HEALTHCARE COMMISSION PERFORMANCE RATINGS 2006/2007
APPENDIX B
EXISTING NATIONAL TARGETS Target Diabetic Retinopathy Screening Description number of people with diabetes receiving screening for the early detection (and treatment if needed) of diabetic retinopathy Healthcare Commission Thresholds Achieved Underach'd Failed 80% >70% <60% PCT Actual Score 91.05% Comments
100% of patients on diabetes registers offered Ach'd screening, however, not all choose to take up the offer. Robust partnership working arrangements in place between the PCT and all secondary care providers to ensure the national waiting time standards are maintained. New services in place in primary care to reduce referrals and waiting times in secondary care, ie. Colposcopy, Dermatology, Musculoskeletel with more to follow.
Maintain a maximum of 26weeks number of patients waiting longer than 26 Inpatient Waits weeks
<0.1%
<0.3%
>0.3%
0.02%
Maintain a maximum wait of 13 weeks for an outpatient appointment. Maintain a maximum waiting time of two months from urgent referral to treatment for all cancers.
number of outpatients waiting longer than 13 weeks All cancers: number of patients waiting longer than two months from GP urgent referral to treatment
<0.1%
<0.3%
>0.3%
0.00%
Ach'd as above
93%
87%
<87%
96%
Ach'd as above Underachieved Achieved
Achieved
Category A calls meeting eight minute target
All ambulance trusts to respond to 75% of category A calls within 8 minutes
75%
>70%
<70%
72.44%
Joint initiative between the Yorkshire Ambulance Service and the PCT established Community Paramedic Scheme Pilot. The aim being to improve CAT response times. Evaluation of the Pilot is underway.
Category A calls meeting nineteen minute target
All ambulance trusts to respond to 95% of category B calls within 19 minutes. Maintain delayed transfers of care at a minimal level.
95%
>90%
<90%
96.81%
Ach'd as above The PCT will continue to support Whole Systems Approach to develop best practice in Ach'd discharge management and build on existing positive joint arrangements The PCT is actively involved on the West Yorkshire Thrombolysis Specialist Group. Various initiatives ongoing; continued roll-out of nurse led thrombolysis work with WYMAS and clinicians to ensure paramedic led thrombolysis will ensure improvements in call to needle time Robust performance management/systems & Ach'd processes in place to actively maintain the waiting time standard.
Delayed transfers of care
3.5%
<5%
>5%
0.77%
Thrombolysis - 60 minute call to needle time
Deliver a ten percentage point increase per year in the proportion of people 68% with a 20 suffering from a heart attack who receive percentage point thrombolysis within 60 minutes of calling annual increase for professional help.
38% or a 20 percentage point annual increase
<38% without a 20 percentage point annual increase
Maintain a maximum waiting time of one All cancers: one month diagnosis month from diagnosis to treatment for all to treatment cancers.
96%
92%
<92%
99.71%
EXISTING NATIONAL TARGETS Target Description Every hospital appointment to be booked for the convenience of the patient, making it easier for patients and their GPs to PCT facilities in place to support choose a hospital and consultant that choice best meets their needs. Patients should be able to choose from at least four health care providers for planned hospital care. Guaranteed access to a primary care Primary Care Access professional within 24 hours and to a primary care doctor within 48 hours. Healthcare Commission Thresholds Achieved Underach'd Failed PCT Actual Score
APPENDIX B
Comments Issues remain with counting Choose and Book and comparing with total GP referrals which are gradually being worked through that should improve PCT achievement of what is acknowledge nationally to be a challenging target.
75% of planned performance
55% of planned performance
<55% of planned 49.33% performance
100%
99%
<99%
99.84%
All GMS and PMS practices within Kirklees Ach'd are committed to delivery of this target. A full CR Team in place locally, however, national issue with counting the numbers of people accessing the Teams, which is being re-evaluated by the DoH. An independent review of all CRTs, undertaken by NIMHE, was completed in September 2007 and the PCT is awaiting feedback and recommendations for 'way forward'. The PCT is actively working with SWYMHT with regard to care pathway re-design and delivery of key national targets.
