Capital Resource Limit.

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4. CHANGES TO PLANNED EXPENDITURE 2015/16

4.1 Appendix C shows the changes in the plan resulting from changes in allocations and from updated estimates for schemes already approved. There have been no major changes to allocations since the previous report to the Board.

5. CAPITAL EXPENDITURE OUTTURN

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

6. CAPITAL RECEIPTS

6.1 For 2015/16 the Capital Programme is partly funded through Capital Receipts from the sale of properties. The estimated value of Capital Receipts required to fund the Capital Programme is £3.650m and is based on the expected sale of Land at Lynebank Hospital and the conclusion of the sale of Forth Park Hospital. Whilst discussions are ongoing with interested parties for the sale of land at Lynebank it is now apparent that Planning Permissions will not be received in time to allow the sale to be concluded before 31st March 2016. There would also appear to be little likelihood of the sale of Forth Park Hospital going ahead this financial year as there is currently no market interest. As these sales are unlikely to materialize this financial year there would be a potential overspend of £3.5m against CRL. We are therefore in discussion with SGHSCD to assist in managing the situation over the year end.

7. RECOMMENDATION

7.1 The Finance and Resources Committee is asked to:

note the Capital Expenditure to 31 October 2015;

note the current Capital Resource Limit position;

note the changes in Planned Expenditure;

note the Capital Expenditure outturn; and

note the Capital Receipts position.

CHRIS BOWRINGDirector of Finance

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24 November 2015

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SECTION CFINANCIAL POSITION TO 31 OCTOBER 2015

REVENUE RESOURCE LIMIT

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

Performance at the end of October is ahead of trajectory. The month on month trend seen since July is very positive; however there is concern about ongoing delivery of the agreed recurring efficiency schemes and identification of further initiatives required to deliver a break even position at the year end.


The Revenue Resource Limit position for NHS Fife for the seven months to 31 October 2015 is showing an overspend of £2.263m. This compares with a £3.045m estimated overspend as included within the Board’s LDP.

Whilst the approved Financial Framework sought to address all likely costs and national, regional and local priorities, it is evident that there will always remain inherent uncertainties and associated risks. The key concerns and risks which have been reported in previous months remain extant:

Continued financial exposure of the delivery of elective and unscheduled care capacity requirements for RTT and waiting times targets;

Management of sickness absence and the resultant impact on additional staff for both medical and nursing;

Pressures within the Primary Care Emergency Service (PCES).

Financial risks and implications of the challenges around delayed discharges and planning for winter.

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Recovery Trajectory

Month May June July Aug Sept Oct Nov Dec Jan Feb MarchActual (1,294) (1,848) (2,238) (2,234) (2,465) (2,263)Plan (1,131) (1,696) (2,134) (2,581) (3,104) (3,045) (2,994) (2,758) (2,140) (1,023) 0Forecast Outturn 0 0Overall Target 0 0 0 0 0 0 0 0 0 0 0

Recovery Plan

A range of forecast outturns for the financial year end has been produced through discussion with operational budget holders. Based on the continuing improvement in the monthly expenditure position, it is estimated that a breakeven position could be achieved. This, however, is entirely predicated on full delivery of all remaining efficiency savings which are due to be implemented in the second half of the financial year. Failure to deliver in full would result in an estimated c. £4m overspend at the year end.

The ability of operational budget holders to identify and deliver cash releasing savings on current budgets remains hugely challenging. Whilst the major change programme now underway across the system will support the identification and delivery of specific projects and workstreams to ensure a more strategic approach to efficiency in future years, it is unlikely to result in any significant financial impact this year. As such, it is critical that the Executive Directors Group consider further potential management actions to support delivery of a balanced financial position by 31 March 2016.


An overview of the overall financial position is set out below.

1. Financial Framework

1.1. The Financial Framework for 2015/16 was approved by the NHS Fife Board on 28 April 2015, subject to further action to close the gap in the level of savings identified at that time. Approval of the Financial Framework by the NHS Board enabled Executive Directors to receive details of their initial annual budgets for 2015/16. All opening budgets have been signed off by the relevant Executive Director.

