Ayrshire and Arran NHS Board - nhsaaa-beta.scot.nhs.uk · PDF file6 of 31 Cardiology Action identified By when Update Progress has been made via extra clinics to clear back log and

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Ayrshire and Arran NHS Board Monday 5 August 2013

Waiting Times Report Author: Fraser Doris, Planning and Performance Officer

Sponsoring Director: Dr Allan Gunning, Executive Director – Policy, Planning and Performance

Date: 15 July 2013

Recommendation The Board is asked to:

review performance against the national waiting times and access targets at the end of April 2013. Where later data is available this is flagged as “update”; and

approve the Board‟s proposed actions against sustainable delivery of the patient access goals.

Summary This paper reports on progress towards achieving waiting time and other access targets set by the Scottish Government as well as progress on local targets set by the Board. Latest available information is reported for the following targets and measures:

Treatment Time Guarantee

18 Weeks Referral to Treatment

Stage of Treatment Targets

Unavailability of patients

Accident & Emergency waiting times

Cancer waiting times

Patients awaiting discharge

Mental Health and Community Services

Other local access targets – Mental Health

Other local access targets – other areas A summary scorecard is at appendix 1. Key Messages:

As at 2 May there have been 67 breaches of the Treatment Time Guarantee since the first qualifying date of 24 December 2012.

18 week Referral to Treatment continues to exceed the target of 90%, with 91.98% performance in April 2013.

Paper 06

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A&E 4 hour wait performance was below the 98% target at 88.75% for April 2013.

31 day Cancer waiting times target was achieved in both the May 2013 and in the January to March 2013 validated results however the 62 day target was not met in either May 2013 or in the January to March validated results.

4 week patients awaiting discharge target was achieved in May 2013.

This report is based on April 2013 data. Information on the position as at the end of May 2013 is becoming available and is flagged as “update” within this report. A verbal update will be given at the NHS Board meeting for any subsequent updates.

Glossary of Terms NHS A&A A&E CAMHS OP IP/DC TTG RTT ANPs GPSIs ENT ICES QuEST ISD SGHSCD MRI DCAQ LDP WLI GJNH PCMHN

NHS Ayrshire and Arran Accident and Emergency Child and Adolescent Mental Health Services Outpatient Inpatient and Day Case Treatment Time Guarantee Referral to Treatment Advanced Nurse Practitioners General Practitioners with Special Interest Ear, Nose and Throat Integrated Care and Emergency Services Quality and Efficiency Support Team Information Services Division Scottish Government Health and Social Care Directorate Magnetic Resonance Imaging Demand, Capacity, Activity & Queue Local Delivery Plan Waiting List Initiative Golden Jubilee National Hospital Primary Care Mental Health Nurse

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1 Treatment Time Guarantee (TTG)

Target: the TTG for patients added to the list from 1 October 2012 places a legal responsibility on NHS Boards to deliver treatment to all day case / inpatients within 12 weeks of the patient agreeing to treatment. NHS Boards are expected to ensure no patient exceeds 12 weeks who has been added to the day case / inpatient waiting list from 1 October 2012. Performance: the cut off date commenced on 24 December 2012 and is in place continuously thereafter. As at 2 May there were 67 breaches: 59 in Trauma and Orthopaedics; 3 in General Surgery; 3 in Urology; 1 in Gynaecology and 1 in Oral and Maxillofacial surgery. In addition, 3 potential breaches had been identified for Trauma and Orthopaedics.

2 18 Weeks Referral to Treatment (RTT)

Targets: the target for 18 weeks RTT is to deliver 90% combined admitted / non admitted performance; to deliver 90% of patients with a total pathway which is linked; and to deliver 90% of completed forms at the end of each clinic outlining the outcome of the consultation. Performance:

Target Feb 2013 Mar 2013 Apr 2013

Combined Performance 90% 90.58% 92.12% 91.98%

Completeness 90% 90.01% 89.68% 90.99%

Clinic Outcomes 90% 86.13% 85.3% 86.3%

18 week RTT performance Although the overall target is being achieved, work is ongoing in the specialties currently performing below the target level, which are detailed at Appendix 2. Remedial action plans:

Renal Medicine

Action identified By when Update

Progress has been made via extra clinics to clear back log and improve performance. DCAQ also underway.

Ongoing April has been a difficult period due to School Holidays and Consultant Annual Leave. Although the short term position is much improved, the continued use of additional clinics will be required to meet demand. Percentage performance 80.0%. A Consultant has retired and a replacement has been appointed.

When will target be achieved? Being assessed currently

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Vascular surgery


To review pathway for patients referred for consideration of varicose vein surgery.

June 2013 All patients who have waited more than 18 weeks are those who presented with varicose veins. Patients were seen in clinic, added to waiting list for Doppler scan, reviewed in clinic and then, where appropriate, added to inpatient/day case waiting list. Total journey was therefore greater than 18 weeks. Feasibility of one stop clinic for outpatient appointment and Doppler scan explored but was determined not to be feasible to implement. Admin process therefore to be refined to ensure minimum delay between clinic appointment and Doppler scan. PMS team requested to consider cardio physiology being an early implementer of „order comms‟ which will mean instant requests for Doppler scans.

When will target be achieved? Performance has improved by 7% on last month. Further improvement will be dependent on improving the time to Doppler scanning and decision to add to inpatient/day case waiting list.

Urology

There has been a small improvement in compliance from March to April (+1.41%) but performance has been compromised for Urology as the outpatient maximum waiting time is currently 12 weeks and the day case maximum waiting time is 9+ weeks for many patients.

Action identified By when

Additional outpatient clinics and day case theatres organised in May and June to reduce stage of treatment waiting times.

May-June

ANP carrying out repeat flexi clinics to free up consultant time. Ongoing

Any space on inpatient theatre lists being filled with day cases. Ongoing

When will target be achieved? By the end of June the outpatient maximum waiting time will be down to 11 weeks; whilst this is unlikely to achieve 90% there should be significant improvement.

