Performance Report by 6SUjxNYI


									Meeting           Bexley Formal Clinical Commissioning
Agenda Heading    For Information
Enclosure         K – 33/12
Date of Meeting   23 February 2012

Title of report   Performance Report to January 2012

Next Steps        Report to be discussed at Performance meetings
                  which are to be set up. Cluster January report will go
                  to Finance and QIPP meeting and also Board

Executive summary

2012/13 Trajectories

The BSU has submitted local trajectories for 3 targets as part of the Operating
Framework and formal feedback has yet to be received. As previously reported, the
BSU has received informal feedback on 2 of the targets, namely Smoking Cessation
where a case is being made for a more achievable target to be agreed and the
smoking team have provided comprehensive evidence to show that our target is out of
line with the rest of the Cluster, the feedback here is that NHS London will need to
review this evidence and make a decision; with regard to the health check trajectory,
there is a large movement in the cohort of eligible clients compared to this year and
the feedback is this may be challenged, however, we have evidence that this year’s
figure is incorrect and a more appropriate figure is being shown for next year. There
has not been any feedback on the IAPT trajectories.

2011/12 Performance

The latest Cluster performance report is attached at Appendix 1 and gives the details
of the position for targets where performance is below standard and the actions being
taken in order to address the situation. The narrative report is supported by Appendix
2 which is a report on all the performance indicators showing the latest reported
performance for that target and the RAG status (the period being reported on is shown
in one of the columns as it is not consistent throughout the document).

The acute information has been validated locally by the BSU information analyst and
there are two small queries which have been raised with the Cluster, one on maternity
(SQU 12) and one on GP referrals (SRS 11), at the time of writing this report feedback
and clarification was awaited. It should be noted however that locally in some cases
we have more up to date information than is being reported by the Cluster and this is
shown on our performance report which is attached at Appendix 3, there is one
difference between our reporting and the Cluster reporting around healthchecks which
has also been taken up with the Cluster and feedback is awaited.

It should be noted that, whilst not an official target anymore, SLHT have not been
achieving the A & E 4 hour waits in the period October to December 2011.The number
of attendances has also been increasing in this timeframe. SLHT have also been
having problems with the new A & E clinical quality indicators especially around time
to treat and total time in A & E, the Cluster are following up on this on our behalf.

I have only set out here issues from Appendix 1 and 2 which need to be brought to the
Committee’s attention. Cluster has also reported on actions taken to date where
targets are not being met.

The areas of concern, all of which are RED rated are as follows;

      CDiff rates at SLHT, Kings and Guys (Cluster lead)
      Mixed Sex Accommodation breaches at SLHT (Cluster lead)
      Non elective activity for Bexley significantly greater than plan assuming correct
       plan is being used (Cluster lead)
      % proportion of people who have had a stroke who experience a TIA are
       assessed and treated within 24 hours (Cluster lead)
      Prevalence of breastfeeding at 6-8 weeks 47.9% ytd
      Number of GP written referrals, assuming plan figures are correct, are
       significantly greater than expected (Cluster lead but GPs influence)
      Number of other referrals again significantly higher than the plan, assuming
       plan numbers are correct (Cluster lead)
      Number of first outpatient attendances after GP referral much higher than plan
       numbers (Cluster lead but GPs influence)
      All first outpatient attendances over planned numbers (Cluster lead but GPs
      % of all adult inpatients who have had a VTE risk assessment very poor at
       SLHT (Cluster lead)
      Diagnostic waits at SLHT, Guys and Kings (Cluster lead)
      RTT especially at Guys and SLHT and further meetings are planned to try to
       rectify the situation (Cluster lead)

Areas to watch which are AMBER rated are as follows;

      Access of NHS Dentistry (Cluster lead – Primary Care)
      % of patients receiving first definitive treatment for cancer within 62 days of a
       consultant decision to upgrade their priority status (Cluster lead)
      % of patients treated in 62 days from GP referral, consultant referral and
       referral from screening programme particularly at Guys (Cluster lead)
      % of patients receiving subsequent treatment for cancer within 31 days where
       the treatment is Radiotherapy Treatment Course (Cluster lead).

Appendix 3 is the local report on all targets which is produced by the BSU information
analyst. All of the above are included in this table but there are some additional
targets being reported such as Public Health targets and those associated with the
Local Authority which should be brought to your attention as they are currently either
red or amber. These are;

      % of completed referrals for home equipment within 7 days which is a Local
       Authority target currently rated AMBER as it is 97% in December against a

       target of 98% which is an improvement from October and November.
      Number of urgent and emergency journeys via ambulance rated as RED,
       activity way over plan (Cluster issue)
      Cat A response within 8 minutes – AMBER – 74.4% compared to target of 75%
       (Cluster issue)
      Ambulance time to answer call 95th and 99th percentile rated AMBER and RED
       accordingly (Cluster issue)
      Time to treatment – 95th percentile – RED – October and November targets
       missed (Cluster issue)
      % of women to receive results of cervical screening tests within 2 weeks rated
       as RED as showing 90.30% against a target of 98% which is an improvement
       on the last reported position
      Number of drug users recorded as being in effective treatment rated as RED as
       target is 293 compared to actual of 269
      Rate of did not attends in community outpatients 11.13% compared to 10.47%
       therefore rated RED
      Smoking quitters target at quarter 2 was 400, achieved 363 therefore RED
       rated, the target for Bexley is very challenging compared to the rest of the
       cluster and this is being taken forward in the agreed targets for next year
      Extension of bowel screening programme to men and women aged 70-75,
       target 50.7%, actual 3.51% rated RED, however further investigation has
       shown that the screening programme has not yet implemented the extension
      % of women who have seen a midwife by 12 days and 6 days of pregnancy
       plan is 90% actual 85.33% AMBER rated
      Breast feeding initiation rates quarter 2, target 80%, actual 69.59% therefore
       rated as RED and a deterioration on quarter 1
      Prevalence of breastfeeding at 6-8 weeks, target 54.02% actual 46.52% a
       deterioration from quarter 1 RED rated
      Mental health targets for IAPT AMBER rated as 44.29% compared to 58.70%
       target, information supplied by MIND
      Quarter 2 immunisation data shows AMBER ratings for all targets except those
       for children aged 5 where the targets are rated RED – details on report.

Section 12 of the report considers our performance at month 8 with acute contracts
and provides an analysis of the key drivers of over performance.

