NHS Calderdale, Kirklees and Wakefield District (NHS CKW)

17th January 2012

Performance Report against Key Performance Indicators for 2011/12

1. Purpose

To inform NHS CKW Cluster Board of NHS Calderdale (NHSC), NHS Kirklees (NHSK) and NHS Wakefield District )NHSWD) PCTs performance against the 2011/12 NHS Operating Framework headline outcomes/measures, together with other identified national supporting outcomes/measures. These outcomes/measures contribute towards the Primary Care Trusts 2011/12 Single Assurance Assessment Process with the Strategic Health Authority and the national annual PCTs National Benchmarking Dataset. Also, to advise the CKW Cluster Board of individual PCT performance against locally identified priorities.

2. Performance Summary

Appendix A sets out a summary position of Commissioner performance against the key 2011/12 NHS Operating Framework headline outcomes/measures (highlighted in „blue‟) and supporting outcomes/measures, details the actual activity against plan, year-to-date position and forecast outturn (end-year position forecast based on year-to-date activity).

The summary incorporates the existing risk management “traffic light” system (RAG) to performance monitor/manage progress being made to achieve delivery of the outcomes/measures:-

Green - target being achieved/no risk to delivery; Amber - below/above target, situation needs reviewing, remedial action needs

Investigation; and Red - serious deviation from target, corrective action plan required.

Appendix B sets out a summary position of Provider performance against the key 2011/12 NHS Operating Framework headline and identified supporting outcomes/measures. Appendix B1 details the new A & E Clinical Quality Indicators at site level for Calderdale & Huddersfield Foundation Trust (CHFT) and Mid Yorkshire Hospital Trust (MYHT). To judge compliance against the thresholds, the 5 new indicators are divided into 2 Groups, Timeliness & Patient Impact. Trusts will be assessed as achieving compliance if the minimum threshold has been achieved for at least one indicator in each of the 2 Groups.

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A point to note in relation to the new Clinical Quality Indicators data source is that it is recognised that not all A & E sites and organisations currently submit A & E Commissioning Data Set (CDS) information to the Secondary Uses Service (SUS) which underpins A & E Hospital Episodes Statistics (HES) and where data is sourced by the Commissioner.

3. National Priorities - Performance Issues Highlighted

Issues highlighted within the performance report:-

Reference

No. Outcome/Measure

Aggregate

CKW

RAG

Calderdale

RAG*

Kirklees

RAG*

Wakefield

RAG*

HQU01 MRSA

HQU02 Clostridium Difficile

HQU03 Category „A‟ - Ambulance Response

Times (8 Minutes)

HQU08 Eliminate Mixed Sex Accommodation

HQU05a 18 Week RTT Admitted

HQU05b 18 Week RTT Admitted – 95th

Percentile

HQU09 A&E 4 Hour Wait

HQU15_01 Cancer 62 Days

HQU15_02 Cancer 62 Days – Screening

Programme

HQU15_03 Cancer 62 Days – Consultant

Upgrade

SQU06_01 90% time On Stroke Unit

SQU06_02 TIA

SQU15

Proportion of adults with Mental

Illness on Care Programme Approach

followed up in 7 days

SQU16_01 Proportion of people with depression

referred for psychological therapy

SQU16_02 Proportion referred for psychological

therapy receiving it

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* *RAG status based on Periodic Review thresholds (previously known as Annual Health Check) where known, if

not known, then actual versus plan is used.

3.1 MRSA The underperformance highlighted is with NHS Wakefield District and is predominantly at MYHT. Refer to Quality Report for reasons and actions being taken to address.

3.2 Clostridium Difficile

The underperformance highlighted is with NHS Kirklees and NHS Wakefield District and is predominantly at MYHT. Refer to Quality Report for reasons and actions being taken to address.

SQU18 Smoking Quitters

SQU19_01 Prevalence of breastfeeding at 6-8

weeks

SQU19_02 Coverage of breastfeeding at 6-8

weeks

SQU27 NHS Health Checks

HRS04 QIPP

HRS06 Non Elective FFCEs

HRS07 Total number waiting at the end of the

month on an incomplete RTT

pathway

SRS11 GP written referrals to hospital

SRS12 Other referrals for a first outpatient

appointment

SRS13 First outpatient attendance following

GP referral

SRS14 All first outpatient attendances

SRS15 Elective FFCEs

SRF12 Proportion of GP referrals to first

outpatient appointment booked using

choose and book

SRF14 Information to Patients

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3.3 Cat A: 8 Minutes- Ambulance Response Times

The underperformance highlighted is across NHS CKW and the issues are with Yorkshire Ambulance Service (YAS).