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Trauma and Orthopaedic Surgery

18wks RTT performance has been slowly improving over recent months. Non admitted pathway performance remains high, and a slow improvement in the admitted patient pathway is contributing to the steady increase in overall performance, although this remains below the 90% target. The main challenges in further increasing the combined pathway performance are:

Overall waiting time for inpatient surgery (less of an issue for day case surgery);

Extension of waiting time resulting from cancellations due to bed pressures, or lately due to significantly increased trauma operating requirements;

Increased waiting time for MRI investigations, which forms a part of a significant proportion of orthopaedic pathways;

Many of the orthopaedic pathways continue to involve a return clinic appointment after a diagnostic investigation.

Furthermore the clinical staff have expressed significant concern at the extended waiting times for physiotherapy (17 weeks). This affects the non-admitted patient pathways, and it is believed that the current practices around clinic outcoming may be artificially masking this particular problem.


Continued actions to reduce waiting time for surgery (as per the Inpatient/Day Case Stage of Treatment Action plan).

Ongoing

Additional non-recurring MRI sessions have been arranged to help reduce the MRI waiting time.

Monthly

Imaging Services DCAQ. July 2013

Conversion of Ortho clinic time to theatre time on a session by session basis, where opportunities arise.

Ongoing

Review some orthopaedic pathways to remove unnecessary steps (action will be taken on commencement of Management Lead for Orthopaedics).

To be confirmed


Oral & Maxillofacial Surgery


Aim to reduce the outpatient wait to 9 weeks, but difficult with a team of only two consultants.

30 June 2013

Patients continue to be dated at 12 weeks for their out-patient appointment and then 9 weeks for admission. Extra clinics in place to maintain 12 weeks for out-patients. Added pressure in April of the dental x-ray machine failing resulting in patients being rescheduled outwith their breach date.

When will target be achieved? The target was achieved for February and March but slipped in April. Aim to be back on target by end June 2013.

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Cardiology


Progress has been made via extra clinics to clear back log and improve performance. DCAQ underway.

Ongoing April has been a difficult period due to Consultant Sickness Absence, School Holidays Consultant Annual Leave and Parental Leave. Percentage performance 88.05%. Although the short term position has improved, the continued use of additional clinics will be required to meet demand.


Performance to Achieve Target: A remedial action plan was agreed for Respiratory Medicine in February 2013 and since then 18 week RTT performance has improved from 71.21% in January 2013 to 91.43% in April 2013. 18 week RTT completeness Although there is no formal target, the expectation is that NHS Boards should achieve 90%, with the Scottish Government requesting details of issues and improvement activities when performance falls below this level. The specialties with the lowest recorded performance in April were Renal Medicine (62.5%), Rheumatology (68.26%), Endocrinology & Diabetes (72.09%), General Medicine (77.97%) and Geriatric Medicine (80%). The detail of performance by specialty is shown at Appendix 2. Clinic Outcome recording The specialties with the lowest recorded performance in April were Rehabilitation Medicine (58.87%), Gastroenterology (59.47%), Anaesthetics (65.74%), Dietetics (68.75%) and Cardiology (69.17%). The detail of performance by specialty is shown at Appendix 2. When considering which remedial action plan to highlight, account has been taken of the number of patients being seen within the specialty as well as the clinic outcome recording performance.

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Remedial action plans:

Gastroenterology

Crosshouse Consultants have been covering Ayr workload due to the lack of Consultants there. Month on month improvements are being made, although performance is not yet meeting the target level. The Gastroenterology Service in Ayr has been significantly affected due to ongoing Consultant absence and an unfilled vacancy. The Service have been unable to recruit to cover the vacancy, either permanently or utilising locum cover.


Consultants advised via Clinical Directors that an improvement is required in compliance with Clinic Outcoming to meet the 90% Target.

30 June 2013 There has been an improvement in compliance since last month, although not yet meeting target. Performance is at 59.7% as at the end of April.


Anaesthetics


Advise Consultants of performance and work with them to identify way to improve.

30 June 2013 Management lead will work with the Consultants to address any issues on the reasons as to why clinical outcoming has slipped.

When will target be achieved? Aim for end of June 2013.

Renal Medicine Action identified By when Update


30 June 2013 There has been an improvement in compliance since last month, although not yet meeting target. Performance is at 72.90% as at end April.


Respiratory



30 June 2013 There has been an improvement in compliance, although not yet meeting target. Performance is at 78.20% as at end April.

When will this target be achieved? Being assessed currently

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Cardiology



30 June 2013

There has been an improvement in compliance since last month, although not yet meeting target. Performance is at 82.00% as at end April.


General Medicine



30 June 2013 There has been an improvement in compliance since last month, although not yet meeting target. Performance is at 78.00% as at end April.


Dermatology


Advise directorate of performance by individual consultant and support operational procedures to ensure improved performance.

15 March 2013

Work ongoing to improve performance.


Neurology


Advise Consultants of performance and work with new neurology lead to identify ways to improve.

31 May 2013 Management lead is working with the two individuals whose performance against this target is particularly low to address any issues.


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3 Stage of Treatment Targets

Targets: in addition to the TTG and 18 weeks RTT, NHS Boards are also required to report on stage of treatment guarantees for inpatient and day case (9 weeks), outpatients (12 weeks) and diagnostics (6 weeks). The percentage of patients seen within the target period is given below alongside the number of breaches in brackets. Performance:

Feb 2013

Mar 2013

Apr 2013

Inpatient & day case patients exceeding 9 weeks 95.1% (163)

96.3% (127)

96.2% (119)

Outpatients patients exceeding 12 weeks 97.7% (371)

98.2% (299)

97.0% (526)

Diagnostics patients exceeding 6 weeks 100% (0)

99.9% (2)

98.7% (45)

Performance update: There were 69 breaches of the Inpatient/Day Case 9 week target with 97.8% of patients being seen; 646 breaches of the Outpatient 12 week target with 96.3% of patients being seen and 21 breaches of the Diagnostic 6 week target in May 2013. Inpatients and day cases The specialties who recorded breaches in April 2013 were: Trauma & Orthopaedics seeing 86.1% of patients with 90 breaches; General Surgery seeing 96.2% of patients with 12 breaches; Ophthalmology seeing 99.0% of patients with 9 breaches and Urology seeing 98.1% of patients with 8 breaches. Remedial action plans:

Trauma & Orthopaedic Surgery

There were 90 breaches of the 9 week target indicating further progress in reducing the waiting times in orthopaedics. This has been delivered via additional funded capacity and some WLIs to maximise theatre utilisation. The overall progress in reducing the waiting time for orthopaedic surgery is being closely monitored and is demonstrating steady improvement. The weekly TTG report monitors the number of patients who have waited over 50 days, by timeband in weeks. The overall number of patients waiting over 50 days has fallen from 442 on 26 October 2012 to 109 by 27 May 2013.