The Committee is asked to note the report and the actions being taken by the Cluster
team and BSU team to improve performance. It should also be noted that the BSU
information analyst has completed the work with the screening lead and the
discrepancy has been solved and in future all systems will be reporting the correct

Organisational implications

Financial          The acute over performance shown in activity terms within this
                   report is reflected in the financial reports which are indicating a
                   significant pressure around acute contracting

Equality      and Not applicable

Risk               Will identify risks associated with acute patient care and also risks
(governance        associated with non delivery of targets
and/or clinical)
Patient impact     Shows performance of acute providers which if it is adverse may
                   lead to an increase in patient complaints and poor treatment

NHS constitution   Failure to secure health care contracts that deliver national and
                   local performance standards will have an impact on non-
                   compliance in offering access to services as set out in the NHS

Which objective does this paper support?                                       Insert
                                                                               Tick ()

Improve choice and access to integrated health services for Bexley patients       

Reduce the level of health inequalities across Bexley                             

Improve care for patients with long term conditions & increase the range of
services offered within the community

Improving the health & wellbeing for people in Bexley                             

Maximizing the opportunities of joint working (APoH, JSNA, Wellness
agenda etc)

Using our resources in the most efficient & effective manner (organisational      
& financial)

Report Author                      Julie Witherall

Date                               01st February 2012

Contact Details                    0208 298 6252

Executive sponsor                  Theresa Osborne

Performance Report

1.        Emergency Care

1.1       A & E – 95% within 4 hours

The threshold of 95% of patients being admitted or discharged within 4 hours, continues to be
monitored as a way of assessing A & E performance despite the introduction of A&E Clinical
Quality Indicators in July 2011. Performance at the beginning of the financial year was strong,
with all Cluster acute trusts exceeding the threshold however, performance since May across all
trusts has fluctuated. For example, between 1 May and 30 October 2011 SLHT had as many
weeks below the standard as above the standard. In October and November SLHT has
consistently averaged c. 90%, well below the 95% standard.

1.2       A & E Clinical Quality Indicators (CQIs)

Since July, trusts have been reporting on performance by hospital site, against the new A & E
CQIs. There continue to be some data quality issues with some of these indicators. For e.g.
the definition for re-attendance rates is still unconfirmed and PRUH are having technical
difficulties in establishing an accurate time to treatment.

All trusts which are reporting1, are struggling to achieve the 95th percentile for admitted patients.
In some cases the non admitted performance is compensating enough to enable the trust to
achieve the overall 95th percentile target, of 4 hours.

    % Left without being seen (< 5%)
                                   JUL   AUG       SEP       OCT
    KCH                            3.7    2.9      3.2       3.3
    LHT                            2.9    3.2      4.1        4
    PRUH                           3.7    4.9      4.9       4.4
    QEH                            3.5    2.9      2.5       3.2

1                                                                                th
    KCH are currently not reporting split between admitted and non admitted the 95 percentile

QMS - CYPAU                     0     0.6      1.1       0.3
St Thomas                      3.3    2.5      2.8       4.0
GSST MIU                                                  1

% Reattendance within 7 days (<5%)
                              JUL    AUG      SEP        OCT
KCH                            4.1    4.4     3.5        3.7
LHT                            7.2    7.7     7.3        6.4
PRUH                           1.3    1.3     0.9        0.7
QEH                            0.4   0.06     0.5        0.7
QMS - CYPAU                     3     5.4     4.3        2.9
St Thomas                      6.2    6.6     6.8         5
GSST MIU                                                  2

Time to Initial Assessment within 15 minutes (95th percentile)
                                JUL AUG        SEP      OCT
KCH                               0     0       0         0
LHT                              13    12       7         9
PRUH                             10    10       11       10
QEH                              44    43       47       50
QMS - CYPAU                           49.1      0         0
St Thomas                        13    11       12       14

Time to treatment (Median wait 60 minutes)
                             JUL AUG       SEP           OCT
KCH                           77    48      59            60
LHT                           57    59      67            80
PRUH                          83    95      96            91
QEH                           57    41     50.5           53
QMS - CYPAU                         20      24            25
St Thomas                     70    59      72            72

Total Time in A&E (< 240 Minutes 95th percentile)
                               Jul   Aug      Sep        Oct
KCH 95%                        240   240      240        240
KCH Non Adm
LHT 95%                        236    238     239
LHT ADM                        294    391     472        483
LHT Non Adm                    229    235     234        235
PRUH 95%                       240    240    342.1       308
PRUH ADM                       359    339     339        398

 PRUH Non Adm                 238   239    264.9     261
 QEH 95%                      240   239     239      383
 QEH ADM                      488   508    665.5     876
 QEH Non Adm                  237   233     235      239
 QMS - CYPAU 95%                    184     207      220
 QMS - CYPAU ADM                    195    195.8     232
 QMS - CYPAU Non Adm                179     208      215
 St Thomas 95%                239   240     240      240
 St Thomas ADM                341   348     344      343
 St Thomas Non Adm            234   240     240      240

1.3    Ambulance Handover KPIs

There are 3 KPIs relating to patient handover from the LAS to acute trusts:
    85% of patients to be physically transferred from LAS to acute trusts within 15 mins
    95% of patients to be physically transferred from LAS to acute trusts within 30 mins
    60 min breaches – all patients waiting more than 60 mins for physical transfer to be
       reported as a Serious Incident.

All trusts have been asked to work with the LAS to develop action plans and trajectories to
improve performance for the above KPIs, and to implement the Hospital Alert System (HAS) as
the electronic replacement to the paper forms used for documenting patient handover.

The original plan was for HAS compliance to be at 90% by September, this has now been
revised to 90% by the end of December. From this point assessment of the KPI 1 and 2, will be
based on HAS rather than the paper information.

Performance against the KPIs is variable and the issue of most concern is the number of 60
minute patient handover breaches. The Cluster has written to each trust requesting an updated
action plan trajectories; to improve performance issues, reduce the numbers of 60 min breaches
and improve HAS completeness.

Breaches         LHT     KCH        GST         QEH           PRUH      Cluster
Sept              34       25         0                 2       12         73
Oct               21       23         0                25        8         77
Nov               12       18         0                27        1         58

The Cluster has undertaken audits at St Thomas’, Queen Elizabeth Hospital and the Princess
Royal Hospital, aimed at assuring the accurate capture of hand over times using HAS. The
findings from the audits are to be reflected in the trusts’ updated action plans.