In October 2011, YAS failed to achieve the required 75% of R1 and R2 (Category A) calls within 8

minutes; the actual performance was 74.23%. As a consequence a Performance Notice has been

served on YAS and in line with the contract sanctions, 2% of the monthly contract value (£246,177

across all commissioners) has been withheld.

The withheld money will be paid at year end if YAS achieves the 75% target for the year – otherwise it will be retained by commissioners.

3.4 Mixed Sex Accommodation

The underperformance highlighted is across NHS CKW – the issues are predominantly at Mid Yorkshire Hospitals Trust (MYHT).

Refer to Quality Report for reasons and actions being taken to address.

3.5 HQU05a/b - 18 Week RTT - Admitted, 95th Percentile

The underperformance highlighted is with NHS Kirklees and NHS Wakefield District – the issues are predominantly at MYHT.

3.5.1 Mid Yorkshire Hospital Trust

Latest unvalidated data, which is for week ending 11 December 2011, reports an over 18 weeks admitted backlog position of 669 at MYHT; this is a decrease in the backlog of 1226 (64.7%) since the implementation of the recovery plan in May 2011.

Median and 95th Percentile RTT

The latest published median and 95th percentile RTT waiting time data which is for October 2011 shows:

Completed Admitted Pathways

Completed Non Admitted Pathways

Incomplete Pathways

Median 95th

Percentile Median

95th Percentile

Median 95th

Percentile

Threshold <11.1 <23.0 <6.6 <18.3 <7.2 <28.0

NHSWD 9 27.4 3.7 17.2 5.2 20.6

NHSK 10 23.91 4.06 15.4 5.6 21

NHSC 9 21.6 2.7 12 5.6 20.3

SHA Average

8 21.1 3.7 15.3 5.4 21.1

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The following provides an update on progress to a sustainable referral to treatment position based on the key factors modelled into the recovery plan. It outlines analysis of the current position and provides an update from MYHT on the winter plan with regard elective activity.

Modelling Parameters

The original modelling focused on three factors assessed to be crucial to achieving a sustainable referral to treatment position; chronology, backlog clearance and decision to admit profile.

The agreed plan was that efforts would focus on:

Backlog clearance from May to October 2011;

Improve chronology to a level that supported sustainability and backlog clearance; and

Reduce the time from referral to decision to admit (DTA) with the peak of DTAs between 6-10 weeks.

Analysis at December 2011

The table below presents by specialty the current position against plan across all of the modelling factors. In addition to the original three factors the percentage of DTAs over 13 weeks has been added. This gives an indication of whether the DTA profile has a significant “tail” of patients having a later than desired DTA.

Performance Against 90% Backlog Clearance Chronology Decision to Admit Peak

% DTA >13

Weeks

Sp

ecia

lty

Act

ual

Var

iati

on

RA

G

Pla

n

Act

ual

Var

iati

on

R

AG

Pla

n

Act

ual

Var

iati

on

RA

G

Pla

n

Act

ual

Var

iati

on

RA

G

Act

ual

RA

G

ENT 87.70% -2.3% 20 25 5 24% 36% 12% 8

12 4 10%

General Surgery 89.50% -0.5% 78 82 4 13% 14% 1% 6

7 1 3%

Gynaecology 91.00% 1.0% 45 40 -5 21% 26% 5% -

Ophthalmology 94.50% 4.5% 69 38 -31 14% 14% 0% 9

11 2 2%

Oral Surgery 72.30% -17.7% 42 115 73 30% 60% 30% 9

10 1 21%

Orthopaedics 86.90% -3.1% 80 105 25 27% 27% 0% 11

9 - 2 6%

Plastic Surgery 77.90% -12.1% 64 142 78 19% 26% 7% 6.5

6 - 1 2%

Urology 80.00% -10.0% 43 86 43 16% 22% 6% 7

7 - 4%

Other 96.70% 6.7% 110 36 -74 14% 4% -10% -

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Ophthalmology

There remain some issues around the Ophthalmology service provided in terms of patients needing further care following screening for diabetic retinopathy and this is being picked up through the Quality Board. Despite this in terms of activity Ophthalmology is achieving the 90% performance target, reducing backlog in line with plan and have achieved the planned chronology levels. Ophthalmology is not quite at the desired peak for decision to admit but has a small tail in terms of over 13 week DTA‟s. This specialty appears to be sustainable in terms of the referral to treatment position.

Gynaecology

Gynaecology is achieving the 90% performance target, reducing backlog in line with plan and has achieved the planned chronology levels. This specialty appears to be sustainable in terms of the referral to treatment position

General Surgery

General surgery has achieved the planned chronology and DTA requirements. The backlog clearance is slightly behind plan by 4 cases and performance against the 90% target is 0.5% under target.