Continued use of GJNH capacity.

Ongoing “Treat only” allocation for Apr–Jun 2013 being fully utilised. Increased See and Treat capacity in place at GJNH from April 2013, however clinical staff expressing difficulty in being able to identify sufficient numbers of suitable patients to fill the allocation. This is being closely monitored and shared

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with the clinical staff doing the referral triage.

Work with GJNH to improve administration processes – meeting with GJNH 06/03/13.

01 June 2013 Phase 1 Completed. A new electronic process for administration of „see and treat‟ activity now successfully implemented. Similar process for „treat only‟ referrals being worked on. Requires orthopaedic staff to be given access to SCI Gateway and trained on same. Action date updated to reflect this second phase.

Pursue increased GJNH see and treat capacity through annual request process.

01 April 2013 Completed. Allocation for 2013/14 confirmed. Some difficulties being experienced by clinical staff in identifying sufficient, appropriate patients to send to GJNH for the increased see and treat component of contract. A revised case mix list has been provided by GJNH to assist with this. Weekly referral rate being monitored.

Continued use of WLI to ensure maximum usage of theatre time.

01 April 2013 In place for April. From May, continuing use of otherwise cancelled theatre lists, within budget constraints.

Embedding of extended theatre days / extra lists into core activity at Ayr and Crosshouse Hospitals.

01 April 2013 Completed.

Use of private sector. Ongoing No patients sent to private sector in April 2013. 1 patient sent in May 2013.


General Surgery 12 confirmed breaches over 9 weeks but all admitted within 12 weeks

TTG.


Continue to arrange additional theatre lists on the Ayr Hospital site.

Ongoing Patients being managed within 12 weeks and the number over 9 weeks is reducing month on month.

When will target be achieved? Being assessed currently.

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Ophthalmology

9 confirmed breaches over 9 weeks but all admitted within 12 weeks TTG.


Patients related to consultant with sub specialty interest. Due to sick and annual leave there was difficulty in dating all patients within 9 weeks.

Ongoing Patients dated within 9 weeks by the end of May 2013.

When will target be achieved? Being assessed currently.

Urology 8 patients breached 9 weeks due to an on-going backlog from the beginning of

the year when no additional theatres were arranged. There were no TTG breaches.


Additional day case theatres arranged to address backlog May-June

Maximise utilisation of all theatre slots (e.g. day cases on main theatre lists)

On-going

When will target be achieved? Due to public holidays, annual leave etc it is likely there will be further breaches over the summer months; every effort will be made to reduce the maximum waiting time for day cases to 8 weeks by September 2013.

Outpatients The specialties which recorded breaches in April 2013 were as follows:

Dermatology seeing 89.3% of patients with 166 breaches;

Neurology seeing 81.7% of patients with 135 breaches;

Urology seeing 95.8% of patients with 58 breaches;

Endocrinology & Diabetes seeing 89.8% of patients with 45 breaches;

Cardiology seeing 96.6% with 43 breaches;

Respiratory Medicine seeing 94.4% with 27 breaches;

General Surgery seeing 99.1% with 17 breaches;

Trauma and Orthopaedic Surgery seeing 98.8% with 13 breaches;

Gastroenterology seeing 98.4% with 7 breaches;

Ophthalmology seeing 99.8% of patients with 4 breaches;

Gynaecology seeing 99.7% of patients with 3 breaches,

Infectious Diseases seeing 97.9% with 2 breaches;

ENT seeing 99.9% of patients with 2 breaches;

Maxillofacial Surgery seeing 99.9% of patients with 1breach;

General Medicine seeing 99.5% with 1 breach;

Paediatrics seeing 99.8% of patients with 1 breach; and

Renal Medicine seeing 98.7% of patients with 1 breach.

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Remedial action plans:

Neurology


Seek locum appointment.

End of May 2013

Locum post advertised in BMJ with closing date of 10th May. Locum agencies have also been approached.

Arrange additional clinics.

Additional clinics continue to be arranged based on limited consultant availability. Weekend locum sessions being arranged.

Work with the Regional centre to identify regional solutions

Ongoing but limited progress. The aim is to send urgent patients who will not be seen in NHS A&A within 6 weeks to Glasgow.

Work with NHS 24 to introduce call reminder call service to reduce DNAs and fill empty slots.

Implementation delayed to May to finalise Caldicott sign off.

Develop business case for longer term solution

30/06/2013 Business case under development, linked to neurology rehabilitation plans.


Dermatology


Additional Consultants, General Practitioners with Special Interest (GPSIs) and nurse led clinics being arranged.

Ongoing Additional clinics continuing. Middle grade review underway to maximise activity benefits from these posts. Consultants have reviewed clinic templates to try to match demand. Review to New ratios have been reviewed and are thought to be appropriate (GPSI activity impacts on review to new ratio national comparisons). Nursing cover also under review. Trajectories agreed to reduce over 12 week waits to zero by mid June.


Urology

Waiting Times co-ordinator is currently on maternity leave and there has been a gap in securing cover for the post; during this time clinics became overbooked and clinics booked inappropriately. This has created a backlog of outpatients that are breaching 12 weeks; 58 outpatients breached the waiting time in April (and a similar number likely to in May). Cover for the Waiting Times co-ordinator post is now in place.


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Review all clinics to check booked in turn. 31st May 2013

Schedule extra clinics to address backlog (including Saturdays). May-June

When will target be achieved? By end of June 2013.

General Surgery 17 patients breached the 12 wk guarantee; all breast patients. Extra Clinics

have been put in place to accommodate the backlog and the waiting time is reducing significantly.