              Issues                                         Action
SLHT            Since April, performance against the 4        Formal escalation to wider health
                 hour target has fluctuated, with both           community.
                 QEH and PRU having performance                Ongoing improvement work to deliver
                 issues, particularly since the end of           the headline indicators, including
                 August.                                         pathway workshops with key
                There are data quality issues relating to       stakeholders
                 the KPI: Time to initial assessment at        Work continues with the IST,
                 both sites.                                     recommendations being implemented,
                SLHT produced a comprehensive                   The Trust continues to make the
                 patient handover action plan and                reduction in the number of medically fit
                 trajectory, however performance is              patients in acute beds a priority
                 currently below expected levels on all        The wider health community is focused
                 three KPIs                                      on ensuring that community service
                                                                 capacity is being fully and effectively
                                                                 utilised to improve throughput in the
                                                                 acute pathway
                                                               UCC on QEH site was retendered and
                                                                 the new service opened on 1
                                                                 December which has improved
                                                                 pathway for urgent care on this site.
                                                               Handover action plan under review in
                                                                 collaboration with LAS.

              Issues                                         Action
KCH             Apart from a dip in performance in May       Detailed action plan developed with IST
                 and more recently in early October,             is managed through the Emergency
                 performance has been above the                  Care Programme Board which is in
                 standard.                                       place to ensure whole system support
                Trust is undergoing a physical                  of emergency pathways
                 redevelopment of ED, bed capacity            Trust continued communication with
                 remains the same, however flexibility to        key stakeholders regarding
                 cope with surges will be more limited.          redevelopment timescales and likely
                Trust do not currently publish CQI data         impact.
                 on web site, however data on CQI is          Action plan has been reviewed and
                 shared with the Cluster on a monthly            additional actions agreed with LAS
                 basis, as part of performance reporting
                Trust has produced a joint patient
                 handover action plan with LAS; however
                 current performance is below plan on all
                High number of handover breaches in
                 September, October and November

  KCH have validated the breaches in November and have confirmed 7 of the 18 to be valid 60 minute

GST             Performance fluctuating, with an           Medical staffing levels increased with
                 occasional dip in performance below the     additional locum staff
                 standard                                   PCT level analysis of higher
                Trust do not currently publish CQI data     attendances discussed at Urgent Care
                 on web site, however separate               Network
                 monitoring information is made             Emergency pathway redesign
                 available to the Cluster                    programme underway
                                                            Trust has now produced a draft action
                                                             plan for patient handover.

LHT              Up until early September performance        Trust has opened some ‘Winter beds’
                  has been well above the standard for         early to cope with emergency admitted
                  the 4 hour target. Since then                patient demand.
                  performance has fluctuated.                 Cluster working with trust and LAS to
                 LHT produced comprehensive patient           understand handover performance.
                  handover action plan and trajectory,        Trust has provided an updated action
                  however performance is currently below       plan.
                  expected levels on all three KPIs
                 High number of patient handover
                  beaches in September, October and

2.     Healthcare Associated Infections – MRSA and CDI

The DH has set challenging targets for both MRSA and C. diff. reduction for 2011/12. The
MRSA trajectories are similar to last year, building in some reductions, particularly for
organisations such as KCH which have historically had higher numbers of infections. The C. diff
reduction required is 25% across SEL, which is challenging given that the numbers of C. diff.
infections have been broadly flat over the last 2-3 years and that GST introduced a new double
testing regime in September 2010 which is detecting more cases than in the baseline period.
Although KCH are significantly over their year to date trajectory, the number of cases identified
since September is lower than in previous months. If this new level is maintained, it is possible
for the trust to end the year within the threshold.

For MRSA, although there were a number of cases reported across acute trusts in April and
May, no attributable cases were reported by acute trusts in June, July and October and
therefore the forecast for the year end position has improved, but still marginally above the year
to date trajectory. For C. diff however, it is highly likely that the targets will not be achieved in
2011/12 by any of the PCTs.

SLHT participate in a Peer Review of HCAI at the end of December 2011. Feedback is awaited
from this visit. The position for each organisation is:

HCAIs – April-October 2011 data (Source: HPA database)
                             MRSA                               C. diff.
Provider          YTD Trajectory YTD Actual          YTD Trajectory      YTD Actual
GST                       6                6              39                 84
KCH                       4                3              48                 71
LHT                       2                1              17                 14
SLHT                      4                3              48                 56
SEL Total                16               13             152                225

N.B. numbers of provider cases are ‘attributable’ not the total recorded, in line with DH performance assessment
methodology. Trajectory relates to the nationally set objective, a higher locally agreed threshold has been agreed
with GST for 11/12 to reflect the more sensitive testing regime at the trust.

                                   MRSA                                         C. diff.
Commissioner             YTD Trajectory YTD Actual                   YTD Trajectory      YTD Actual
Bexley                         5            1                             32                 70
Bromley                        2            3                             50                 66
Greenwich                      3            1                             26                 49
Lambeth                        7            5                             53                 80
Lewisham                       5            4                             33                 45
Southwark                      5            6                             51                 79
SEL Total                     27           20                            215                389

                Issues                                              Action
GST               Trust introduced a new testing regime for            Trust recently took part in a Critical
                   C. diff. and the numbers are now                      Friend Visit from Central Manchester
                   considerably higher than last year                    as part of the Peer Review
                                                                         Programme introduced by NHS L.

3.      Planned Care - Referral to Treatment Times (RTT) and Diagnostics

SLHT and GST have continued to fail to meet most of the RTT standards in the year to date.
Both Trusts are subject to weekly monitoring by SEL Cluster and DH.

                Issues                                              Action
SLHT              Trust is not delivering on any of the RTT         Trust has developed another specialty
                   standards                                            level trajectories to clear backlog. This
                  Backlog exists in a number of specialties            indicates backlog clearance and
                   with Orthopaedics for admitted and                   performance improvement by mid
                   Ophthalmology for outpatients being the              February.
                   greatest numbers. Although significantly          IST supporting Trust on pathway and
                   smaller numbers, also issues with long               productivity improvements
                   waits for bariatric surgery.                      Outsourcing required for both
                                                                        Orthopaedics and bariatric surgery.
GST               Trust not delivering on admitted RTT              IST supporting RTT delivery, and
                   standard, and current trajectory will not            capacity and demand modelling.
                   deliver target until Q2 2012/13                   Trust’s view is that to deliver the
                  Performance issues across a number of                trajectory earlier than Q2 ‘12/13 will
                   specialties.                                         require outsourcing of paediatric ENT,
                                                                        paediatric orthopaedics and adult
                                                                        plastic surgery.