2. Allocations

2.1. Since the previous report to the NHS Board, we have received additional core allocations from the Scottish Government Health and Social Care Directorate (SGHSCD) of £2.406m. These include additional earmarked recurring funding of £0.606m and additional non-recurring funding of £1.800m.

2.2. The new allocations include £0.850m for vaccines for Flu, Shingles and Rota Virus and the contribution of £0.475m towards the cost of the Police Custody and Forensic Service. Additional funding of £0.395m has been received to support Winter Resilience. Mental Health Innovation funding of £0.288m has also been received in respect of specific bids that were submitted to SGHSCD.

2.3. A full list of allocations received is shown in Appendix A.

2.4. In addition to allocations from SGHSCD the Board also received miscellaneous income from other sources. For the month of October additional sources of income

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amounted to £4.718m and was mostly additional CNORIS income to cover the cost of legal claims. .

3. Analysis of Financial Performance

3.1. A summary for individual divisions and Corporate Directorates is shown below. The overall position for NHS Fife is largely driven by the overspend reported within Acute Services. The key drivers are consistent with the recognised cost pressures and it is encouraging to see the positive impact of efforts to more tightly manage these.

FY CY YTD Actual Variance Variance£'000 £'000 £'000 £'000 £'000 %

Acute Services Division 184,365 188,662 109,222 114,097 4,875 4.46%Integration Services- Community & Primary Care Services 134,691 145,750 84,457 84,250 (207) -0.25%- FHS 35,889 40,353 23,585 23,585 (0) 0.00%- Prescribing 72,336 73,852 43,488 43,461 (26) -0.06%- PMS 46,859 48,804 28,566 28,562 (5) -0.02%Estates & Facilities 65,305 65,401 37,939 38,045 106 0.28%Board Admin & Other Services 31,903 50,818 33,634 32,753 (880) -2.62%Non Fife & Other Healthcare Providers 97,654 105,144 60,718 60,521 (197) -0.33%OHSAS 3,976 4,501 2,774 2,712 (61) -2.20%Depreciation 18,028 18,775 11,232 11,232 (0) 0.00%Reserves- Impairments & provisions 10,000 9,255 0 0.00%- General 29,417 7,291 1,147 (1,147) -100.00%Efficiency Savings (3,230) (5,155) 0 0.00%

Total Expenditure 727,194 753,452 436,760 439,218 2,458 0.56%

Miscellaneous Income (64,266) (86,782) (56,745) (56,940) (195) 0.34%

Net position including income 662,928 666,670 380,015 382,278 2,263 0.60%

Budget Expenditure

Acute Services

3.2. The Acute Services Division is reporting an overspend of £4.875m for the period. The key drivers are consistent with those reported in previous months i.e. the purchase of healthcare from other providers, medical staffing and nursing:

There is an overspend (£432k) on the use of independent healthcare providers for Orthopaedic activity, Dermatology activity, Laboratories and Radiology. The measures put in place to control the use of the independent sector capacity to address treatment time guarantees are reducing the rate of overspend. This is expected to continue to reduce over the coming months.

The use of agency and locum medical staffing to meet the recruitment challenges continues to have a major impact within Orthopaedics, General Surgery, Anaesthetics, Urology, General Medicine, Paediatrics, Neurology, Obstetrics & Gynaecology and Ophthalmology. The overspend on medical staffing is £1.8m for the period.

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There is a relatively significant overspend reported within nursing (£1.8m) which is attributed to both bank and agency usage, and the residual impact of incremental progression. The pressures are apparent across a number of specialties including: Orthopaedics, Obstetrics & Gynaecology, Elderly Medicine, Theatres and Critical Care. Strict controls on the use of agency staff are now in place and whilst any specific requests on the grounds of patient safety need to be considered, this action is reducing the level of additional expenditure with the rate of overspend continuing to slow down.