Additional evening clinics continue.

Ongoing By end of May no patient will have waited over 12 weeks. Waiting time for rapid access clinic is around 6 weeks. Waiting time for benign breast disease clinic is around 9 weeks.

Advert out for a further Breast Consultant.

Jul 2013 New Breast Surgeon appointed who will join the team in September 2013. One consultant will go on maternity leave in August 2013. Advert out for locum to cover this leave.

When will target be achieved? May 2013.

Trauma and Orthopaedics

There are a small number of patients waiting more than 12 weeks. A review of these over March and April has demonstrated that the issue relates almost entirely to referral letters which have been delayed as a result of typing backlogs. Around 50% of these typing backlog delays originate within Orthopaedics (i.e. consultant to consultant referrals within specialty) and around 50% originate in other specialties (i.e. consultant referrals from another specialty). The Orthopaedics department has taken action to address the former as noted below, and is dependent on other specialties taking action to address their own typing backlogs.


Engage 2 additional fixed term short hand typists. April 2013

Use Digital Dictation system to reassign typing workload to secretaries with shorter backlogs.

Ongoing

Use Digital Dictation reports and the 2011 A&C audit to undertake a mini-DCAQ on the orthopaedics administrative requirements compared to current resource.

July 2013


Diagnostic tests At the end of April 2013, 45 of 3550 patients had waited longer than 6 weeks for a diagnostic test, so 98.7% of patients were within target.

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Imaging

The demand for various imaging investigations, and in particular MRI and CT scans, has been rising significantly and is proving challenging to manage within available capacity. Additional weekend sessions have been running since mid April and are beginning to have some beneficial impact on the CT waiting time. Furthermore the recently installed 3rd CT scanner should be operational by June with a phased introduction of this additional capacity. MRI scanning remains a pressure point. Additional sessions are scheduled and ongoing, but further work is being done to explore other options as the pressure continues. A DCAQ analysis is underway to inform future NHS Board considerations on any need for further investment.


Install additional CT scanner. July 2013

Continue use of weekend sessions and other WLI activities Ongoing

Undertake DCAQ analysis. July 2013


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Unavailability of Patients and Full Waiting List Size The number of patients waiting for Inpatient and Day Case treatments or Outpatient appointments is shown below.

Total waiting list size Feb 2013 Mar 2013 Apr 2013

Inpatient and Day Cases 3326 3398 3148

Outpatients 16184 17062 17578

Total 19510 20460 20726

Unavailability of patients is monitored closely based on “reasonable offers” being made to patients for access to outpatient, inpatient and day case slots within the Board‟s services. The overall position is detailed below, with the percentage measurable against the total waiting list shown in brackets:

Total patients unavailable Feb 2013 Mar 2013 Apr 2013

Inpatient and Day Cases 557 (16.7%) 538 (15.8%) 602 (19.1%)

Outpatients 250 (1.5%) 197 (1.15%) 219 (1.24%)

Total 807 (4.14%) 735 (3.59%) 821 (3.96%)

April 2013 Inpatient & Day Cases Outpatients

Social unavailability 388 167

Medical unavailability 214 52

Total 602 219

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Patient unavailability rates by specialty are shown at appendix 3, both in terms of the numbers and as a percentage of the total waiting list. The number of patients currently unavailable over the waiting times standards are also shown. The highest levels of Inpatient and Day Case unavailability are in Vascular surgery (53.1% of the total number of patients waiting), Cardiology (38.2%), General Surgery (31.9%), and Gynaecology (29.6%). The highest levels of Outpatient unavailability are in General Medicine (7.3%), Trauma and Orthopaedic surgery (1.8%) and Ophthalmology (1.7%). Performance update: In May 2013 there were 477 socially unavailable and 197 medically unavailable Inpatients or Day Cases. The total of 674 was 21.5% of the 3140 total patients waiting. For Outpatients there were 180 socially unavailable and 57 medically unavailable patients. The total of 237 was 1.35% of the 17523 total patients waiting.

5 Accident and Emergency Waiting Times

Target: The Board is required to ensure that the maximum length of time from arrival at Accident and Emergency to admission, discharge or transfer is 4 hours for 98% of patients. Performance:

Feb 2013 Mar 2013 Apr 2013

A&E 4 hour wait 88.12% 89.58%. 88.75%

There has been a significant increase in the number of frail elderly admissions requiring a longer than average length of stay in the acute sector (and also in many cases a period of geriatric rehabilitation). It is suspected this is part of the predicted impact of demographic change in the number of over 75‟s and over 85‟s in our population, rather than simply the knock on effect of flu and increased virulence of the upper respiratory tract virus currently circulating. These patients all require acute hospital care. Evidence of the impact of shifting the balance of care, specifically around anticipatory care and intermediate care initiatives, including Change Fund initiatives, are still awaited. The Scottish Government has confirmed that this pattern is emerging across Scotland and in light of the increasing evidence base which links increased morbidity and increased mortality to long A&E waits and A&E overcrowding the government is prioritising improvement in 4 hour A&E performance. It has introduced a new HEAT Target to support this with a first milestone of 95% performance required in the year ending September 2014. This will require consistent compliance above 95% from September 2013 if this new target is to be delivered. Patient flow is managed in response to very robust and responsive demand forecasting. Proactive patient flow management arrangements are in place on both acute sites which aim to support both the 4 hour standard and delivery of elective waiting time targets. This is supported by the designated Duty manager for daily patient flow meetings, with triggers for a range of escalations and additional meetings earlier and later each day, as required, and senior support for bringing into use

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additional inpatient capacity and ambulance service, primary care and social services responses as required. Patient Flow Capacity Management and Escalation Procedures have been reviewed and updated and escalation triggers agreed last year have been updated to include new escalation triggers for both managers and clinicians. Breach analysis meetings are still held on both sites every week. The Associate Medical Director (ICES) is leading on a number of Emergency Care Quality Improvement Programme (ECQIP) projects with additional Programme Support being provided by the Programme Manager, Service Futures. In addition, the Associate Medical Director is leading on bringing forward those workforce and service redesign changes which can be delivered in advance of the Building for Better Care investments, for which a revised outline business case has been prepared and has now moved to full business case stage. This includes consultant expansion and increasing the consultant contribution to the A&E middle grade rotas, including during the out of hours period. The ECQIP Steering Group has agreed that the programme will continue until January 2014 to allow completion of the agreed projects. Performance update: In May 2013 performance improved to 92.23%, though remains below target.