3.1.    Diagnostics

                Issues                                              Action
SLHT              Along with RTT, trust has been unable to          Additional routine Endoscopy lists
                   deliver on trajectory for planned decrease           scheduled
                   in 6 week waiters.                                Using InHealth to supplement in
                  Endoscopy and non-obstetric ultrasounds              house capacity.
                   key drivers of performance issues.

GST          Along with RTT, trust has a backlog in            Mobile unit in place and providing
              diagnostic waits.                                  additional capacity
             Endoscopy , Sleep studies and paediatric          For paediatric urodynamics additional
              urodynamics, key drivers of performance.           capacity has been put in place,
                                                                 however there is a mismatch between
                                                                 capacity and demand, and is
                                                                 therefore likely that there will continue
                                                                 to be some breaches in the coming
                                                                Additional physical capacity and
                                                                 clinics have been put in place for
                                                                 sleep studies.
                                                                Trajectory developed to clear backlog
                                                                 by the end of January

4.     Cancer Waits

            Issues                                           Action
GST           The Trust has consistently performed           The Trust is focusing on those
               below the 85% standard for the 62-day             elements of the Pathways where it
               target for time from urgent GP referral. A        can ensure that any internal reasons
               significant proportion of the breaches,           for breaches are eliminated, including
               although not all, are due to late referrals       through     improved      access     to
               from cancer units, including SLHT but             endoscopy and eliminating delays in
               also from outside London.                         the urological pathway
              Improvements have been made in the             The Trust is using the new mobile unit
               urology pathway, however still work to be         to address waits for colonoscopy.
               done by the trust on pathway for Lower         SLHT has engaged the IST to provide
               GI, particularly access to colonoscopies.         support on two cancer wait pathways
                                                                 that are contributing to overall
                                                                 breaches of the 62-day standard

5.     Mixed Sex Accommodation

            Issues                                           Action
SLHT          Reduction in the number of MSA                 Trust had introduced ring fenced
               breaches with step change in August.              elective beds on QEH DSU, however
              Day surgery unit (DSU) on QEH site,               pressures in emergency care has
               continues to be the most challenging area         meant that the trust has not been able
               due to emergency pressures.                       to maintain this ringfencing

6.     NHS Health Checks

            Issues                                           Action
Southwark     Southwark is currently behind the rest of      Implementation plan in place to
               the cluster on establishing the new NHS           extend the programme across the
               Health Checks programme, (and is 28               whole borough during the second half
               lowest nationally).                               of the year, building on the learning
              Quarter 1 performance was 0.3%                    from the pilot phase and also lessons
               improving to 0.7% in Quarter 2.                   on what has worked elsewhere
              compared to Cluster average of 7.8%            Shifting focus from GP practice to

            Still in the pilot phase of the Health Check         QMS.
             programme, which although only reaching             Discussions with QMS to secure a
             small numbers to date is being targeted              better contract and improved software
             at the higher risk population groups in line         solution are underway.
             with Strategic Plan                                 Software rollout to GP practices
            Length of pilot phase was extended to run            continuing into the new year.
             through the whole of 2010/11, partly due            DPH adding focus of Health Checks
             to prioritisation given the financial position       at QMS.
            Data Quality and deterioration in IT
             support an issue
Bromley     Quarter 1 performance was 3.0%                      The BSU has an incentive scheme in
             improving to 5.5% in Quarter 2.                      place with GPs and there are health
                                                                  check nurses in post.
                                                                 GPs     are    already  undertaking
                                                                  additional work and the BSU has
                                                                  agreed to extend the LES for the
                                                                  remainder of 11/12.

7.    Immunisation

           Issues                                             Action
Lewisham     Lewisham PCT has the lowest                      The Trust has implemented a new
              immunisation rate across all indicators,           MMR care pathway and prepared new
              especially for children at 5 years of age          pathways for immunisation with Pre-
              where the rate is significantly below the          School Booster and HPV. An MMR
              target as well as the London and sector            dashboard has been designed to
              average.                                           understand performance and monitor
             For children at 5 years of age the                 pathway changes.
              performance is 63% for DTA/IPV and               Immunisations Strategy Group has
              66% for MMR against thresholds of 90%.             been re-organised with amended
             The highly mobile population locally,              Terms of Reference
              which means that children may move               Proposal for catch-up programme for
              before primary courses are complete.               older children through Health Visitors
             Children who have left Lewisham not                is being reviewed.
              being removed from databases locally,            Communication has also been
              resulting in a probable bias in calculated          improved with the publication of a new
              uptake rates.                                       e- newsletter and the distribution of
             Very complex data collection systems,               immunisation schedules to parents of
              overly reliant on paper reports on                  all children under 5, reminding them
              individual children, which have been very           of the importance of immunisation
              difficult to improve.                            Utilising the information management
             Lack of clarity as to the relative roles of         work to establish regular reporting
              General Practitioner and Health Visitor.            and feedback to GPs.
                                                               Monitoring implementation of the
                                                                  MMR pathway and identifying barriers
                                                                  to successful completion of the
                                                                  pathway for all children, including
                                                                  developing the programme by which
                                                                  health visitors follow up hard to reach
                                                                  children who have failed to respond to
                                                                  invitations from their GP.
                                                               Working with relevant stakeholders to
                                                                  ensure implementation of a preschool
                                                                  booster pathway (similar to the MMR
                                                                  pathway). This will come on stream in

                                                                 Engaging with primary schools and
                                                                  early years providers to implement
                                                                  standardised collection of information
                                                                  on the immunisation status of new
                                                                  entrants, exploring options for offering
                                                                  vaccinations to under-vaccinated
                                                                  children, and identify opportunities to
                                                                  promote immunisation (e.g. among
                                                                 Ongoing work to “clean the
                                                                  denominator”, i.e. to remove children
                                                                  no longer resident in Lewisham from
                                                                  our population lists.