Integration Services

3.3. Across the former CHP budgets, primary medical services, primary care emergency service (PCES) and family health services, the budgets are showing a net underspend of £212k for the period to date. There are underspends across a range of budgets largely due to vacancies in community nursing, health visiting, school nursing and administrative posts. However, these are offset by the level of expenditure on complex care packages, incremental progression within the Palliative Care service, Mental Health nursing and medical locums. There remains an issue within the Primary Care Emergency service due to sessional rates.

Corporate Services

3.4. Within the Board’s corporate services, including Estates & Facilities, there is an underspend of £774k due mainly to vacancies across a number of departments. However, this continues to mask a pressure within Estates & Facilities on energy and equipment costs relating to service contracts across the system.

Non Fife and Other Healthcare Providers

3.5. The budget for healthcare services provided out with NHS Fife is showing an underspend of £197k for the period. This is based on an estimated underspend of £498k on Service Level Agreements with other Health Boards and an overspend of £323k on Unplanned Activity (UNPACs) and Out of Area Treatments (OATS) activity. The major driver of this overspend is the estimated increased UNPACs activity with NHS Lothian for cancer drugs. The OATS expenditure has increased due an additional Learning Disability patient being treated in England. These remain estimates at this point in the year pending ongoing discussions.

Reserves

3.6. Current estimates suggest that the Board could incur £9.2m on property impairments and provisions during 2015/16. The actual amounts will not be fully known until later in the year, for example once property revaluations have been carried out. The actual costs are matched with additional funding from SGHSCD.

3.7. Funding of £1.147m has been released from the Fife-wide general reserve, offsetting the overall financial position across the system. This recognises any slippage from financial plan commitments and new allocations received and is reviewed on a monthly basis.

Miscellaneous Income

3.8. A small over-recovery in income of £195k is shown for the first seven months of the financial year.

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4. Efficiency Savings

4.1. The Board’s Financial Framework set out the need to deliver a total of £10.143m cash efficiency savings to support financial balance. At the end of October, cash releasing schemes totalling £8.279m had been identified (including those which require further action) with a balance of £1.864m remaining. As previously highlighted, more than 40% of savings delivery remains high risk, which equates to £4.260m for the full year.

4.2. Shortfall in the delivery of the required efficiency savings for the year has not yet been factored into the reported overspend for the period. If non delivery of high risk savings were recognised in the financial position to the end of October, it would increase the overspend for the period from £2.263m to £4.748m.

4.3. The graph below highlights that the planned trajectory assumes back-loading of savings toward the second half of the year and delivery of savings is marginally behind trajectory for the period.

5. RECOMMENDATION

5.1. The Finance & Resources Committee is asked to:

note the financial position for the seven month period to 31 October 2015

consider potential management actions to support delivery of a break even position by 31 March 2016

CHRIS BOWRINGDirector of Finance13 November 2015

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New Allocations Received

Baseline Earmarked Non - Description Recurring Recurring Recurring Total

£ £ £ £

Flu, Shingles and Rota Vaccines 850,420 850,420Police Custody and Forensic Services 475,373 475,373Winter Resilience 394,689 394,689Mental Health Innovation Fund 287,601 287,601Neonatal Managed Clinical Networks 131,304 131,304Information Sharing Board 86,762 86,762Cancer Waiting Times 70,500 70,500Mental Health Waiting Times 65,000 65,000MSK Orthopaedics Quality Drive 33,000 33,000Outpatient Recovery Medinet Admin Support 25,000 25,000Health Visiting Pathway 1,358 1,358Menengitis C -14,771 -14,771

Total New Allocations Received 0 606,677 1,799,559 2,406,236

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SECTION D

THE SCOTTISH PATIENT SAFETY PROGRAMME (SPSP)

1. PURPOSE

The purpose of this report is to update the NHS Fife F&R Committee of the ongoing activity underway across NHS Fife to implement the Scottish Patient Safety Programme (SPSP). This report incorporates progress in September.

2. SITUATION

The aim of the SPSP is to reduce the HSMR by 20% by December 2015; and to ensure that 95% of patients receiving acute care should be free from harms as identified by the Scottish Patient Safety Indicator (SPSI).