6 Cancer Waiting Times

Targets: 95% of all eligible patients should wait no longer than 62 days or 31 days. A 5% tolerance level is applied to these targets as for some patients it may not be clinically appropriate for treatment to begin within target. The 62 day urgent referral to treatment target includes screened positive patients and all patients referred urgently with a suspicion of cancer. The 31 day target includes all patients diagnosed with cancer (whatever their route of referral) from decision to treat, to treatment. Performance:

Jan 2013 Feb 2013 Mar 2013

62 days 92.9% 96.6% 95.1%

31 days 97.6% 99% 99.1%

In March 2013 Urology (87.5%, 2 patients), Colorectal (88.9%, 1 patient) and Upper GastroIntestinal (91.7%, 1 patient) were below the 62 day target, and were the only areas achieving less than 100%. Only Urology (95.2%) did not achieve 100% in the month for the 31 day target. There are capacity pressures in Urology and all potential breaches are escalated to the general manager. These are as a result of two main issues, the wait for surgery at first treatment and recent pressures with laparoscopic nephrectomy. The Colorectal breach was as a result of the patient‟s wait for investigation. The Upper GastroIntestinal pathway is long and complex with staging investigations and is vulnerable to any delay. Current issues are with performance of this pathway in Ayr.

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Performance update: 62 day performance for April 2013 was 95.2% and for May 2013 was 90.3%. 31 day performance for April 2013 was 100% and for May 2013 was 95.2%. The validated, quarterly, ISD-published performance information for January to March 2013 shows 31 day performance at 98.4% and 62 day performance just below target at 94.6%.

7 Patients Awaiting Discharge

Targets: the current target is that no one will wait more than 28 days to be discharged from hospital into a more appropriate care setting once treatment is complete. This will reduce to 14 days from April 2015. Performance :

Mar 13 Apr 13 May 13

28 day delayed discharges

2 0 0

14 day delayed discharges

20 8 11

The 11 patients waiting more than 14 days in May 2013 was less than the monthly trajectory of 13 and were spread across the three local authorities, 5 in North Ayrshire, 3 in South Ayrshire and 3 in East Ayrshire.

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Mental Health and Community Services

Targets : there are three national targets in this area: 1) By March 2013, 90% of clients will wait no longer than 3 weeks from referral

received to appropriate drug or alcohol treatment that supports their recovery; 2) From March 2013, deliver 26 weeks referral to treatment for specialist Child and

Adolescent Mental Health Services (CAMHS); reducing to 18 weeks by December 2014;

3) From December 2014, deliver 18 weeks referral to treatment for Psychological Therapies.

Performance: 1) Performance on Drug or Alcohol Treatment waiting times is consistently above

target, with the latest available information for October to December 2012 at 98.7% against a target of 90.1%

2) CAMHS performance met the 26 week wait trajectory for March 2013, with 4 people waiting over 26 weeks compared to the monthly trajectory of 4. The 18 week monitoring has changed to a percentage compliance format (number of patients seen within 18 weeks divided by the number of patients waiting, expressed as a percentage) and at 60.29% for April 2013 is above the LDP trajectory of 45%.

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3) Being progressed at a national level. Local information is being produced and will

be included in the next CMT Waiting Times report.

There is a significant piece of work underway under the auspices of the Psychological Therapies and CAMHS 18 RTT Programme. The appointment of a senior data analyst, from Quality and Efficiency Support Team (QuEST) funding, to give support to the data collation and analysis, has led to a significant amount of work in reviewing and understanding the data on the CAMHS Waiting Times Access database. The data „cleansing‟ work may go some way to explaining the increase in numbers waiting. There were an increased number of urgent referrals during the time period which took up a considerable amount of staff time. The ongoing work of the Team with the Analyst is allowing an increased understanding of the data being reported and the definitions being used. From April 2013, the target for Referral to Treatment for Psychological Therapies was to be measured as percentage access to Mental Health Services. From then on, data will be reported against trajectories set within the Local Delivery Plan (LDP) 2013/14. A performance workbook, based on referrals to Psychology and the Primary Care Mental Health service is sent to Information Services Division (ISD) on a monthly basis. The service is currently unable to report on Psychological therapies delivered outwith Psychology and Primary Care Mental Health Teams. Discussions are ongoing with the Scottish Government Health and Social Care Directorate (SGHSCD) regarding data recording issues.

9 Additional Local Access Targets – Mental Health

Targets: The Board monitors access performance in a range of services not covered by national targets. These are expressed in terms of patients waiting longer than 18 weeks. The Mental Health services covered are:

a) Inpatients - Detoxification; b) Mental Health Consultant Specialties; c) Psychology Services; d) Adult Community Mental Health Teams; e) Primary Care Mental Health Teams; f) Elderly Community Mental Health Teams; g) Addiction Services; and h) Learning Disability Service.

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Performance: As at the end of April 2013, only Psychology Services were below the 90% threshold set for acute services, i.e. 90% of patients seen within 18 weeks.

Service Feb 13 Mar 13 Apr 13

Inpatients – Detoxification 100% 100% 100%

Mental Health Consultant Specialties 96.26% 96.05% 96.02%

Psychology Services 57.12% 56% 61.71%

Adult Community Mental Health Teams 100% 100% 100%

Primary Care Mental Health Teams 89.18% 91.1% 92.6%

Elderly Community Mental Health Teams 100% 100% 100%

Addiction Services 100% 100% 100%

Learning Disability Service 100% 100% 100%

The figures given in the table above is produced from management information captured within Mental Health Services. Psychology Services Challenges to the services remain, including:

an increase in referrals;

a changing referral mix, for more specialist assessments and complex treatments; and

capacity issues to train and supervise other healthcare professionals. Members of staff in Physical Health have been undertaking NES training with a view to skilling up non-psychologists in the long term but this had a short term negative effect on waiting times. In addition, the equivalent of a post has reduced due to ending of voluntary agency funding. Although the return of a member of staff from maternity leave in May will boost capacity, it is not expected that this alone will cause the overall resource to reach a level to meet the target. The input of additional resource as approved at the 25 March Board meeting will increase capacity within the service and increase performance within this target. It is anticipated that the improvements in performance should be seen by September/October given the time for recruitment into these posts. Remedial action plan:

Title Due Date Status Update

Skilling up other staff to increase the resource available to manage the waiting lists.