ENT

ENT is almost achieving backlog clearance and has exceeded the requirements for chronology. The main concern in ENT is that the DTA profile remains peaked at 12 weeks and 10% of the DTAs are over 13 weeks. The specialty is not yet achieving the 90% standard. The analysis indicates that this is likely being driven by the outpatient position and the DTA position.

Orthopaedics, Plastic Surgery and Urology

These three specialties are all showing similar positions in terms of the analysis in the table. Backlog clearance is the only element to be a significant variance from plan and this appears to be driving the performance against the 90% target. This would suggest that driving factor in these specialties is elective capacity.

Oral Surgery

Oral surgery is the specialty of most concern. The DTA profile has improved and the peak is now around 10 weeks against a plan of 9 weeks, however there is a significant tail of patients receiving a DTA beyond 13 weeks (21%). The specialty chronology has improved to 60% against a plan of 30%, this however presents a risk as it can create a bow wave of patients on the list building up which could negatively impact on backlog in the future. Backlog clearance has improved significantly over recent months but remains at variance to plan. The combination of these factors means that the specialty continues to perform significantly below the 90% target.

Other

The “other” specialties category continues to exceed the 90% performance standard and has gone beyond the trajectory for backlog clearance.

Summary

In summary Ophthalmology and Gynaecology demonstrate being in the most sustainable referral to treatment position. The biggest risk areas are, Orthopaedics, Plastic Surgery, Urology and Oral Surgery. Both Oral Surgery and Plastics are exceeding the contracted activity plans with demand continuing to exceed capacity.

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Winter Plan

The Trust has produced a winter plan for managing elective capacity across the Trust with the aim of mitigating the impact of winter on the 18 week performance position and backlog levels. The plan has three objectives:

Reducing elective in-patient demand at Pinderfields;

Improving acute patient flow; and

Management via command & control structure.

The 18 Weeks Recovery Board continues to monitor progress against the 18 Weeks Referral to Treatment MYHT Recovery Plan, which was implemented in May 2011.

3.6 A & E 4 Hour Wait – 95% Waiting Time Standard

The underperformance highlighted is with NHS Kirklees and NHS Wakefield District. Refer to Appendix B1 for site specific data for the additional Clinical Quality indicators.

3.6.1 Mid Yorkshire Hospitals Trust

MYHT had pushed to reach 95% at each of its three hospital sites and achieved this for some weeks in December however performance at Pinderfields Hospital continues to fluctuate. This has been as a result of a lack of medical beds and patients presenting being more acutely ill. The position has improved with the opening of discharge lounges.

Dewsbury District Hospital (DDH) and Pontefract General Infirmary (PGI) continue to achieve a year-to-date performance above 95%, however, it remains a significant challenge at Pinderfields General Hospital (PGH).

MYHT year-to-date A & E activity for the whole trust is 93.9% and including walk in centre activity 95.2%. The breakdown by site shows:

DDH = 96.2%

PGH = 90.5%

PGI = 97.2%

The MYHT has an Emergency Care Recovery Board which meets regularly and actively manages A & E pressures. Targeted work is happening at ward level to facilitate speedy discharges and meetings have been set up with providers of Child and Adolescence Mental Health Services (CAMHS) and Crisis Resolution services to facilitate closer working.

3.6.2 Calderdale and Huddersfield Foundation Trust

A&E Quality Indicators: Time Spent in A&E (admitted patients) Data on the median wait times in A&E indicate patients wait approximately 1 hour and 30 minutes in the department. Data reporting the patient waiting times at the 95th centile suggests that those patients who require admission following attendance to A&E are waiting a disproportionately greater time.

This issue is being addressed as part of the Non Elective QIPP scheme which aims is to encourage only those who need to attend A&E do so and ensure that those people who actually need A&E services are able to access them in a timely way without undue delay, including those patients who ultimately require admission. Key actions involve:

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Intermediate Tier – a single, integrated intermediate tier of services in Calderdale are being designed/ redesigned to support people who are taken ill to remain in their own home if it is safe for them to do so and to support people after an accident, injury or illness to regain their mobility and optimise their independence.

Services involved in this programme include rapid response, falls prevention, community rehabilitation and reablement. This will:

Provide the right support and care in the right place at the right time;

Reduce the number of emergency hospital admissions and re-admissions;

Reduce unnecessary hospital admission;

Facilitate timely hospital discharge;

Prevent premature and avoidable admissions to residential care homes;

Reduce dependency on significant packages of home care; and

Optimise independence through rehabilitation and recuperation and the use of telecare and telehealth.

This large scale programme is being delivered jointly by health and social care staff and involves key stakeholders from across the local health economy and will reduce the demand for and facilitate timely discharge from acute services. This will help to optimise A&E and bed management in hospital and as a consequence help reduce the waiting times for people who require admission via A&E.