8.        Breastfeeding

               Issues                                         Action
Lambeth          Data coverage and hence reported             A focused multi-disciplinary action
                  continuation of breastfeeding have been        group has been established under the
                  below trajectory and peers for some            leadership of the AD Children’s
                  years.                                         Commissioning – Fiona Mortlock, and
                 Data quality issues have been identified,      a comprehensive action plan is in
                  including reconciliation of GP practice        place
                  and RiO data                                 Identifying GP practices that are
                 51.2% Prevalence of breastfeeding at 6-8       underperforming and planning
                  weeks after birth compared to Cluster          education event
                  average of 64.2%.                            Commissioning the development of a
                 However performance improved in Q2             breastfeeding and weaning policy in
                  from 44% and this is due to the extensive      line with BFI for Lambeth
                  work that the HV team have been              BSU has identified capacity within the
                  undertaking across Lambeth and                 service improvement team to provide
                  Southwark, to move it to 95% there are         project support to the work
                  however further actions that would need      Focusing on improving and making
                  to be implemented.                             consistent the way practices capture
                                                                 information and forward for entry onto
                                                               Detailed work with QMS to review data
                                                                 on GP systems to see if data is better
                                                                 recorded on GP IT systems with a
                                                                 view to extracting data to update RiO.
                                                               Work to improve data flow between
                                                                 GP practices and community services
                                                                 to ensure accurate population of the
                                                                 RiO system
                                                               Developing action plan to take into
                                                                 account learning from partners in
                                                                 Southwark where results for
                                                                 prevalence at 6-8- weeks are
                                                                 considerably higher than Lambeth.

9.        Smoking Quitters

               Issues                                         Action
Overall          Although all PCTs were behind their Q1

               trajectories most have reported that
               taking account of late data submissions
               from      providers     the     trajectories
               performance is far more positive and all
               expect to achieve their annual trajectories
Southwark    Data quality and data capture is an issue        More time will be allowed for
              due to a reduction in resources and a lack        processing future returns
              of clarity around processes.                     Intention is to get the team of Level 3
             10/11 figures have been recast and target         specialist stop smoking advisers to
              would have been achieved although it              learn how to use the Quit Manager
              was too late to submit this.                      data base so that they can assist with
                                                                data entry at busy times.
                                                               Have identified that the process of
                                                                data entry is considerably slowed
                                                                down due to poorly completed
                                                                monitoring forms by Level 2 stop
                                                                smoking advisers, mainly those in
                                                                community pharmacies. In the coming
                                                                months will work with these advisers
                                                                to improve their performance in this
                                                               Conducted a restructure of the
                                                                smoking team to address weakness of
                                                                recording the quitters.
                                                               Commissioned marketing drive in
                                                                supermarkets and shops.
                                                               Created a locality stop smoking Local
                                                                Enhanced Service to improve

10.   Mental Health Measures - IAPT

            Issues                                            Action
Lewisham      Lewisham performance in KPI of people           Lewisham submitted recovery plan to
               waiting more than 28 days is the highest          NHS London in December.
               in London.                                      Recovery actions such as people
              Highest referral rate in London due to the        moving off sick pay and benefits have
               promotion of self referral routes.                been realised.
              Lewisham is 14.79% adrift of IAPT               Work between commissioner and
               access trajectory at Quarter 2.                   provider to improve waiting list
              Actual performance at Q2 is 5.1% against          management.
               planned performance of 5.9%.                    Work to balance clinical effectiveness
              The rest of SEL Cluster is green at Q2.           with volumes seen.
                                                               Performance is delivering to previous
                                                                 levels but ambitious plan to achieve
                                                                 improvement has not been met.
                                                               NHS London and London MH
                                                                 Programme        IAPT     team    have
                                                                 conducted a joint review of the
                                                                 recovery plan.
                                                               NHS London have provided feedback
                                                                 that although Lewisham will fall short
                                                                 of the trajectory there is a clear
                                                                 understanding of the issues and a
                                                                 robust approach in developing the
                                                                 services to deliver the requirements of

                                                                 the 2012/12 Operating Framework.
                                                                NHS      London     has      requested
                                                                 milestones for each of the initiatives in
                                                                 the recovery plan and details of the
                                                                 governance arrangements for the
                                                                 service by the 16 January.

11.        Bowel Screening

                Issues                                         Action
Cluster           The bowel cancer national awareness          SELCN         management     team   to
                   campaign due to start on the 28 January        establish a steering group to meet
                   will pose a threat to current performance      fortnightly.
                   across the cluster.                          Drive the planning process to prepare
                  The Cluster attended the workshop on           for the national campaign
                   the National Awareness campaign and          Inform primary care of the campaign
                   have been working alongside Angela             messages and importance of using
                   Bhan the Cancer Screening lead for             clinical judgement when referring
                   South East London and the South East           patients to endoscopy services
                   London Cancer Network who are                Engaged with secondary care to plan
                   concentrating on the age awareness and         for increased capacity as a result of
                   national campaign in Bowel Screening.          the national campaign
                  Workstreams have been identified and         Dealing with existing endoscopy waits
                   are currently being worked through.            to enable extension of screening to
                                                                  people aged 70-75 where necessary
                                                                Prepare for the longer term need to
                                                                  improve uptake to the national
                                                                  screening programme

12.        Acute Hospital Contract Performance

12.1       Overview

The purpose of this section of the Clinical Commissioning Cabinet report is to provide an
overview of the performance of acute hospital services that are contracted to provide health
care services to the population of Bexley. The data sources are drawn from the Secondary
Uses Service (SUS) data warehouse, Mede Analytics, and SEL Cluster performance analysis.

The report covers the period with the latest data available from April until November 2011
(month 8). Due to the nature of health care provider contract management, there is a normal
time-delay in data due to a period for ‘data cleansing’ and validation as set out in the NHS
Standard Contract. The month 8 information in the report has taken into account the application
of contract guidance and agreements relating to emergency baselines and QIPP savings

Bexley has a total of 22 contracts with acute hospitals and LAS currently managed on our behalf
by NHS south east London Cluster. The top 6 Trusts in terms of activity and costs are:

      1.     South London Health Care Trust
      2.     Guys & St Thomas’ Foundation Trust
      3.     Dartford & Gravesham Trust
      4.     King’s College Foundation Trust
      5.     London Ambulance Services
      6.     Lewisham Hospital Trust

Bexley has significant patient activity and associated contracts outside of south east London,
that equates to around 8% of the total costs. These contracts are negotiated and managed by
other NHS Clusters.