Revised date December 2014

On target Skilling up of other staff remains a dynamic ongoing process.

Discussions taking place with referrers to review and prioritise patients on waiting lists.

30-Apr-2013 Completed New Suitability Criteria in place with ongoing feedback to referrers.

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Input from the Service Improvement Team for further advice (in Physical Health and Community Paediatrics)

31-May-2013 On target Meetings have taken place. Services continue to maximise efficiency around waiting. However, the Corporate Management Team have provided the opportunity to increase capacity in order to get waiting times to meet and exceed the waiting times target.

The Programme Board for 18 weeks referral to treatment for CAMHS and Psychological Therapies (incorporating projects on, for example, demand capacity activity)

30-Jun-2013 On target Programme Board meets regularly and work stream groups identified to progress key projects.

Underspend due to vacancies this year is currently being used to fund extra clinics across all specialties to reduce waiting times.

31-Mar-2013 Completed Extra clinics have been funded.

The use of Assistant Psychologists to reduce neuropsychology and stroke wait times.

Revised date June 2013

On target Assistant interviews 8th May 2013. New clinical psychology post will also assist with this.

Pain service working on pain pathway which in time will have impact on wait times by investing in multidisciplinary group work.

30-Apr-2013 On target Multi-disciplinary pain pathway nearing completion. Additional clinic have had slight impact on general medical waiting times. New clinical psychology post will accelerate this.

Improvement activity was identified in areas where performance has been below target in the previous months, and an update of these actions is included below.

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Child and Adolescent Mental Health Services (CAMHS) Workforce vacancies and individuals returning to area of practice continue to affect overall capacity. Remedial action plan:

Title Due Date Status Update

Staffing complement returned to full capacity linked to workforce review

Revised date 31 August 2013 from 31-Mar-2013

Slightly adrift of target

The CAMHs Programme activity continues to progress as planned although taking a bit longer than first anticipated. The workforce work stream is reviewing current workforce, skill mix, skill sets and job plans. This is in tandem with the review of the service model and the development of the clinical pathways within the service.

1.5 whole time equivalent nursing staff due to return to the service from development opportunities

Revised date December 2013

Ongoing The situation remains as before with secondment activity continuing to link to development work around primary mental health (ABC Project) and University of the West of Scotland (UWS) teaching commitment/infant mental health strategy.

Ongoing waiting list management to address breaches through the programmed work with Service Futures and the CAMHs and Psychological Therapy Programme Board in the redesign of response to assessment, treatment and discharge process.

30-Jun-2013 Ongoing The work of around the CAMHs Programme activity continues with a detailed focus on all aspects of service activity in particular further refining waiting time from assessment to treatment/intervention targeting 18 wk RTT. Locality meetings in place to review process further and associated clinical pathways, this is linked to the overall review of workforce, skill sets and importantly the need to define treatment.

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Primary Care Mental Health Teams The level of sickness absence within the Primary Care Mental Health Nurse group in South Ayrshire was high for a long period which created a significant reduction in capacity. A long term counsellor vacancy has also now been filled and the new staff member commenced in January. From February through to March additional clinical sessions are being delivered to address some of the backlog. Remedial action plan:

Title Due Date

Status Update

A systematic review of „Opt in‟ arrangements, DNA‟s and CNA‟s to improve efficiency will be undertaken

Revised date 03-July-2013

In progress Discussions taking place as part of wider 18 wk RTT Programme. Data analyst has started to review data with Team Leaders.

Waiting times initiative through February and March for PCMHN waiting times. Evening clinics arranged to offer assessment and treatment.

31-Mar-2013

Completed Numbers of those waiting over 18 weeks has decreased from 106 in February to 94 in March. Overall numbers waiting decreased from 1125 in February to 1066 in March.

A systematic review of demand/activity (DCAQ) as part of 18 week RTT programme

30 Sept 2013

In progress Discussions taking place as part of wider 18 wk RTT programme. Data analyst has started to review data with Team Leaders.

10 Additional Local Access Targets – Other Areas

Targets: The Board monitors access performance in a range of services not covered by national targets. These are expressed in terms of patients waiting longer than 18 weeks The services covered are:

i) Children, Women‟s and Sexual Health Services; j) Community Allied Health Professions Services; and k) Community Paediatrics.

Performance: As at the end of February 2013, only Community Paediatrics was below the 90% threshold set for acute services, i.e. 90% of patients seen within 18 weeks.

Service Feb 13 Mar 13 Apr 13

Children, Women‟s & Sexual Health Services 100% 100% 100%

Community AHP Services 100% 100% 100%

Community Paediatric Services 87.6% 84.7% 68.3%

Community Paediatric Services Staffing issues continue, particularly with AHP maternity leave. An additional post is being filled and Waiting List reduction activity, including offering part time staff additional hours, is ongoing.

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Monitoring Form

Policy/Strategy Implications

The Patients Rights Act and the Treatment time Guarantee (TTG) has a profound effect on Waiting times management and monitoring.

