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									HEALTHCARE COMMISSION PERFORMANCE RATINGS 2006/2007
                                                                                                                                                                                     APPENDIX B
EXISTING NATIONAL TARGETS
                                                                                 Healthcare Commission Thresholds                   PCT
Target                             Description                                  Achieved     Underach'd     Failed             Actual Score                              Comments
                                   number of people with diabetes receiving
                                                                                                                                              100% of patients on diabetes registers offered
                                   screening for the early detection (and
Diabetic Retinopathy Screening                                                    80%              >70%           <60%         91.05%   Ach'd screening, however, not all choose to take up
                                   treatment if needed) of diabetic
                                                                                                                                              the offer.
                                   retinopathy
                                                                                                                                                         Robust partnership working arrangements in
                                                                                                                                                         place between the PCT and all secondary care
                                                                                                                                                         providers to ensure the national waiting time




                                                                                                                                         Achieved
Maintain a maximum of 26weeks number of patients waiting longer than 26                                                                                  standards are maintained. New services in
                                                                                 <0.1%            <0.3%           >0.3%        0.02%
Inpatient Waits               weeks                                                                                                                      place in primary care to reduce referrals and
                                                                                                                                                         waiting times in secondary care, ie.
                                                                                                                                                         Colposcopy, Dermatology, Musculoskeletel
                                                                                                                                                         with more to follow.
Maintain a maximum wait of 13
                                   number of outpatients waiting longer than
weeks for an outpatient                                                          <0.1%            <0.3%           >0.3%        0.00%    Ach'd as above
                                   13 weeks
appointment.
Maintain a maximum waiting time
                                   All cancers: number of patients waiting
of two months from urgent
                                   longer than two months from GP urgent          93%              87%            <87%          96%     Ach'd as above
referral to treatment for all
                                   referral to treatment
cancers.




                                                                                                                                         Underachieved
                                                                                                                                                         Joint initiative between the Yorkshire
                                                                                                                                                         Ambulance Service and the PCT established -
Category A calls meeting eight     All ambulance trusts to respond to 75% of
                                                                                  75%              >70%           <70%         72.44%                    Community Paramedic Scheme Pilot. The
minute target                      category A calls within 8 minutes
                                                                                                                                                         aim being to improve CAT response times.
                                                                                                                                                         Evaluation of the Pilot is underway.

Category A calls meeting           All ambulance trusts to respond to 95% of
                                                                                  95%              >90%           <90%         96.81%   Ach'd as above
nineteen minute target             category B calls within 19 minutes.
                                                                                                                                              The PCT will continue to support Whole
                                   Maintain delayed transfers of care at a                                                                    Systems Approach to develop best practice in
Delayed transfers of care                                                         3.5%             <5%             >5%         0.77%    Ach'd
                                   minimal level.                                                                                             discharge management and build on existing
                                                                                                                                              positive joint arrangements
                                                                                                                                              The PCT is actively involved on the West
                                   Deliver a ten percentage point increase                                     <38% without                   Yorkshire Thrombolysis Specialist Group.
                                                                                                38% or a 20




                                                                                                                                         Achieved
                                   per year in the proportion of people       68% with a 20                         a 20                      Various initiatives ongoing; continued roll-out
Thrombolysis - 60 minute call to                                                                percentage
                                   suffering from a heart attack who receive percentage point                   percentage                    of nurse led thrombolysis work with WYMAS
needle time                                                                                     point annual
                                   thrombolysis within 60 minutes of calling annual increase                    point annual                  and clinicians to ensure paramedic led
                                                                                                 increase
                                   for professional help.                                                        increase                     thrombolysis will ensure improvements in call
                                                                                                                                              to needle time
                                 Maintain a maximum waiting time of one                                                                       Robust performance management/systems &
All cancers: one month diagnosis
                                 month from diagnosis to treatment for all        96%              92%            <92%         99.71%   Ach'd processes in place to actively maintain the
to treatment
                                 cancers.                                                                                                     waiting time standard.
EXISTING NATIONAL TARGETS
                                                                                   Healthcare Commission Thresholds                    PCT                                               APPENDIX B
Target                             Description                                    Achieved     Underach'd     Failed              Actual Score                               Comments
                                   Every hospital appointment to be booked
                                   for the convenience of the patient, making                                                                               Issues remain with counting Choose and Book
                                   it easier for patients and their GPs to                                                                                  and comparing with total GP referrals which
                                                                                 75% of           55% of          <55% of