The (three) SPSI harms are:

Cardiac arrests Falls Pressure ulcers

A revised measurement plan has been released in response to feedback from NHS Boards on the challenges in providing adequate support across the broad SPSP agenda. The amended measurement plan focuses on elements of work which will best support the aims of reduction in mortality and harm. To facilitate this, measures have been separated in to core and supplementary for the purpose of national reporting.

Core:

Outcome measures relating to the harms of SPSI (including CAUTI) Process measures relating to the harms of SPSI (including CAUTI and Sepsis) Measures relating to Medicines

Supplementary:

Process measures relating to VTE, Heart Failure and Surgical Site Infection

One of the key changes to the measurement plan is the amendment to the pressure ulcer indicator. The new aim is seeking a 50% reduction in the pressure ulcer rate by December 2017.

The “Cauti” harm which was removed from reporting temporarily is expected to join the suite of outcome measures in December since a new definition has been agreed.

CAUTI Definition:

Does the patient have a urethral urinary catheter insitu or has it been removed within the previous 48 hours

CAUTI defined as: Temp <36◦c or >37.9◦c OR 1.5> baseline on 2 occasions in last 12 hours and 1 or more of the following:

o Shaking chills (rigors)o New costovertebral (central lower back) tendernesso New onset or worsening delirium (confusion)

AND: on antibiotics for treatment of UTI

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2.1 HSMR

Chart 1: HSMR (Fife v Scotland)

Chart 1 shows the NHS Fife HSMR in comparison to NHS Scotland. The most recent HSMR data, released in August, demonstrated a reduction of 22.7% since December 2007 with a HSMR of 0.92. This is a slight deterioration from the previous HSMR data release (22.8% reduction, HSMR of 0.88). The next data is due for release on 17 th

November.

Chart 2: HSMR (Fife and Regression Line)TARGET REACHED

Chart 2 demonstrates NHS Fife’s HSMR with regression line.

Although the HSMR target has been reached, the rate has been climbing for the last four quarters.

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2.2 SPSI HARMS

Chart 3: Cardiac Arrests (Acute Hospitals)SUSTAINED DETERIORATION

Chart 3 demonstrates an increase in the median from January 2014 when it increased from 1.3 to 1.6. The daily hospital huddle was introduced during July 2015. The data points for July and August sit just on and under the median. The data has been extracted from the Resuscitation Officer database.

Chart 4: Fall With Harms (Acute Hospitals)RANDOM VARIATION

Chart 4 demonstrates random variation. However although run chart rules cannot be applied yet, the performance from November 2014 appears visually more stable. Data has been extracted from the Datix system.

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Chart 5: Pressure Ulcer Rate Grade 2 to 4 “Developed” in Acute HospitalsRANDOM VARIATION

Median 1 is based on the first 12 months’ data (to provide a benchmark); Median 2 is based on a new median from month 14 (April 2014) to provide a more stable benchmark of activity (recording of pressure ulcers on Datix began with Phase 2 of SPSP which may explain why the first 12 months appear artificially low).

Again although run chart rules cannot be applied, the performance from June 2015 appears improved with the data points sitting under the median. There has, however, been a rise during September.

3. BACKGROUND

3.1 In September 2013, CEL 19 outlined ten patient safety interventions “ten essentials” that should be reliably delivered to every patient in NHSScotland that can benefit from them.

The ten patient safety essentials are:

1. Hand washing2. Leadership walkrounds3. Communications: surgical pause and brief4. Communications: general ward safety brief5. ICU daily goals6. VAP bundle7. Early warning scores8. CVC insertion9. CVC maintenance10. PVC maintenance

3.2 In May 2015, an additional letter from the Chief Executive of Health Improvement Scotland (HIS) advised Boards that they were no longer required to submit national reporting on the “ten essential” data in recognition of the reliable local self-assurance and governance mechanisms that Boards had set in place to ensure that each of these processes were reliably implemented and sustained.

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Healthcare Improvement Scotland has agreed with the Scottish Government that external assurance of the reliable implementation of the ten essentials should be sought via the new Quality of Care Reviews which are currently being designed, within the scope of the annual review processes and through ad hoc Minister updates.