Signposting - a review of A&E attendances and admissions activity to develop a robust process to ensure that patients can be appropriately signposted at the point of triage in A&E. This will ensure that patients are cared for and managed in the most appropriate setting following an A&E or Medical Assessment Unit attendance.

GP Practice - data on A&E attendances has been circulated to all GP practices in Calderdale. This will enable the practices to review and compare attendance with other practices in the same geographical area. This data sharing is being followed up with a series of meetings with practices to encourage the development of actions plans to address A&E/ unplanned admission as part of their QOF plans.

Communication -a communication plan has been established for the Non Elective QIPP scheme which encourages people who do not need to access A&E, to choose appropriate alternative routes for care, for example; primary care, pharmacies, self-care.

Review - monthly meetings are held between commissioners and the A&E management team to review performance. Whilst no significant rise in the volume of breaches has been reported through this meeting, it is anticipated that improving the triage and signposting will enable the service to manage those patients who require admission with a greater intensity of resources and enable patients to be admitted or discharge quicker. A Clinical Operations Group is being established which includes Primary, Secondary and Community Health Partners who will review the ways of working that currently push out the waiting time for people who need admission via A&E.

Surge and Escalation - clear plans and means of communication are in place across the system. Weekly teleconferences have commenced to deal with any changes/ spikes in demand.

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3.7 HQU15_01 – Cancer 62 Days Standard

The underperformance highlighted is with NHS Wakefield District – the issues are predominantly at MYHT and Leeds Teaching Hospitals Trust (LTHT).

3.7.1 Mid Yorkshire Hospitals NHS Trust NHS WD position for all providers using October‟s data shows achievement of the cancer targets for all standards except the 62 day target. The delivery of the 62 day cancer waiting time performance across West Yorkshire remains a challenge.

All Trusts in the Yorkshire Cancer Network (YCN) area have been asked to review all cancer specialties and work towards improving performance in three key areas:

To commit to a trajectory to improve the diagnostic pathway to a higher proportion of patients seen within 7 days and move away from those close to 14 days;

To decrease the proportion of patients treated close to 62 days and increase the proportion treated by 54 days; and

To develop action plans to support trajectories. The action plans will increase the chance of early decision to treat and therefore treatment within target.

MYHT is committed to sustaining its 14 day position and has therefore reviewed its cancer pathways and has identified specific actions in the Lung specialty as being a service that would be able to improve the pathway towards achieving a 7 day target. Lung cancer is the 4th largest cancer population diagnosis in the country and the largest provider service to Leeds Teaching Hospital (LTHT).

We are in the process of writing to all Wakefield GPs outlining MYHT‟s intention to offer urgent suspected cancer patients their first appointment within 7 to 14 days wherever possible which we hope will start to have some effect in contributing to meeting the 62 day target.

In addition, at a recent Inter-Provider meeting held with LTHT to identify and agree actions to help minimise avoidable patient breaches, the following was also agreed to help support improvement:

Fitness testing for lung cancer patients to be carried out at MYHT by the end of Q4 2011/12. This will reduce the Pathway by 2 days;

Rapid dating of lung cancer patients for surgery using extra capacity at Spire to be completed by the end of November with monitoring required to ensure timely response to peaks in demand. LTHT have informed the YCN Board that this will not be achievable before March 2012. This means that the Pathway for lung cancer patients requiring thoracic surgery is likely to take 68 days at the present time. LTHT is aware that this is unacceptable to Commissioners;

Clarity required for tracking responsibility of lung cancer patients referred for possible surgery. Handover of patients to Leeds via an improved electronic process has been agreed. MYHT has already successfully piloted this in Upper GI and are currently also doing this for Urology. Full rollout across the YCN is expected Q4 2011/12; and

Medical Oncology support to lower GI Medical Team requires agreement on ability to employ locum. This has been agreed between MYHT and LTHT. It is expected this will ensure timely access to Oncology support within the 62 day target.

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Performance information provided in relation to Inter-Provider Transfers

In line with YCN and SHA agreement MYHT has completed a trajectory against which to measure improvement in the numbers of patients with a decision to treat (DTT) by day 38 and the % of patients treated locally by day 54. Performance against this trajectory is shown in the graphs below.

Detailed performance information has been produced (including Patient Tracking Lists monitoring undertaken by the Network) and local meetings are being held with colleagues from MYHT and YCN on a regular basis in addition to Inter-Provider meetings with LTHT and the SHA in an effort to bring about and maintain performance improvements. A review of the full situation will be undertaken at the end of December 2011 involving YCN and any further actions discussed and agreed.

Consultant Upgrade

The underperformance highlighted is with NHS Calderdale and NHS Wakefield District.