                                                                                                                                            Failed
PCT facilities in place to support choose a hospital and consultant that                                                                                    are gradually being worked through that
                                                                                 planned          planned         planned     49.33%
choice                             best meets their needs. Patients should                                                                                  should improve PCT achievement of what is
                                                                                 performance      performance     performance
                                   be able to choose from at least four                                                                                     acknowledge nationally to be a challenging
                                   health care providers for planned hospital                                                                               target.
                                   care.
                                   Guaranteed access to a primary care                                                                           All GMS and PMS practices within Kirklees
Primary Care Access                professional within 24 hours and to a            100%             99%             <99%         99.84%   Ach'd are committed to delivery of this target.
                                   primary care doctor within 48 hours.
                                                                                                                                                            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
                                  Improve life outcomes of adults and                                            performance
                                                                                 performance      performance                                               review of all CRTs, undertaken by NIMHE,




                                                                                                                                            Failed
Commissioning of crisis           children with mental health problems by                                        poorer than
                                                                                consistent with   poorer than                                               was completed in September 2007 and the
resolution services               ensuring that all patients who need them                                        plans by a
                                                                                     plans            plans                                                 PCT is awaiting feedback and
                                  have access to crisis resolution services                                      clear margin
                                                                                                                                                            recommendations for 'way forward'. The PCT
                                                                                                                                                            is actively working with SWYMHT with regard
                                                                                                                                                            to care pathway re-design and delivery of key
                                                                                                                                                            national targets.

                              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




                                                                                                                                            Underachieved
                              assessments undertaken within 24 hours
                                                                                                                  yes' to only                              Healthcare Commission carried out evaluation
Commissioning a comprehensive or during the next working day where                                yes' to two
                                                                         yes' to all three                       one or none of                             of service provision at Q3 (Sept 06), however,
child and adolescent mental   indicated? 2. Is a full range of CAMHS                              out of three
                                                                           questions                               the three                                the PCT position changed at Q4 (March 07),
health service                for children and young people who also                              questions
                                                                                                                   questions                                showing 'yes' to all 3 questions.
                              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.
EXISTING NATIONAL TARGETS
                                                                            Healthcare Commission Thresholds                  PCT                                              APPENDIX B
Target                       Description                                   Achieved     Underach'd     Failed            Actual Score                                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
                             Update practice-based registers so that
                                                                                                                                                  LDP process or subsequent 'refresh'




                                                                                                                                   Not assessed
                             patients with coronary heart disease and
                                                                                                                                                  processes. No plans in place and no 'actuals'
                             diabetes, and the majority of patients at
Practice based registers -                                                                                                                        reported during 2006/07. This is a PCT
                             high risk of coronary heart disease,          data not available - indicator not assessed
patients called for review                                                                                                                        priority for the immediate future and the
                             continue to receive appropriate advice
                                                                                                                                                  performance team will work with the Lead
                             and treatment in line with national service
                                                                                                                                                  Manager(s) to ensure plans are submitted for
                             framework standards.
                                                                                                                                                  2007/08 as a matter of urgency and robust
                                                                                                                                                  systems & processes in place to support
                                                                                                                                                  delivery.
                             Maintain a two week maximum wait from
                             urgent GP referral to first outpatient                                                                               Robust systems and processes in place to
All cancers: two week wait                                                   97%               94%             <94%      100%     Ach'd
                             appointment for all urgent suspected                                                                                 support delivery.
                             cancer referrals.
                             Maintain the four hour maximum wait in                                                                     Emergency Care Strategy developed and
A & E Waits                  A&E from arrival to admission, transfer or      98%               97%             <97%      98.67%   Ach'd implemented in collaboration with the PCT and
                             discharge.                                                                                                 all relevant partners
                             Maintain a three month maximum wait for                                                                    Robust systems and processes in place to
CHD - Revascularisation                                                      0.5%              1%              >1%        0%      Ach'd
                             revascularisation                                                                                          support delivery.
                                                                                                                                                                                  APPENDIX C
HEALTHCARE COMMISSION PERFORMANCE RATINGS 2006/2007