Commissioning of crisis resolution services
Improve life outcomes of adults and children with mental health problems by ensuring that all patients who need them have access to crisis resolution services
performance consistent with plans
performance poorer than plans
performance poorer than plans by a clear margin
3 part indicator assessing PCTs on their commissioning of a comprehensive CAMHS: 1. Are arrangements in place to ensure that 24/7 cover is available to meet the urgent needs of children and young people and specialist mental health assessments undertaken within 24 hours Commissioning a comprehensive or during the next working day where yes' to all three child and adolescent mental indicated? 2. Is a full range of CAMHS questions health service for children and young people who also have a learning disability explicitly commissioned by or on behalf of the PCT? 3. Do all 16 and 17 year olds in the PCT who need CAMHS have access to service appropriate to their age and level of maturity. Data should be consistent with 2006/2007 CAMHS service mapping.
yes' to two out of three questions
yes' to only one or none of the three questions
Underachieved
Failed
Failed
Healthcare Commission carried out evaluation of service provision at Q3 (Sept 06), however, the PCT position changed at Q4 (March 07), showing 'yes' to all 3 questions.
EXISTING NATIONAL TARGETS Target Description Healthcare Commission Thresholds Achieved Underach'd Failed PCT Actual Score
APPENDIX B
Comments The PCT was not assessed against this indicator as no Local Delivery Plans submitted to the SHA as part of the original 2003-2005 LDP process or subsequent 'refresh' processes. No plans in place and no 'actuals' reported during 2006/07. This is a PCT priority for the immediate future and the performance team will work with the Lead Manager(s) to ensure plans are submitted for 2007/08 as a matter of urgency and robust systems & processes in place to support delivery. Robust systems and processes in place to support delivery.
Practice based registers patients called for review
Update practice-based registers so that patients with coronary heart disease and diabetes, and the majority of patients at high risk of coronary heart disease, continue to receive appropriate advice and treatment in line with national service framework standards.
data not available - indicator not assessed
All cancers: two week wait
A & E Waits CHD - Revascularisation
Maintain a two week maximum wait from urgent GP referral to first outpatient appointment for all urgent suspected cancer referrals. Maintain the four hour maximum wait in A&E from arrival to admission, transfer or discharge. Maintain a three month maximum wait for revascularisation
97%
94%
<94%
100%
Ach'd
98% 0.5%
97% 1%
<97% >1%
98.67% 0%
Emergency Care Strategy developed and Ach'd implemented in collaboration with the PCT and all relevant partners Robust systems and processes in place to Ach'd support delivery.
Not assessed
APPENDIX C
HEALTHCARE COMMISSION PERFORMANCE RATINGS 2006/2007 NEW NATIONAL TARGETS Target Description Achieve year on year reductions in MRSA levels, expanding to cover other healthcare associated infections as data from mandatory surveillance becomes available. Improve the quality of life and independence of vulnerable older people by increasing the proportion of older people being supported to live in their own home by 2008. Healthcare Commission Thresholds Achieved Undera'chd Failed yes' to all 4 questions yes' to 3 of 4 questions PCT Actual Score Comments The PCT is monitored against the performance of the 2 local acute Trusts. yes' to fewer yes' to all Achieved Root Cause Analysis is carried out for each than 3 questions 4 case and any actions identified, implemented. National target - 100% of equipment to be delivered within 7 working days. The national target has not been achieved due Under<85% 87.88% to Joint Contingency, this equipment is achieved specially built, ordered and fitted on an individual basis which is not feasible within 7 working days. Number of actions taken to maintain/improve performance; Service provider has completed a Retention Achieved Improvement Plan; service users with lower support needs are transferred into shared care services with GP practices, etc. Dedicated 'specialist advisers' working with the acute Trusts to support women to stop smoking during pregnancy. Smoking Cessation, service moving to operate Kirklees-wide and planning to achieve challenging targets set by the SHA. Outcomes of 'Smoking Summit' held to look at reducing health inequalities and improve Under-achieved
Infection Control - MRSA
Older People - Community Equipment
95%
85%
Substance Misuse
Increase the participation of problem drug users in drug treatment programmes by Performance 2008; and increase year on year the consistent proportion of users successfully with plan sustaining or completing treatment programmes. Reduce smoking during pregnancy by 1% year-on-year Increase breastfeeding initiation rates by 2% year-on-year Increase data quality on ethnic group Reduce number of people smoking Increase number of four week smoking quitters
Performance poorer than plan
Performance poorer than plan by a clear margin
below plan above plan 75% 100% above plan 55% 90% <55% 85% 81% 93.22%
Reduce Health Inequalities by 10% by 2010
APPENDIX C
NEW NATIONAL TARGETS Target Description Healthcare Commission Thresholds Achieved Undera'chd Failed PCT Actual Score Under-achieved Failed Achieved Under-achieved Under-achieved 58% Comments Various initiatives ongoing; Implement and evaluate Teenage Pregnancy Strategy; Implement Sex and Relationship Education programmes in community as well as school setting and involving community workers, schools nurses, Sure Starts, etc; increase access to condoms and sexual health advice for young people in a range of settings
Sexual Health - Teenage Conception Rates
Reduce the under-18 conception rate by 2010, as part of a broader strategy to improve sexual health.