Workforce Implications

Workforce implications identified –

Recruitment of permanent staff or retention of locum staff where currently being utilised

Availability of staff to hold additional clinics

Financial Implications

The current service pressures have been reviewed and it has been identified that there is a requirement for £1.9 million non-recurring funding to meet the targets. £1.4 million had been provided in the carry forward from 2012/13 and slippage on the introduction of a drug, which has been funded in 2013/14, will cover the balance of the non-recurring requirement. The funding requirements may vary during the year as it is difficult to anticipate all the potential issues at this stage e.g. spikes in demand or unexpected sickness absence are likely to require additional funding to meet the access targets. This will need to be closely monitored as it cannot be guaranteed that funding will always be available at the time and to the extent required. For 2014/15 DCAQ analysis will identify areas of shortfall which may require recurring funding; there will be the on-going need to fund contingency arrangements as they arise. In April the overspend is £62k; this has arisen due to additional sickness; rising demand for MRIs and using any available capacity to perform additional orthopaedic activity to ensure compliance with the targets. The financial position will be closely monitored to allow remedial action to be taken as appropriate.

Consultation (including Professional Committees)

This report is compiled by summarising information from a variety of sources and other NHS Ayrshire & Arran reports. A Waiting Times report is reviewed monthly by the Corporate Management Team.

Risk Assessment

There is significant risk to the organisation in failing to ensure that accurate data and trajectories are used in the management of performance against waiting times targets. This is a particular concern in areas where local targets have been set, i.e. Community and Mental Health Services. Risks remain that exigencies of the service such as

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unforeseen circumstances, e.g. ward closures due to illness could adversely affect the present recovery programme. As all internal relevant staff and facilities are already committed to this effort no contingency plans are possible. Risk mitigation is being delivered by close scrutiny and management of the scheme. There is also significant risk to the organisation in failing to improve against the waiting times targets and in failing to monitor progress at the highest management and governance levels. The Detect Cancer Early initiative may impact on diagnostics as well as directly on some to the Cancer measures.

Best Value - Vision and leadership

Successful management of Waiting times requires leadership, and engagement with clinical staff.

- Effective partnerships Partnership issues could affect Delayed Discharge performance .

- Governance and accountability

Local performance management information is used to provide as up to date a position as possible in this report. Some information may change when the data is quality assured by ISD in readiness for publication.

- Use of resources - Performance management

Compliance with Corporate Objectives

The achievement of the waiting times targets set out within this paper comply with a number of the corporate objectives: improving health; safety/outcomes; quality of experience; equality; transforming and patient flow; supply and demand.

Single Outcome Agreement (SOA)

The achievement of the targets reported within this paper provides better access to healthcare services and should therefore have a positive effect on the health inequalities priority within our local SOAs. The achievement of the patients awaiting discharge targets will have a positive contribution towards the Outcomes for Older People priority.

Impact Assessment An Equality and Diversity Impact Assessment (EDIA) is not required for this paper. Service improvement plans referred to within the paper will be assessed as appropriate.

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Appendix 1

Waiting Times summary scorecard

Generated on: 06 May 2013

Status

Alert

Warning

OK

Trend

Improving

No Change

Getting Worse

Measure May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 Trend

TTG - Number of patients who have breached the

Treatment time Guarantee

18 weeks Referral To Treatment - Performance 93.34% 92.06% 91.52% 90.37% 89.56% 90.75% 90.03% 91.82% 91.37% 90.58% 92.12% 91.98%

18 weeks Referral To Treatment - Completeness 92.01% 92.55% 92.75% 92.44% 93.08% 85.84% 92.65% 88.49% 88.85% 90.01% 89.68% 90.99%

Clinic outcome recording 80.09% 79.65% 77.76% 77.87% 80.34% 82.44% 85.18% 84.96% 85.98% 86.13% 85.3% 86.3%

New Outpatients: Maximum 12 weeks from referral 142 291 285 355 359 295 351 479 421 371 299 526

Inpatients & Day Cases: Maximum 9 weeks 298 326 359 411 286 302 319 185 128 163 127 119

Patients waiting more than 6 weeks for Diagnostic

checks

307 446 375 149 74 18 1 1 17 0 2 45

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Total Outpatient waiting list size 17,810 18,082 18,713 17,940 17,214 17,188 17,061 16,397 15,183 16,184 17,062 17,578

Unavailable Outpatients on waiting list 251 311 326 292 260 192 211 280 179 250 198 219

Total Inpatient/Day case waiting list size 3,804 3,851 3,943 3,847 3,667 3,761 3,779 3,213 3,178 3,326 3,398 3,148

Unavailable Inpatient/day case patients on waiting list 656 628 617 692 612 555 658 786 507 557 539 602

A&E waits to be a maximum of 4 hours 90.55% 93.3% 96.44% 94.15% 94.1% 92.35% 94.11% 87.76% 85.17% 88.12% 89.58% 88.75%

62-day Cancer: Suspicion-of-cancer referrals (62 days) 94.3% 95.8% 94.6% 96.4% 96.1% 95.2% 96.6% 94.4% 92.9% 96.6% 95.1% 95.2%

31-Day Cancer: All Cancer Treatment (31 days) 97.1% 100% 99.2% 100% 100% 98.3% 99.1% 100% 97.6% 99% 99.1% 100%

Delayed discharges - 4 week waits 7 5 6 5 3 4 3 7 4 4 2 0

Delayed discharges - 2 week waits 24 14 19 12 13 20 8

Drug and Alcohol Treatment: Referral to Treatment

97.6% 97.2% 98.7%

Faster access to CAMHS - 26 wks

12

7

14

19

18

16

14

9

13

15

4

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Inpatients - Detox 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Consultant Specialty 96.98% 96.44% 95.96% 98.73% 98.42% 97.35% 95.85% 96.54% 95.63% 96.26% 95.88% 96.02%

Psychology Services 56.88% 56.93% 57.49% 52.48% 52.96% 57.69% 58.62% 58.23% 63.46% 57.12% 56% 61.71%

Adult community Mental Health Teams 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Primary Care Mental Health Teams 83.25% 83.32% 84.58% 85.62% 85.96% 87.45% 85.44% 82.17% 81.66% 89.18% 91.1% 92.6%

Elderly Community Mental Health Teams 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Addiction Services 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Learning Disabilities Service 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

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Children Womens & Sexual Health Services 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Community AHP Services 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Community Paediatric Services 85.5% 78.1% 65.9% 75.0% 67.9% 74.0% 100.0% 98.6% 87.9% 87.6% 84.7% 68.3%

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Appendix 2 18 week RTT recorded performance 18 week RTT completeness of recording Clinic outcome recording