3.3 A series of RAG reports have been developed and are used locally to provide an overview of the implementation and spread of the ten essentials within the Acute and Community Hospitals. In addition, an overview of progress of the additional specialised strands of SPSP is also fed back to the relevant teams regularly.

3.4 A monthly SPSP update is provided for each of the Directorates in the Acute Hospitals and these form part of the performance reviews. A monthly update on the number of reported SABs is included. The SABs provide an “outcome” measure for process measures relating to devices. During the past six months there has been an increase in the reported SABs. These are reviewed at SAER meetings to determine local learning for improvement and prevention.

3.5 A self-assurance framework tool based on the Acute Adult Measurement Plan has been developed locally to assist Directorates within the Acute Hospitals and Community Services to support NHS Fife’s self-monitoring process. The tool provides general guidance around “sustainability” and stepping down processes when improvement measures are truly embedded and are reflected in associated outcomes.

3.6 The development of the Clinical Dashboard across NHS Fife is being led by the Associate Director of Nursing in Acute Services and will provide an overview of the status of performance once all of the patient safety / quality interventions have been migrated onto the system. At present hand hygiene process measures are captured on the system along with some associated outcome measures “Clostridium Difficile and Staphaureus Bacteraemia”. The safety brief process measure has also recently been added.

Ward based data will be entered into LANQIP and exported to the Clinical Dashboard. A series of Standard Operating Procedures (SOP) are being developed to support the robust implementation of the ten essentials. The SOPs are designed to incorporate clear escalation mechanisms and improvement plans to drive improvement.

4. ASSESSMENT

4.1 SPSI HARMS

4.2 Cardiac Arrest / Deteriorating Patient

Following on from the review of cardiac arrests undertaken by the Resuscitation Committee Lead Consultants following a rise in the number of cardiac arrests in January 2015 a Deteriorating Patient Short Life Working Group was set up to address key areas for improvement.

4.3 The group has agreed five key components that should be prioritised:

Robust processes are in place to ensure that Patientrack is embedded. Appropriate management of patients that trigger FEWS by ensuring that the

correct skills and education around Acute Illness Management Training are available to staff

Clear escalation processes in every clinical area Improved decision making around DNACPR and clear management plans Standardised review processes for patients that have previously triggered

Patientrack compliance is provided at Directorate level via the Performance Reports.

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4.4 At the daily hospital huddle led by Professor Mclean the widespread rollout of the Scottish Structured Response Bundle was launched for all wards at VHK. Patients with elevated Early Warning Scores are highlighted during the huddle and assurance sought from the Nursing Team that the correct interventions highlighted in the bundle are in place. Directorates have been asked to monitor compliance with the escalation process.

Chart 6: Days Between a Cardiac Arrest in the Medical Assessment Unit

The last data point (astronomical point) displays the number of days reached without a cardiac arrest occurring in the unit. The chart demonstrates “non-random variation” i.e. “a change in the system”. The “y” axis demonstrates the number of days since the last event occurred. A cardiac arrest occurred during October. The Medical Assessment Unit did however achieve 122 days without a cardiac arrest occurring, which was an improvement.

4.5 An audit tool has been developed to monitor compliance of the Scottish Structured Response at VHK. Weekly monitoring is expected to commence in October.

4.6 Patientrack has now been implemented (at some level) in nineteen wards within the Acute Division. The electronic system provides a standardised track and alerting system that identify patients at risk of deteriorating and then alerts the responsible Clinician so that a timely response is initiated.

4.7 The introduction of Emergency Bleep Meetings to review a sample of cardiac arrests to determine if preventable deterioration has occurred. The purpose of these meetings is to establish if any learning can be gleaned during the reviews to improve systems and processes to improve patient outcomes. The first meeting is taking place during October.

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5. FALLS – PROCESS

5.1 The improvement work around falls is being led by the Associate Director of Nursing in Acute Services. This work links to the Frailty Intervention Group led by Dr Sue Pound. The “Falls Implementation Group” has implemented a number of interventions across NHS Fife which includes a complete overview of the Falls documentation used across NHS Fife and the introduction of comfort rounds.