NEW NATIONAL TARGETS
                                                                            Healthcare Commission Thresholds                           PCT
Target                       Description                                  Achieved    Undera'chd      Failed                  Actual         Score                 Comments
                             Achieve year on year reductions in MRSA                                                                             The PCT is monitored against the
                             levels, expanding to cover other                                                                                    performance of the 2 local acute Trusts.
                                                                          yes' to all 4   yes' to 3 of 4     yes' to fewer  yes' to all
Infection Control - MRSA     healthcare associated infections as data                                                                   Achieved Root Cause Analysis is carried out for each
                                                                           questions       questions       than 3 questions     4
                             from mandatory surveillance becomes                                                                                 case and any actions identified,
                             available.                                                                                                          implemented.
                                                                                                                                                 National target - 100% of equipment to be
                             Improve the quality of life and                                                                                     delivered within 7 working days. The
                             independence of vulnerable older people                                                                             national target has not been achieved due
Older People - Community                                                                                                                 Under-
                             by increasing the proportion of older           95%              85%               <85%         87.88%              to Joint Contingency, this equipment is
Equipment                                                                                                                               achieved
                             people being supported to live in their                                                                             specially built, ordered and fitted on an
                             own home by 2008.                                                                                                   individual basis which is not feasible within
                                                                                                                                                 7 working days.
                             Increase the participation of problem drug                                                                           Number of actions taken to
                             users in drug treatment programmes by                                         Performance                            maintain/improve performance; Service
                                                                        Performance       Performance
                             2008; and increase year on year the                                           poorer than plan                       provider has completed a Retention
Substance Misuse                                                        consistent        poorer than                                    Achieved
                             proportion of users successfully                                              by a clear                             Improvement Plan; service users with lower
                                                                        with plan             plan
                             sustaining or completing treatment                                            margin                                 support needs are transferred into shared
                             programmes.                                                                                                          care services with GP practices, etc.
                             Reduce smoking during pregnancy by 1%                                                                                             Dedicated 'specialist advisers' working with
                                                                                             below plan




                                                                                                                                              Under-achieved
                             year-on-year                                                                                                                      the acute Trusts to support women to stop
                             Increase breastfeeding initiation rates by                                                                                        smoking during pregnancy. Smoking
                                                                                            above plan
Reduce Health Inequalities   2% year-on-year                                                                                                                   Cessation, service moving to operate
by 10% by 2010               Increase data quality on ethnic group                          above plan                                                         Kirklees-wide and planning to achieve
                             Reduce number of people smoking                  75%            55%                <55%           81%                             challenging targets set by the SHA.
                             Increase number of four week smoking            100%            90%                 85%          93.22%                           Outcomes of 'Smoking Summit' held to look
                             quitters                                                                                                                          at reducing health inequalities and improve
                                                                                                                                                                                                APPENDIX C
NEW NATIONAL TARGETS
                                                                          Healthcare Commission Thresholds                            PCT
Target                      Description                                 Achieved    Undera'chd      Failed                   Actual         Score                                              Comments
                                                                                                                                                                             Various initiatives ongoing; Implement and
                                                                                                                                                                             evaluate Teenage Pregnancy Strategy;