All specialties 91.98%



Anaesthetics 100.00%

Anaesthetics 100.00%

Orthodontics 96.57%

Infectious Diseases 100.00%

Audiology 100.00%

Rheumatology 96.57%

Rehabilitation Medicine 100.00%

Community Dental Practice 100.00%

Occupational Therapy 94.59%

Community Dental Practice 100.00%

Restorative Dentistry 100.00%

Ophthalmology 93.56%


GP (Other than Obstetrics) 100.00%

Oral and Maxillofacial Surgery 93.35%

GP (Other than Obstetrics) 100.00%

Haematology 100.00%

Physiotherapy 92.32%

Endocrinology & Diabetes 98.39%


Podiatry 92.31%

Rheumatology 98.25%

Dermatology 98.26%

Plastic Surgery 91.02%

Audiology 97.64%


Audiology 90.49%

Paediatrics 97.39%

Neurology 97.69%

Prosthetics/orthotics 90.08%

Gastroenterology 97.28%

Trauma and Orthopaedic Surgery 97.48%



Ear, Nose & Throat (ENT) 97.00%

Gynaecology 88.28%


Gynaecology 96.98%

Urology 87.38%

Haematology 96.15%



General Medicine 94.93%

Vascular Surgery 96.61%

General Surgery 85.12%

Gynaecology 94.29%


Paediatrics 84.45%

Geriatric Medicine 94.23%

Urology 94.71%


Dermatology 93.82%


Neurology 82.70%


Orthodontics 89.55%

Haematology 81.84%


Cardiology 87.85%


Neurology 92.13%

Paediatrics 86.93%


Respiratory Medicine 91.43%



Cardiology 88.05%



Orthodontics 86.67%


Clinical Oncology 79.29%




Urology 84.26%





Renal Medicine 71.13%


Rheumatology 68.26%

Dermatology 71.05%



Cardiology 69.17%

Dietetics 68.75%

Anaesthetics 65.74%



Page 30 of 31

Appendix 3

MMI April 2013 Unavailable Patients

Inpatient & Day Cases

Total Unavailable

Over 9 Weeks

Specialty List size Medical

Social

Total

Medical Social Total

Cardiology 55 20 36.4% 1 1.8% 21 38.2%

0 0 0

Community Dental Practice 59 1 1.7% 2 3.4% 3 5.1%

0 0 0

Ear, Nose & Throat (ENT) 207 10 4.8% 41 19.8% 51 24.6%

0 0 0

General Medicine 20 2 10.0% 1 5.0% 3 15.0%

0 0 0

General Surgery (Excl Vascular) 313 24 7.7% 76 24.3% 100 31.9%

1 2 3

Gynaecology 199 9 4.5% 50 25.1% 59 29.6%

0 0 0

Ophthalmology 926 56 6.0% 39 4.2% 95 10.3%

5 11 16

Oral And Maxillofacial Surgery 106 6 5.7% 18 17.0% 24 22.6%

0 0 0

Plastic Surgery 82 2 2.4% 3 3.7% 5 6.1%

0 0 0

Trauma And Orthopaedic Surgery 648 61 9.4% 112 17.3% 173 26.7%

9 12 21

Urology 428 19 4.4% 23 5.4% 42 9.8%

0 1 1

Vascular Surgery 49 4 8.2% 22 44.9% 26 53.1%

0 0 0

Other specialties 56 0 0.0% 0 0.0% 0 0.0%

0 0 0

Grand Total 3148 214 6.8% 388 12.3% 602 19.1%

15 26 41

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Outpatients

Total Unavailable

Over 12 Weeks

Specialty List size Medical

Social

Total

Medical Social Total

Anaesthetics 159 0 0.0% 1 0.6% 1 0.6%

0 0 0

Cardiology 1258 2 0.2% 7 0.6% 9 0.7%

0 0 0

Dermatology 1555 0 0.0% 7 0.5% 7 0.5%

0 2 2

Ear, Nose & Throat (ENT) 1670 0 0.0% 15 0.9% 15 0.9%

0 0 0

Endocrinology & Diabetes 442 0 0.0% 1 0.2% 1 0.2%

0 1 1

Gastroenterology 430 0 0.0% 5 1.2% 5 1.2%

0 0 0

General Medicine 968 31 3.2% 40 4.1% 71 7.3%

0 0 0

General Surgery (Excl Vascular) 1799 2 0.1% 16 0.9% 18 1.0%

0 0 0

Geriatric Medicine 175 0 0.0% 1 0.6% 1 0.6%

0 0 0

Gynaecology 947 0 0.0% 9 1.0% 9 1.0%

0 0 0

Haematology 69 0 0.0% 1 1.4% 1 1.4%

0 0 0

Neurology 736 1 0.1% 0 0.0% 1 0.1%

0 0 0

Ophthalmology 1866 2 0.1% 29 1.6% 31 1.7%

0 0 0

Oral And Maxillofacial Surgery 883 0 0.0% 6 0.7% 6 0.7%

0 0 0

Paediatrics 557 0 0.0% 1 0.2% 1 0.2%

0 0 0

Plastic Surgery 79 0 0.0% 1 1.3% 1 1.3%

0 0 0

Renal Medicine 79 0 0.0% 1 1.3% 1 1.3%

0 0 0

Respiratory Medicine 482 3 0.6% 3 0.6% 6 1.2%

0 0 0

Rheumatology 306 1 0.3% 1 0.3% 2 0.7%

0 0 0

Trauma And Orthopaedic Surgery 1105 6 0.5% 14 1.3% 20 1.8%

0 2 2

Urology 1384 3 0.2% 8 0.6% 11 0.8%

0 0 0

Vascular Surgery 266 1 0.4% 0 0.0% 1 0.4%

0 0 0

Other specialties 363 0 0.0% 0 0.0% 0 0.0%

0 0 0

Grand Total 17578 52 0.3% 167 1.0% 219 1.2%

0 5 5

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Ayrshire and Arran NHS Board - nhsaaa-beta.scot.nhs.uk · PDF file6 of 31 Cardiology Action identified By when Update Progress has been made via extra clinics to clear back log and