Mid Yorkshire Hospitals NHS Trust

There is no national target applicable to Consultant upgrades and performance achieved by MYHT is a YTD average of around 75%. It should be noted this category affects relatively low numbers of patients and out of a total number of 33 patients upgraded this year at October 2011, 25 of these were treated on time and there were 8 breaches.

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Calderdale and Huddersfield Foundation Trust

Overall, NHS Calderdale continues to achieve strong performance against the cancer waiting time standards.

Year to date, 9 patients have required their first definitive treatment within 62 days following consultant decision to upgrade their priority status. In September, 1 patient breach was reported for this pathway. Review of the patient journey highlighted the patient chose to arrange their outpatient assessment at day 42 of the pathway. This delay placed pressure on the service to initiate first treatment within the 62 day standard.

The waiting times for this standard have been achieved in October. Year to date performance is now 89% and is expected to improve throughout the remainder of 2011/12.

3.8 SQU06_01 Stroke and TIA

The underperformance highlighted is with NHS Kirklees and NHS Wakefield District – the issues are predominantly at Mid Yorkshire Hospital Trust (MYHT).

The table below shows unvalidated Q3 IPMR data (from MYHT Stroke Register, as at 9th November 2011) compared with Q2. The data have a +/-5% error rate

3.8.1 Stroke

Performance is looking to improve for Q3 and to achieve the 80% trajectory (if not exceed this). The presence of the Stroke Assessment nurses continues to have a positive impact. They will start their 24/7 cover from 9th January 2012. A critical incident reporting system is being established for those stroke patients who are admitted via the wrong pathway (e.g. presenting to DDH instead of PGH). These are not large numbers by any means but the incident reporting will help to iron out any issues. Regional work is ongoing with YAS for all the hyperacute stroke units to ensure that the expected pathway is clearly understood by all crews.

The Stroke Early Supported Discharge service provided by MY Therapy for Wakefield patients is taking around 40% of patients with the aim of continuing their rehabilitation in their own home. This is contributing to a reduction in length of stay. There is currently no similar service for patients in Kirklees going home from DDH.

Site Trajectory Quarter MYHT Overall

DDH PGH

Proportion of stroke patients spending >90% stay on a stroke unit

80%

2 N/A N/A N/A

3 (unvalidated)

89% 77% 92%

Proportion of high risk TIA patients being seen and treated within 24hrs of presentation to a health professional

60%

2 23% - -

3 (unvalidated)

17% - -

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3.8.2 Transient Ischaemic Attack TIA The TIA service is lagging behind and is dependent on consultant job planning. However, it is anticipated that there will be a significant improvement towards the trajectory when the Stroke Assessment nurses start to take TIA calls as well as stroke (from January 9th 2012). TIA patients will then be able to be seen on 7 days a week. Clearly, this indicator also relies on rapid referral from primary care and other front line health professionals. A multi faceted campaign is being organised, including direct mail shots, email and publicity materials to promote the single phone line for both stroke and TIA referrals. This publicity campaign is planned over the short, medium and longer term to ensure that all relevant health professionals are made aware of the new service.

Regional Stroke Peer Review The visit of external stroke consultants and the Strategic Health Authority (SHA) to MYHT took place on 12th December 2011. This was a very positive event, and MYHT were given provisional accreditation (in line with the majority of other Yorkshire & Humber stroke services). A formal report is due in early January 2012. There were a number of action points which will need to be addressed, but these were as anticipated. A follow up review will take place in 6 months to ensure actions have been implemented. The external reviewers noted examples of good practice, and ideas have been taken back to their Trusts for implementation.

3.9 SQU15 Proportion of adults with Mental Illness on Care Programme Approach followed up in 7

days

The underperformance highlighted is with NHS Calderdale – the issues are with South West Yorkshire Partnership Foundation Trust (SWYPFT)

To date, 67 people under CPA were discharged from psychiatric in-patient care. Of these, 62 people were successfully followed up within 7 days of discharge.

5 breaches have been reported by the provider. Each case has been reviewed to determine the reasons behind the failure to follow up the patients. These breaches will be raised at the contract meeting with the provider to review the issues and confirm the actions needed to address this under performance.

3.10 SQU16 Proportion of patients referred for Therapy at Improved Access to Psychological Therapy

(IAPT)

The underperformance highlighted is with NHS Kirklees and NHS Wakefield District – the issues are with SWYPFT.

NHS Kirklees The under achievement of the IAPT targets with the current provider are under monthly review. A remedial action plan has been developed, to show ongoing improvement through the final quarter of the current financial year. This is being supported by the performance clauses included within the contract, which includes the implementation of a financial penalty at the end of quarter 4 calculated on the % of underperformance. Actions taken to date include: - A GP event held by the service – to raise awareness & improve the knowledge of the service &

inclusion thresholds; - Development of the single point of Access into services – the aim is to ensure that individuals are

directed into the service at the right point & time; and - Improvement plan for data capture & reporting.