                                                                                                                                             Under-achieved
                                                                                                                                                                             Implement Sex and Relationship Education
                                                                                                           Performance
                            Reduce the under-18 conception rate by     Performance        Performance                                                                        programmes in community as well as
Sexual Health - Teenage                                                                                    poorer than
                            2010, as part of a broader strategy to     consistent         poorer than                                                                        school setting and involving community
Conception Rates                                                                                           plan by a clear
                            improve sexual health.                     with plan          plan                                                                               workers, schools nurses, Sure Starts, etc;
                                                                                                           margin
                                                                                                                                                                             increase access to condoms and sexual
                                                                                                                                                                             health advice for young people in a range of
                                                                                                                                                                             settings
                              Secure sustained national improvements   Performance                         Performance
                                                                                          Performance                                            Action plans produced from feedback of
                              in NHS patient experience by 2008 as     consistent                          poorer than
Patient Experience                                                                        poorer than                                   Achieved survey results, implemented to improve
                              measured by independently validated      with or better                      average by a
                                                                                          average                                                patient experience.
                              surveys                                  than average                        clear margin
Mental Health - substantially Care programme approach seven day
                                                                                        consistent with plan
reduce mortality rates by     follow up                                                                                                                                      The PCT has now commissioned an Early
2010 from suicide and         Commissioning of early intervention in                                                                                                         Intervention Service that will be up and




                                                                                                                                             Failed
undetermined injury by 20% psychosis services                                 poorer than plan by a clear margin                                                             running from December 2007.

                            Cancer mortality rate                                       consistent with plan
Cancer - substantially
                            Implementation of NICE improving                                                                                                                 Robust systems and process in place to
reduce mortality rates by                                                           11 out of 24 milestones                             Achieved
                            outcomes guidance                                                                                                                                performance manage/monitor the service.
2010
                            Breast cancer screening                                     consistent with plan




                                                                                                                                             Under-achieved Under-achieved
                            Blood pressure                                          consistent with plan
Substantially reduce                                                                                                                                                         The PCT continues to actively support
                             Cholesterol levels                                     consistent with plan
mortality rates by 2010 from                                                                                                                                                 practices in the establishment of disease
heart disease and stroke     Practice based registers                         poorer than plan by a clear margin                                                             management registers, moving from
and related diseases.                                                                                                                                                        secondary to primary care prevention
                             Cardio Vascular Disease Mortality                          consistent with plan
Halt the rise in obesity
among children under 11 by                                                                                                                                                   Issues with DoH definitions for recording.
2010, as part of a broader                                                                                                                                                   The PCT is actively working with practices
                              GP recording of body mass index              75%               55%               <55%           58%
strategy to tackle obesity in                                                                                                                                                to ensure recording improvement during
the population as a whole.                                                                                                                                                   2007/08.
                                                                                                                                                                        APPENDIX C
NEW NATIONAL TARGETS
                                                                          Healthcare Commission Thresholds                   PCT
Target                          Description                             Achieved     Undera'chd          Failed     Actual         Score                             Comments
                                Waiting times for diagnostic tests          poorer than plan by a clear margin
                                Outpatient waiting times milestone                     above plan




                                                                                                                                    Under-achieved
Ensure that by 2008 nobody
                                                                                                                                                     The PCT is actively working with all
waits more than 18 weeks
                             Inpatient waiting times milestone                          above plan                                                   secondary care providers to ensure national
from GP referral to hospital
                                                                                                                                                     waiting time standards are maintained/met.
treatment.

                            Data collection for referral to treatment
                                                                          all three months data submitted on time
                            waiting times
                                       Emergency bed days                          consistent with plan
Improve health outcomes for
people with long term       Community matrons and additional case
                                                                            poorer than plan by a clear margin
                                             managers                                                                                                Action plan developed to deliver the
conditions by offering a
                                                                                                                                                     challenging targets assigned to the PCT for
personalised care plan for
                                                                                                                                                     staffing levels and numbers of VHIUs.
vulnerable people most at




                                                                                                                                    Failed
                                                                                                                                                     Specifically, an additional 495 patients have
risk; and reduce emergency
                                                                                                                                                     been identified as having the potential to
bed days by 2008 through
                                        Very high intensity users           poorer than plan by a clear margin                                       benefit from a case management approach
improved care in primary
                                                                                                                                                     to care through the use of the PARR+
care and community
                                                                                                                                                     predictive tool.
settings for people with long
term conditions.
                                                                                                    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.

								
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