Bexley’s contract portfolio overall is performing higher than the agreed contracted levels of
patient hospital activity. In particular, the over performance for month 8 of the four main SEL
providers is £5.599m (6.4%) higher than plan. This rate of over performance is comparable to
other Cluster BSU average year-to-date over performance of 6.2%.

At Trust level the South London Health Care Trust’s (SLHT) over performance is the key driver
of this overall position, although the percentage over performance at Lewisham Healthcare is
more significant. The levels of over performance at Guy’s and St Thomas’ and King’ College
Hospital is much smaller in both percentage and absolute terms. At Point of Delivery (POD)
level the most significant cause of the over performance relates to non-elective admissions.
Other significant areas of over performance are electives, critical care, emergencies and
outpatient procedures. Percentage variances for these three areas against plan are very large.
In considering the overall position it is important to note that at the beginning of 2011/12, Bexley
did make some significant QIPP reductions to plan, particularly for SLHT, although current
areas of over performance such as critical care will not correlate to these QIPP reductions.

As reported in previous months, there has been a consistent rise in patient activity at Dartford
and Gravesham Trust as more patients are referred to the trust. Until August 2010 around 300
Bexley referrals were made per month, and subsequently steadily increased to an average of
c550. The notable variance at month 8 is first outpatient attendances in genitor-urinary (GU)
medicine, largely comprising self referrals. Over performance continued with a November
cumulative higher contract value against the contracted plan of £2,334,666 (16.25%). This
compares to a peak of 20.5% in August (month 5); since then over performance has been just
above 16% above plan for each consecutive month.

12.2   In Summary - Drivers for Contract Variances

      Higher than planned patient activity across all providers, particularly unplanned non-
       elective admissions.
      526 Bexley patients were admitted to hospitals who are very high users of inpatient care.
       The cost was £1.575m in November (slight rise on previous September report)
      3,973 patients who are very high users of inpatient services were admitted to hospital in
       the previous 12 months with a total cost of £19.447m (slight fall on last report).
      53 patients had an unplanned non-elective admission for a complex elderly care. The
       cost was £165k (43% increase on last report)
      86 patients aged over 75 had an admission for respiratory conditions in November. The
       cost was £233k (132% increase on September report)
      184 patients were categorised as having an 'inappropriate' admission. The cost was
       £221k (static position to last report).
      2,070 of Bexley’s very high users visited provider A&E departments across all trusts.
       The cost was £285k for the month of November (slightly lower patient numbers but
       higher costs reflecting severity of emergency presentation)
      17,626 of the same cohort of very high Bexley users visited A&E in the prior 12 months
       with a total cost of £3.240m (slight rise since September report).

The following section looks in greater detail of some of the considered causes of the contractual
over performance. Detailed plans are available for each Trust within SEL Cluster.

13.       Drivers of Performance Pressures by Trust

The graph below illustrates the variances in patient activity and finance across the four SEL
hosted Trusts.

                     Total SLHT, LHNT, GSTT and King's - Month 8 Performance - Bexley Care Trust

                                                 Over performance against plan %


                                                                 Source: Trust SLA Monitoring, - Flex,
                                                                 adjusted for assessment of uncoded + applications of agreed QIPPs



          Elective    Emergency   Non Elective   A&E   Outpatient -   Outpatient -   Outpatient   Critical Care   Drugs &     All Other
                                                           1st         follow Ups    Procedures                   Devices   Expenditure


                                                 Under-performance against plan %

                     Providers: GST, KCH, LHNT, SLHT             Bexley Costs –               % Variance             to
                                                                 £’000 under/(over)           Plan

                     Elective                                    (1,250)                      (5.8)

                     Emergency                                   (743)                        (3.8)

                     Non-Elective                                (1,381)                      (23.9)

                     A&E                                         42                           1.5

                     Outpatient – 1st                            (163)                        (2.6)

                     Outpatient – follow ups                     203                          2.6

                     Outpatient Procedures                       (588)                        (44.3)

                     Critical Care                               (796)                        (16.3)

                     Drugs & Devices                             91                           2.0

                     All other expenditure                       (1,015)                      (4.9)

                     Total                                       (5,599)                      (6.4%)

13.1      South London Healthcare (SLHT)

Bexley is over performing by £4.1m (7.2%) at South London Healthcare Trust as set out in the
graph below. Given the level of over performance with this contract, a more in-depth analysis is
provided in this report.

                                        SLHT- Month 8 Performance - Bexley Care Trust

                                               Over performance against plan %


                                                                 Source: Trust SLA Monitoring, - Flex,
                                                                 adjusted for assessment of uncoded + applications of agreed QIPPs


  0.4                                                                                                                                      Activity


         Elective   Emergency   Non Elective      A&E   Outpatient -   Outpatient -   Outpatient   Critical Care   Drugs &    All Other
                                                            1st         follow Ups    Procedures                   Devices   Expenditure

            Under-performance against plan %

The most significant areas of variance to plan that have generated further investigation are:
non-elective admissions (28%), outpatient procedures (60%) and critical care (22%). The most
significant driver of over performance is older peoples’ admissions. However, there is a fall from
emergency admissions seen in 2010/11 to non elective admissions (non emergency). Some of
this is explained in coding errors, which the Trust has agreed to rectify. General medicine is
another area of over-performance largely related to an increase in legitimate coding of people
with malignant stomach disorders and non-interventional acquired cardiac conditions. There
has been a detailed review of counting and coding practice at health related group (HRG) level
so as to identify the drivers behind over performance. The review has resulted in the
identification of a significant number of areas where there is some evidence of apparent coding
or counting changes that are significantly impacting Bexley’s reported position and which are
being investigated.

There have been no significant changes in trend contract performance compared to month 7.
The lines of enquiry are being followed-up through the monthly Finance and Information Group
meetings with the Trust.

In detailing performance by specialty, the narrative is based on analysis of pre-challenge data
by Cluster and BSUs and does not therefore reflect the month 8 challenged position, i.e.
successful changes to the data activity. These adjustments have been applied in the reporting
of the financial position in the finance report.