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The two clinical commissioning Groups within Kirklees have agreed to undertake an IAPT service review during 2012, to develop proposals regarding the retendering of the service at the end of the current contract period. NHS Wakefield

The IAPT service is tiered between step 2 and step 3 interventions with an expectation that the majority of activity will be seen at step 2. The Wakefield service is experiencing a backlog demand at step 3 interventions because it is believed that GPs are triaging and referring patients they deem to be the most needy, who enter the system at step 3, thus inadvertently creating a bottle neck. The service has started raising awareness of this issue and held an event on 13 October 2011 which was, unfortunately, poorly attended by GPs. Dr Senior is the GP lead for the service and following the event she has been working to improve knowledge and understanding of the service across the GP community.

In addition to this, there has been a new IT system introduced which has caused numerous data quality issues, which is impacting on the achievement of the target. The service is currently working to rectify these issues.

3.11 SQU18 Smoking Quitters

The underperformance highlighted is across NHS CKW.

Smoking is the single greatest cause of preventable illness and premature death in the UK. The effects on health from smoking have been known for many years and are well documented with 80% of the deaths from lung cancer being related to smoking. For smokers who give up, the chances of developing serious conditions or diseases are also greatly reduced. Calderdale has a higher smoking attributable death rate than the regional and England average.

NHS Calderdale

In Calderdale approximately 1700 male and 1000 female hospital admissions per year are directly attributable to smoking (7% and 4% of their respective totals). The costs of this have been analysed by ward and GP practice and circulated to smoking cessation teams in each practice.

For smokers who give up, the chances of developing serious conditions or diseases are greatly reduced. In Calderdale approximately 1700 male and 1000 female hospital admissions per year are directly attributable to smoking (7% and 4% of their respective totals).

70% of all smoking quitters come through General Practice smoking cessation services. 21 practices have now signed up to the new LES ensuring that 77% of registered patients in Calderdale have access to level 2 quit services. 6 practices have not signed up to the LES (namely Nursery Lane, Keighley Road, Queens Road, King Cross, Rosegarth, Station Road). The reasons for non sign up are either workload or preference to refer to specialist service. Smoking Cessation level 2 services will be opened up to pharmacies in those areas not covered by the LES, with a particular focus on town centre provision.

The target for 2011/12 is to enable 1595 smokers to successfully quit at 4 weeks demonstrating a quit rate of 945/ 100,000 for the population.

The first 6 months show 700 quitters. Data is awaited from a further 6 practices and it is estimated that a further 30 quitters will be recorded.

However this will likely to be below plan by approximately 45 quitters but does show significant improvement on last year‟s figures.

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Primary Care

Once all data is available for the first 6 months, practice performance will be compared against ambition and will be discussed with the relevant practice personnel to identify any further actions which may be necessary across the area.

Tobacco Control

Calderdale has submitted a bid for additional resources to undertake a programme of tobacco control within routine and manual workers working in the local authority. Furthermore Calderdale is exploring options regarding a tobacco programme aimed at eastern European community - a community which has high smoking prevalence.

A scheme aimed at reducing second hand exposure to smoking has been commissioned and will commence in January 2012. Although not its primary purpose this will result in an estimated additional 40 quitters per year

Governance

The Calderdale Tobacco Control Group has been re-established. A draft strategy and operational plan has been circulated for consultation. This group reported to the LSP Healthy Communities Partnership and given reconfiguration of partnership groups will report to the Health and Well being Board subject to confirmation of tobacco as a key priority. Progress will continue to be reported to the Finance and Performance Group.

NHS Kirklees

Reported quits to date are below target at 832 against a target of 1467, this is due to a combination of an aspirational and challenging target and the delayed reporting system for the Intermediate Advisor service.

The Specialist Stop Smoking Service has achieved near to its Q2 target with 233 quits against a target of 268 and has a 41% quit rate. The Intermediate service quit reports have a 2 month time delay therefore the figure of 599 quits (a 65% quit rate) against a target of 1007 is not a true picture of Q2 performance, this data will not be complete until December. It is expected that performance will be improved but remain below target when complete figures are available. The Intermediate service target accounts for 80% of the Kirklees target.

Measures are planned to increase usage of the Intermediate service and thus improve quit numbers. The Locally Enhanced Service Schemes have been reviewed for both GP practices and pharmacies and a new pricing structure is to be introduced. A voucher scheme to improve access to NRT is to be introduced to be used by Pharmacist Intermediate Advisors and Specialist Advisors. A Stop Smoking LES for Dental Practices is also being introduced to widen availability of stop smoking services in Kirklees. Training for Intermediate Advisors is being promoted widely among other workforce groups to offer new routes to quit.