Examples of improvement initiatives include:

The development of a Falls Prevention Toolkit The development of a post falls bundle (which is being tested) The development of a Rapid Event Investigation Tool Patient leaflet review Testing Falls Hazard Walkrounds “Be a Link in our Chain”; is a piece of focussed work involving patients and carers

5.2 The group is attended by representatives across NHS Fife and the improvement initiatives implemented in acute and community beds.

5.3 Agreement on the process measurement plan has recently been reached and wards have been supported to implement these bundles and commence reporting their compliance. Pareto charts have been developed to highlight areas for prioritised interventions.

5.4 A Standard Operating Procedure is being developed to support implementation of the Falls care bundles and their use in the drive to reduce patient harm.

6. PRESSURE ULCERS - PROCESS

The improvement work around pressure ulcer care is being led by the Associate Director of Nursing/Head of Service Delivery GNEF. The group have progressed a number of interventions which include:

Review of the grading tool Two reviews of Datix recording across both acute and community hospitals to

establish levels of duplicate reporting across services and to gauge accuracy of levels of harm aligned to the pressure ulcer grading assigned

Amendments to the Datix system to reduce duplication Pressure ulcer recording charts now situated with patients at home NHS Fife-wide REI tool developed Learning from themes and trends from REIs and cluster reviews to drive

improvement

The Team are planning to launch the Grading tool and deliver a series of educational drop in sessions for staff across the organisation.

7. CAUTI

7.1 The CAUTI Prevention, Insertion and Maintenance bundles have been widely implemented in inpatient areas throughout the Acute Services Division and Community Services.

7.2 The Short Life Working Group convened to review the improvement processes and documentation used across both the Acute Hospitals and Community Services Division has identified several areas for improvement. Although the focus is to reduce the number of CAUTIs, the Group membership includes professionals with a remit beyond this to incorporate wider continence issues.

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In the Acute Division, the reported infections have been reviewed by the improvement team to determine that they are actually CAUTI infections.

7.3 The national CAUTI Short Life Working Group was reconvened in June with the aim of agreeing a national CAUTI definition. At the meeting the group agreed that the “signs and symptoms” definition was the preferred operational definition that would more effectively drive improvement. The group also agreed that “catheter bed days” as a denominator was a useful measure to determine if the numbers of catheters inserted ultimately reduced.

8. NINE PRIORITIES

1 Sepsis - Improvement work around sepsis began in 2012. Since that time the bundles have been applied:

o 865 occasions in A&E o 381 occasions in AU1o 28 times in AU2o 65 times in ward 34

Chart 7: Sepsis, Time to First Antibiotic Dose

Chart 7 illustrates the “time to first antibiotic dose” for patients that trigger the Sepsis 6 pathway in the Emergency Department. The target of one hour has been reached in the majority of cases; the one significant breach was due to exceptional circumstances which required an external consultation.

The ED Team review every breach in order to identify the reason and to implement learning if required.

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 3623:45

00:00

00:14

00:28

00:43

00:57

01:12

01:26

01:40

01:55

02:09

00:25

00:02

00:1500:10

00:25

00:45

00:3000:3000:4000:4500:45

00:15

00:40

01:0000:55

00:1400:20

00:35

00:1500:20

01:00

00:45

00:10

01:00

00:17

02:09

00:05

00:2300:17

00:2500:13

01:00

01:20

00:1500:28

00:05

Admissions to A & E Time Zero to TFAD

Triggered Sepsix Six Pathway PatientsJuly 2015

Hrs

:Min

s

Time capped at 02:09

TFAD: 03:00hrs - Tazicon - Discuss with N/castle - Lung T/P - patient attends New-castle every 4-6 wks

TFAD: 01:20hrs - Amoxicillin/Gentamicin

Chart 8: Sepsis, First Antiobitic Dose Compliance

Chart 8 demonstrates the improvement that has been made over the last 3 years with compliance in patients receiving the first antibiotic dose once triggering the Sepsis 6 bundle. In July, average compliance was 32 minutes.