Performance consistent with plan
Performance poorer than plan
Performance poorer than plan by a clear margin
Secure sustained national improvements in NHS patient experience by 2008 as Patient Experience measured by independently validated surveys Mental Health - substantially Care programme approach seven day reduce mortality rates by follow up Commissioning of early intervention in 2010 from suicide and undetermined injury by 20% psychosis services Cancer mortality rate Implementation of NICE improving outcomes guidance Breast cancer screening Blood pressure
Performance consistent with or better than average
Performance poorer than average
Performance poorer than average by a clear margin
Action plans produced from feedback of Achieved survey results, implemented to improve patient experience.
consistent with plan The PCT has now commissioned an Early Intervention Service that will be up and running from December 2007.
poorer than plan by a clear margin consistent with plan 11 out of 24 milestones consistent with plan consistent with plan consistent with plan poorer than plan by a clear margin consistent with plan
Cancer - substantially reduce mortality rates by 2010
Robust systems and process in place to performance manage/monitor the service.
Substantially reduce Cholesterol levels mortality rates by 2010 from heart disease and stroke Practice based registers and related diseases. Cardio Vascular Disease Mortality Halt the rise in obesity among children under 11 by 2010, as part of a broader GP recording of body mass index strategy to tackle obesity in the population as a whole.
The PCT continues to actively support practices in the establishment of disease management registers, moving from secondary to primary care prevention
75%
55%
<55%
Issues with DoH definitions for recording. The PCT is actively working with practices to ensure recording improvement during 2007/08.
APPENDIX C
NEW NATIONAL TARGETS Target Description Waiting times for diagnostic tests Outpatient waiting times milestone Healthcare Commission Thresholds Achieved Undera'chd Failed poorer than plan by a clear margin above plan PCT Actual Score Under-achieved Comments
Ensure that by 2008 nobody waits more than 18 weeks Inpatient waiting times milestone from GP referral to hospital treatment. Data collection for referral to treatment waiting times Emergency bed days Improve health outcomes for Community matrons and additional case people with long term managers conditions by offering a personalised care plan for vulnerable people most at risk; and reduce emergency bed days by 2008 through improved care in primary care and community settings for people with long term conditions.
above plan
The PCT is actively working with all secondary care providers to ensure national waiting time standards are maintained/met.
all three months data submitted on time consistent with plan poorer than plan by a clear margin Action plan developed to deliver the challenging targets assigned to the PCT for staffing levels and numbers of VHIUs. Specifically, an additional 495 patients have been identified as having the potential to benefit from a case management approach to care through the use of the PARR+ predictive tool.
Very high intensity users
poorer than plan by a clear margin
Failed
APPENDIX A
HEALTHCARE COMMISSION PERFORMANCE RATINGS 2006/2007 CORE STANDARDS Safety (9 standards - C01a-C04e)
Healthcare organisations protect patients through systems that identify and learn from all patient safety incidents and other reportable incidents, and make improvements in practice based on local and national experience and information derived from the analysis of incidents. Healthcare organisations protect patients through systems that ensure that patient safety notices, alerts and other communications concerning patient safety which require action are acted upon within required timescales. Healthcare organisations protect children by following national child protection guidelines within their own activities and in their dealings with other organisations. Healthcare organisations protect patients by following National Institute for Clinical Excellence (NICE) interventional procedures guidance. Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that the risk of healthcare acquired infection to patients is reduced, with particular emphasis on high standards of hygiene and cleanliness, achieving year on year reductions in Methicillin-Resistant Staphylococcus Aureus (MRSA). Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that all risks associated with the acquisition and use of medical devices are minimised. Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that all reusable medical devices are properly decontaminated prior to use and that the risks associated with decontamination facilities and processes are well managed. Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that medicines are handled safely and securely. Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that the prevention, segregation, handling, transport and disposal of waste is properly managed so as to minimise the risks to the health and safety of staff, patients, the public and the safety of the environment.