The Stop Smoking Service is implementing learning points from pilot work with routine and manual workers carried out 2010-11 to improve acceptability of the service to this target population.

NHS Wakefield District

There is a high smoking prevalence in Wakefield with a local culture of smoking. The Smoke Free Wakefield Tobacco Control Strategy features key pieces of work that are being undertaken in partnership to reduce the number of smokers. There is also a time lag in the reporting of quitters for

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some of the Nicotine Replacement Therapy used as it is taken over a 16 week period before results can be measured.

Actions to mitigate the risk to achieving the target include:

Healthy workforce initiative;

Every Contact Counts training;

Review service specification and Local Enhanced Services;

Work with MYHT on smoking cessation before elective surgery;

Social norms pilot in Featherstone;

E-learning training for brief advice in smoking cessation; and

Smoking cessation in secondary care pilot. This is further supported by a commissioning review on all smoking cessation services provided in Wakefield with the development of a revised specification.

3.12 SQU19 Coverage and Prevalence of Breastfeeding

The underperformance highlighted is with NHS Calderdale and NHS Kirklees.

Research shows that infants who are not breastfed are more likely to suffer infections in the short-term such as gastroenteritis, respiratory and ear infections, and particularly infections requiring hospitalisation. In the longer term, evidence suggests that infants who are not breastfed are more likely to become obese in later childhood, which means they are more likely to develop type 2 diabetes, and tend to have slightly higher levels of blood pressure and blood cholesterol in adulthood. Promotion of breastfeeding features within the QIPP messages from the region. For mothers, breastfeeding is associated with a reduction in the risk of breast and ovarian cancers. Breastfeeding at 6/8 weeks continues to form part of the operating framework and revised plans for 2011/12 have been developed

NHS Calderdale

The prevalence of breastfeeding at 6-8 weeks has shown a slight drop over the corresponding period last year and from the previous quarter results and it remains below the plans established locally but above the average for Yorkshire and Humber (40%). The coverage of breastfeeding has again reached 100% and above plan. To achieve the target of 42.9% a further 17 women from a total of 596 women would have had to choose breastfeeding rather than artificial formula.

The trend data indicates that Calderdale may not reach the overall target of 42.5% target by March 2012. The data collected over period of 3 years now shows that the Calderdale 'system' produces breastfeeding rates of between 39-41%.

Comparisons between Calderdale, Yorkshire and Humber, England and our comparator PCTs demonstrate:

Calderdale continues to have highest levels of initiation - approximately 80%

Breastfeeding at 10 days is 55% (other areas do not report on this data)

Breastfeeding at 6-8 weeks is below the national average (45%) but higher than our comparator group (39%)

Calderdale has the highest drop off rate between initiation and 6-8 weeks due to the highest initiation rates

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Data at ward level circulated at previous meetings of the Committee continues to show the most deprived areas have the lowest breastfeeding rates. This is in line with national evidence.

The latest data by ward area has been circulated via the Maternity and Early Years Board for providers to consider.

The electoral wards of Elland, Illingworth and Mixenden and Ovenden show breastfeeding rates at 10 days to be below 40%.

At 6/8 weeks, the additional areas of Luddendenfoot, Greetland and Stainland show substantial drops in breastfeeding rates. These issues will be raised with the provider services at the next Maternity and Early Years Board meeting on 16th November 2011.

The data continues to suggest that focussed work during the first few days of birth and the period leading up to birth are critical if we are to achieve a target of 50% in the coming years.

Implementation of the Breastfeeding Strategy continues. Calderdale achieved stage 2 of Baby Friendly Accreditation in October, one of only two community services to reach this level across Yorkshire and Humber.

CHFT is pursuing its BFI re-accreditation and this is expected to be completed by December 2011.

Actions Taken:

1. Continue implementation of breastfeeding strategy. Community services established a multi-agency group including GP representation to deliver actions.

2. Calderdale plans to implement Baby Friendly Status (community-wide approach to promoting breastfeeding, for example; increasing the number of public places) in Calderdale where mums are encouraged to breastfeed. Calderdale has been awarded level 2 status. Achieving full baby friendly status is recognised as good evidenced based practice. It provides a high profile for breastfeeding issues to be considered by partner agencies and ensures a consistent approach and message re breastfeeding to partners and the community.

3. Drop off rate at 10 days discussed again at the Maternity and Early Years Board earlier this month. It was requested that the drop off rate at 10 days needs to be reviewed and the rates increased in order for Calderdale to reach the 6-8 week target. The possibility of data being available at 3 days is being explored

4. Commissioner has shared drop off rates by ward with teams and confirm peer support/support group‟s rate established in the high drop off areas.

5. Breastfeeding pathway in line with national pathway is being introduced. In order to utilise the whole workforce, a scoping exercise is being taken on how we use Community Nursery Nurses to support breast feeding mothers.