2 Deteriorating patients - covered earlier in the report

3 Heart failure - embedded

4 Pressure ulcers – covered earlier in the report

5 Surgical site infections

6 Venous thromboembolism (VTE) - the assessment bundle has been implemented within AU1, and the reassessment bundles have been implemented within Ward 52 (Surgical). Plans to implement the VTE improvement interventions more widely are currently being developed.

7 CAUTI – covered earlier in the report

8 Falls with Harm – covered earlier in the report

9 Safer Medicines - the Pharmacist based in AU1 is measuring compliance with medicines reconciliation on admission within AU1.

8.1 Forthcoming Events

SPSP IA Networking Day 4th February 2016SPSP National Event 9th November

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RECOMMENDATIONS

The Finance & Resources Committee is asked to:

Note the overview of progress for each work stream.

Advise on aspects of the report that they found valuable and if they would value continuing reports in this format

Executive SponsorDr Frances Elliot

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SECTION EFreedom of Information Requests

Freedom of Information Requests received in the period 1st October – 31st October 2015

NumberReceived

SourceNumber

responded to

Responded within 20 days

Responded outwith 20

days

%age of responses within 20

daysMP / MSP / SGHSCD

Commercial Media Other

October2015

38 10 6 11 11 21 20 1 95.2%

October 2014

59 17 0 22 20 59 58 1 98.3%

Please note that at the time of writing 17 requests are still outstanding and remain within the 20 working days.

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SECTION FCOMPLAINTS

We will achieve and sustain response times of no less than 95% (acknowledged within 3 working days) and 65% (responded to fully within 20 working days).

Key Concerns and Risks

Each of the operational parts of the system is developing action plans in partnership with Patient Relations Team.

The actions described will ensure that response times improve whilst the quality of responses are maintained.

The biggest risks to achieving and sustaining the planned improvements are:

Complexity of complaints which cross different organisational units Ownership of complaints Patient Relations Capacity Delay in Director sign off

Recovery Trajectories

3-day Acknowledgement

20-day Completion

Recovery Plan

All identified actions in the Recovery Plan have been progressed, with the redesigned internal departmental processes implemented on 2nd November, which will help to address the risk associated with ownership of complaints.

Action has been taken to address the risk reacting to Patient Relations capacity by utilising a staff member from redeployment and bank to cover unexpected long term absences.

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Delay in Director sign off is currently impacting on performance, as a result of a recent requirement to include the Divisional General Managers and Director for Health and Social Care Integration.

Complaints, Concerns, Compliments and Comments

April May June July August September0

20

40

60

80

100

120

ComplimentsCommentsComplaintsConcerns

Context of Complaints in Relation to Other Forms of Feedback

The Patient Relations Team deal with concerns from patients, their families and the general public. In many instances, this promotes local resolution and prevents issues being progressed to formal complaints. It often involves meeting with people at an early stage to identify what can be done to resolve an issue early on. There is no related target to this work although this forms a significant part of the Patient Relation Team daily workload.

Patient Opinion provides a route for people to tell us about their experience of NHS care anonymously. Seven posts were received during September, 4 of which provided positive feedback about excellent care in the following areas: A&E, Endoscopy, End of Life Care and the Breast Service.

More critical postings indicated issues concerning administration and care issues; however one post in particular shared a very critical personal miscarriage experience.

The approach taken in Fife in responding to posts is to be engaging and to encourage further dialogue with people where significant concerns are raised. In the example of the miscarriage experience, the person concerned agreed to meet with the Head of Midwifery and the Senior Charge Nurse from A&E where she had encountered difficulties. The staff were able to listen directly to the person’s experience and respond empathically and offer a meaningful apology. The person concerned agreed to work with staff to develop patient information relating to miscarriage.

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Ombudsman Cases Concluded in September

The Ombudsman published one report about Lothian NHS Board concerning a Fife patient who had been transferred for cardiac investigations and subsequently underwent cardiac surgery. The Medical Advisor reviewing the case commented on a lack of referral documentation at the point of transfer. A joint recommendation was made, asking the Boards to ensure that the Advisor’s comments were brought to the attention of relevant staff. This has taken place.

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