Clinical and cost effectiveness (5 standards: C05a-C06)
Healthcare organisations ensure that they conform to National Institute for Clinical Excellence (NICE) technology appraisals and, where it is available, take into account nationally agreed guidance when planning and delivering treatment and care.
Healthcare organisations ensure that clinical care and treatment are carried out under supervision and leadership. Healthcare organisations ensure that clinicians continuously update skills and techniques relevant to their clinical work.
APPENDIX A Healthcare organisations ensure that clinicians participate in regular clinical audit and reviews of clinical services. Healthcare organisations cooperate with each other and social care organisations to ensure that patients’ individual needs are properly managed and met.
Governance (12 standards: C07a-C12)
Healthcare organisations apply the principles of sound clinical and corporate governance and C7c Healthcare organisations undertake systematic risk assessment and risk management. Healthcare organisations actively support all employees to promote openness, honesty, probity, accountability, and the economic, efficient and effective use of resources.
Healthcare organisations challenge discrimination, promote equality and respect human rights. Healthcare organisations support their staff through having access to processes which permit them to raise, in confidence and without prejudicing their position, concerns over any aspect of service delivery, treatment or management that they consider to have a detrimental effect on patient care or on the delivery of services. Healthcare organisations support their staff through organisational and personal development programmes which recognise the contribution and value of staff, and address, where appropriate, under-representation of minority groups. Not met Healthcare organisations have a systematic and planned approach to the management of records to ensure Issue Due to changes in assessment criteria the PCT was not meeting this standard up to 28th March 2007. The PCT has now an identified lead for records management/information governance who has the necessary experience to carry out the function of records management, and also advise staff around specific records management issues. Action Actions planned to rectify this gap in assurance. Role of records manager has been identified within the structure for corporate services directorate of the PCT. Action plan developed, lead identified to ensure PCT address gaps in compliance. 28th March 2007 actions completed to address gap. Records management/information governance lead in post.
Patient focus (9 standards: C13a-C16)
Healthcare organisations have systems in place to ensure that staff treat patients, their relatives and carers with dignity and respect.
APPENDIX A Healthcare organisations have systems in place to ensure that appropriate consent is obtained when required, for all contacts with patients and for the use of any confidential patient information. Healthcare organisations have systems in place to ensure that staff treat patient information confidentially, except where authorised by legislation to the contrary. Healthcare organisations have systems in place to ensure that patients, their relatives and carers have suitable and accessible information about, and clear access to, procedures to register formal complaints and feedback on the quality of services.
Healthcare organisations have systems in place to ensure that patients, their relatives and carers are not discriminated against when complaints are made. Healthcare organisations have systems in place to ensure that patients, their relatives and carers are assured that organisations act appropriately on any concerns and, where appropriate, make changes to ensure improvements in service delivery.
Where food is provided, healthcare organisations have systems in place to ensure that patients are provided with a choice and that it is prepared safely and provides a balanced diet. Where food is provided, healthcare organisations have systems in place to ensure that patients’ individual nutritional, personal and clinical dietary requirements are met, including any necessary help with feeding and access to food 24 hours a day.
Healthcare organisations make information available to patients and the public on their services, provide patients with suitable and accessible information on the care and treatment they receive and, where appropriate, inform patients on what to expect during treatment, care and after care.
Accessible and responsive Care (2 standards: C17-C18)
The views of patients, their carers and others are sought and taken into account in designing, planning, delivering and improving healthcare services. Healthcare organisations enable all members of the population to access services equally and offer choice in access to services and treatment equitably.
Care environment and amenities (3 standards: C20a-C21)
Healthcare services are provided in environments which promote effective care and optimise health outcomes by being a safe and secure environment which protects patients, staff, visitors and their property, and the physical assets of the organisation.
Healthcare services are provided in environments which promote effective care and optimise health outcomes by being supportive of patient privacy and confidentiality
APPENDIX A
Public health (4 standards: C22a-C24)
Healthcare organisations promote, protect and demonstrably improve the health of the community served, and narrow health inequalities by cooperating with each other and with local authorities and other organisations and C22c Healthcare organisations promote, protect and demonstrably improve the health of the community served, and narrow health Healthcare organisations promote, protect and demonstrably improve the health of the community served, and narrow health inequalities by ensuring that the local Director of Public Health’s annual report informs their policies and practices. Healthcare organisations have systematic and managed disease prevention and health promotion programmes Healthcare organisations protect the public by having a planned, prepared and, where possible, practised response to incidents and emergency situations, which could affect the provision of normal services.