Older Peoples’ (Geriatric) Medicine
The most significant driver of over performance is older peoples’ admissions which accounts for
around 80% of the total. Whilst over performance in geriatric medicine non-electives are very
significant, it is offset by far greater under performance in geriatric medicine emergency
admissions. The net impact is year to date financial under performance in excess of £1.6m.

The shift from emergency to non-elective PODs has resulted from an increased level of intra-
site transfers following the changes to service configuration at Queen Mary’s. Incorrect

recording of activity by the trust in relation to these transfers has resulted in multiple spells been
recorded for single admissions. This issue has been raised and acknowledged by the Trust and
agreement has been reached on to make an appropriate financial adjustment.

General Medicine
General Medicine admissions are over performing by around £310k. This can be explained by
a reduction in the plan against the baseline and some growth on the previous year. In particular
it has been noted that from Month 2 there has been a significant increase in activity recorded for
musculoskeletal services where historically activity has been nominal. Inappropriate recording
of intra-site transfers has also been reflected in the reported growth of activity, challenged and
will be corrected.

Neonatal Medicine
Neonatal admissions are over performing by £225k. This can be explained by a reduction in
activity less than the reduction in plan made against the baseline to account for the closure of
services at Queen Mary’s. It has been noted that there has been an increase in admissions for
minor neonatal diagnoses and this may have resulted from a reduction in the admission


Emergency admissions are 14.4% above activity plans and finance 4.7% (£785K) above plan.
The headline over performance of £785k masks a very significant over performance in general
medicine admissions of c£3.6m and an under performance of c£2.6m in emergency geriatric
medicine and further work is necessary to understand the reasons for the residual net
underperformance. Clinical haematology admissions are also significantly above plan by £470k.

General Medicine
A review of the General Medicine activity indicates that the drivers of over performance can be
reconciled to a reduction of the plan against the baseline and a very significant increase in
activity across two health related grouping families: non-interventional acquired cardiac
conditions have increased from 67 to 167 compared to the same period last year; and
malignant stomach disorders/ non-malignant large intestinal disorders where no admissions
have been reported prior to July and 37 since.

Medical Oncology
259 emergency admissions have been recorded against medical oncology against a plan of
only 1. Normally this type of activity would be recorded as day case elective. Furthermore, most
of this activity is reported to have occurred at Queen Mary’s and only since June 2011. The
estimated year-to-date impact is a cost pressure of £197k.

Clinical Haematology
Clinical haematology spells have over performed by 468 admissions resulting in financial over
performance of c£470k. The key drivers for this have been a change in recording practice for
PbR activity resulting in with over 400 spells being recorded as emergency admissions whereas
they would previously have been recorded as planned day case activity. These codes include
delivery of chemotherapy and transfusions. Pricing this activity as day case as opposed to
emergency would lead to a cost reduction to Bexley of c£330k which has been accepted by the
Trust and awaits actioning.

Furthermore, it has been noted that there has been significant over performance within
emergency clinical haematology minor pain procedures where 72 admissions have been
recorded against a negligible plan. This appears to relate to a change in recording practice at
Queen Mary’s that took place in March resulting in the activity being recorded as emergency as

opposed to day case. Re-pricing the activity as day case would result in a saving to Bexley of

Other expenditure: Services classified under “all other expenditure” are over financial plan by
12.6% (£965k). The key drivers within this are: direct access pathology (£507k) and the drug
treatment Lucentis (£313k).

Critical care is over plan in terms of both activity (17.8%) and finance (22%) and includes both
intensive care and special care baby unit (SCBU). SCBU is over performing by £153k, however
it should be noted that the contracting responsibility for a significant element of SCBU is being
passed over to London Specialised Commissioning (LSC). Funding arrangements have yet to
be finalised between LSC, commissioners and the Trust and as such the Trust is continuing to
report all activity against the understated BSU plans. Over performance in adult critical care is
significant at £393k.


Outpatient procedures are very significantly over plan in terms of both activity (85.8%) and
finance (60%), indicating that volume is the main driver of over performance. At a specialty
level the most significant over performance areas are ophthalmology, orthodontics, oral surgery
(where the plan has zero activity) and dermatology. Over performance in ophthalmology and
orthodontics relates to an improved rate of recording that has taken place over the last year.

Oral surgery activity is at a similar level to the previous year however all oral surgery outpatient
procedures had been removed from Bexley’s baseline plan at the outset of the year.

Within dermatology the most significant area of growth is phototherapy. These procedures were
not charged through the payment by results (PbR) element of the contract in 2010/11 and were
not been included within plan. It is unclear as to whether the activity has been historically
recorded as dermatology follow-ups or has been included within the Non-PbR ‘block’ contract.
This needs further investigation.

13.2   Guy’s & St Thomas’ (GSTT)

Bexley’s over performance position at this Trust for month 8 compared to last month has
remained constant at 4.4%. However, month 8 reporting is based on unfrozen data with
estimates for uncoded activity and an error has subsequently been found in the A&E and quality
payment (CQUINs) figures reported by GSTT. This is an under statement of A&E cost and an
over statement of CQUINs which will be corrected at month 8 freeze. The net estimated effect is
a small reduction in Bexley’s over performance overall and once adjusted the A&E position
would come into line with October.

The position is also complicated by the in-year transfers of renal and SCBU to London
Specialist Commissioning actioned in month 8. These were under performing for Bexley in the
renal elective areas transferred and consequently have the effect of increasing the over
performance at GSTT when removed. This effect accounts for a large part of the increase in
elective. After allowing for these effects the most significant movements in month are elective
and outpatient procedures, which have increased, and non elective and critical care, which have
decreased, although critical care remains one of the most significant over spends. The increase
in electives is mainly in orthopaedics, upper GI surgery and cardiac surgery. Outpatient
procedures overspend is being driven by dental.

A significant factor for Bexley’s over performance is radiotherapy which is included in “all other
expenditure”, but this is being offset by an under performance in medical oncology day

For Outpatients the performance has increased to 36.9% over plan. The main variances are in
dentistry. The percentage variance may be variable as activity is low but there is a likely impact
where more patients are choosing to go to the hospital rather than using primary care dentists.

Whilst critical care over performance of 18.2% has decreased this remains a significant
overspend in an area that can be very volatile.

13.3   Lewisham Healthcare

Bexley’s element of the contract is over performing by £294K (10.6%), with activity only 5%
over, indicating that a different case mix than planned is part of the issue. The over performance
is seen across many POD areas, but most notably emergency admissions (32%), non-elective
admissions (33%), drugs & devices (49%) and critical care (39%).

At POD level the main driver is Emergencies, which is £120K over plan. This in part is
considered the impact of the QMS working its way into the system. Electives are also over plan
by £104K, this reflects higher than planned levels of referrals feeding through the system. The
bulk of the elective activity is ear, nose & thought (ENT) orientated.

13.4   King’s College Hospital

Bexley is experiencing elective inpatient financial over performance. There is a significant case
mix issue involved with a financial over performance of almost 11%, but an activity under
performance of almost 22%, indicating a more complex case mix than was assumed in contract
plan. Renal dialysis activity is showing a very large activity underperformance, which is skewing
the overall elective in-patient case mix.

Month 8 activity rose slightly, in contrast to other SEL BSUs who showed a significant elective
increase in November. The key specialties driving the financial over performance are: vascular
surgery, clinical haematology (regular day attendees) and neurosurgery – the latter in particular
being very high cost/ low volume and therefore relatively small activity increases can have a
significant financial impact.

Month 8 is traditionally a month with heavy activity, which has resulted in an increase in financial
over performance from 3.1% to 3.8% (339k) in M8. The most significant month 8 financial
increases in over performance were in outpatient follow ups (3.9 to 5.4%), inpatient non-elective
(10.2 to 12%) and critical care (-5.0 to -0.8%). For outpatient follow ups there were no clear over
performance outlier specialties. However, non-elective inpatient increases were largely driven
by an increase in neurosurgery. For critical care, the key drivers in the month 8 rise were adult
critical care (2 & 3 organs supported).

Year-to-date, the key over performance drivers are Inpatient Elective & New Outpatients. In
terms of underperforming PODs, Outpatient procedures and Emergency are both
underperforming by 6.6% and 10.9% respectively. A&E is 19.5% higher than plan to date.

13.5   Dartford and Gravesham NHS Trust (Darent Valley)

As reported in previous months, there has been a consistent trend for activity growth at Dartford
and Gravesham Trust (D&G). At month 8 over performance continued with the cumulative
contract variance against plan at £2,334,666 (16.25%). This compares to 20.5% at month 5;
month 6 at 16.6%, and month 7 at 16.06%.

The extrapolated year end position remains the same as forecasted at month 7 at £3.502m.
This assumes an unchanged rate of performance and service demand. It should be noted that
whilst there is a trend of continuing over performance, the rate of increase on a monthly basis is
not as significant as that experienced through 2010/11, and the over performance is measured
against what now appears to be a low contract baseline, which was set at a time when the effect
of service changes at Queen Mary’s Sidcup could only be estimated.

Contract activity continues at a higher over performance against plan than on finance, but at
month 8 at a lower rate of 28.7% compared to the 33% rates at month 6 and 7. Compared to the
financial position this suggests a lower cost case mix, and over performance can be seen in all
areas with the exception of emergency admissions. The most significant drivers of over
performance at month 8 continue from those reported in previous months, namely critical care,
electives, day cases, outpatient first attendances and maternity activity recorded as non-elective
non-emergencies. Notably at month 8 there was significant over performance with non-elective
inpatient episodes for general surgery and trauma and orthopaedics in combination exceeding
£220k, but offset by other specialties so the non-elective budget remains significantly under
spent. This pattern possibly reflects patient demand following the summer holidays and the
specific waiting list issues at SLHT.

Critical care activity is the major area of over performance and now amounts to a cumulative
over spend of £586k comprising £434k adult care and £152k Neonatal care. This is activity that
cannot be easily forecast, and Bexley has experienced one long-stay very high cost patient
episode that skewed the position across quarter 1, with further complex cases at month 7 and
month 8 that have been discharged. It should be noted that by month 6 the full year’s planned
activity and budget for critical care has been reached. It is also worth noting that this budget
also includes neonatal care, which if this were a London Trust would be contracted through
Specialised Services arrangements involving financial risk pooling.

A consistent pattern of over performance has been reported this year for trauma and
orthopaedics, urology, general surgery, cardiology, and gynaecology across outpatient first
attendances, electives and day cases. However subtle changes more evident since month 7
have meant that gastroenterology has decreased over performance by half since month 5 and
at month 8 is £13k overspent. This has been more than over-compensated by two specialties:
medical oncology day cases (by £21k) and a surge in GU medicine (over performance of £57k
and 357 attendances) that at month 8 has the second highest rate of outpatient attendances.

In outpatient follow ups, different patterns of demand and services are apparent although the
rate of activity is evidently over performance. The key specialties with over performance at
month 8 are medical oncology, gynaecology, obstetrics, cardiology, urology and in particular
trauma and orthopaedics. What can be noted is that the performance pattern across outpatient
follow ups has varied across the year with cardiology as the only specialty with constant over

With the exception of cardiology this activity is driven by GP referrals across all of these
specialties. Cumulatively across all specialties including midwifery there has been a significant
net increase in the volume of GP referrals made to the Trust. Until August 2010 around 300
referrals were made per month. Since November 2010 the volume of monthly referrals has
varied around 600, with an apparent small decline from June on an extrapolated trend basis. At
August 2011 new referrals were approximately 550 and in September 500. The notable

variance at month 8 as highlighted above is first outpatient attendances in GU medicine, largely
comprising self referrals.

Over performance in non elective non emergency is principally made up of normal deliveries
with some over performance in admissions for minor neonatal diagnoses. This is believed to
have resulted directly from the service closure at Queen Mary’s Sidcup. Access to obstetric
referrals for Bexley women is under investigation with the Cluster and Trust in response to local
GP concerns.

A principle challenge for commissioners and contractors is to differentiate which variances has
arisen due to incorrect planning assumptions and which have arisen due to other reasons. To
this end work is ongoing to assess performance, and collaborate with the host commissioner to
scrutinize service delivery and over performance that will set realistic activity baselines for
2012/13 contracts.

13.6   Great Ormond Street Hospital (GOSH)

GOSH has notable over performance, which at month 8 is £277k against plan. The remainder of
providers to Bexley patients under contract has much less significant and variable performance.
The GOSH over performance has been consistent through the year, comprising child and
adolescent mental health (CAMHs) bed days at £102k and the remainder high cost drug
exclusions and HDU bed days. All this activity is high cost and challenging to predict accurately.


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