6. Expected improvements and pathway integration through further development of integration of hospital and community services.

7. Quarterly data continues to be collated to produce trend data. Data quality is sufficiently robust. However a check of health visitor records with GP records on system 1 is being undertaken.

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NHS Kirklees

The difference in prevalence between North and South Kirklees continues, indicating that progress to address the wider cultural and socio-economic factors associated with different communities in Kirklees has been limited. These deprivation linked wider determinants of health are intractable and difficult to address in the short term. Actions Taken:

Ensure that the Children and Young People Plan identifies and utilises the interdependencies between programmes to address inherent cultural and socio-economic factors in areas with low Breast Feeding prevalence.

Moving towards Stage 2 of the BFI accreditation process is the next stage which focuses on breastfeeding knowledge and skills in all health visiting teams across Kirklees and will be assessed to BFI best practice standards. The development of an infant feeding training package conducive to community practice will soon be made available to support the learning and development of all relevant staff in the community. Collaboration with Kirklees Partnership continues to develop since the first workshop in Jan 2011 to support women/employees who wish to breastfeed for longer through the development of family friendly breastfeeding policies in workplaces across Kirklees. Since October 2010 the development of Breastfeeding Resource Packs have been accessed by over 800 women across Kirklees from Health Centres and now KCHS are piloting a Health visiting team in Cleckheaton (where prevalence of formula / bottle feeding is higher than in other areas in north Kirklees - sourced from quarterly locality based 6-8 week breastfeeding data) to distribute breastfeeding resource packs to all mothers at the antenatal visit. Breastfeeding Face Book site continues to develop with a steady increase in numbers and now has 135 breastfeeding fans which offers information and a social network of support. The training of breastfeeding volunteers continue to support the Baby Bistro programme which currently stands at 67 trained breastfeeding peer supporters in Kirklees. Plans are underway to develop a series of Buddies Baby Bistro's and the first one is being piloted in Dewsbury town centre targeting teenage and young mums and dads. Young trained breastfeeding volunteers will support the BBB programme and further support collaborative working with the Family Nurse Partnership and teenage pregnancy midwives and existing young parent groups in Sure Start Children Centres. To aid a consistent approach in raising awareness of supportive breastfeeding drop in groups in Kirklees plans are underway for the Personal Child Health Record (Red Book) to include an A5 insert of all local supportive groups to include all Baby Bistro's in Kirklees which mothers will receive at Delivery and which will have been put in the Red Book at the printers.

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3.13 SQU27 Coverage of NHS Health Checks

The underperformance Highlighted is across NHS CKW.

The NHS Health Check programme is a national systematic CVD risk assessment programme. It is for people aged 40-74 who have not been previously diagnosed with one of these conditions (including hypertension) and consists of a face to face individual risk assessment followed by risk management advice (the risk assessment element of the check) and interventions (the risk management element of the check). For those at low risk, the risk management might be no more than general advice on how best to stay healthy. Others may be assisted to join a weight management programme or a stop smoking service. Those at the highest risk might also require preventive medication with statins or blood pressure treatment.

The NHS Health Check: Vascular Risk Assessment and Management Best Practice Guide was published in April 2009 and this clearly explains the core tests and measures in the risk assessment element of the NHS Health Check, along with similar information about risk management interventions. It describes what every person should receive as the national offer of an NHS Health Check.

NHS Calderdale

On behalf of NHS Calderdale, the Cluster Board accepted a target of 18% on advice from the centre in June 2011. The take up rate is expected to be 90%.

NHS Calderdale has developed a local plan to offer NHS health checks to 10.7% of the eligible population for 2011/12. Of those offered a healthcheck, 64% are expected to take up the offer.

18% coverage was not expected to be delivered due to the time needed to negotiate an acceptable LES with practices.

It was expected that sign up to the scheme would be complete by October 2011. A phased implementation of the scheme will enable practice learning and ensure sufficient quality of the check. It was expected that some NHS health checks would have been delivered by practices as part of their opportunistic screening between June and September. Data for this period will not be available until Jan 2012 along with Q3 data.

Actions Taken:

24 practices signed up to scheme;

3 practices still to confirm involvement;

1 practice Todmorden will begin checks in April 2012;

Lead manager will contact those practices not yet signed up to scheme by 22nd November 2011; and

Lead manager will liaise with primary care via practice management group re: process of implementation December 2011.

NHS Kirklees A decision was taken by Business and Finance Group in June last year for an outreach–only NHS Health Checks service to be commissioned, within a set budget of £209,000. This included decommissioning of a number of practice-based Health Checks services in the North.

The new NHS Health Checks Outreach service began on the 1st April 2011. The service is provided by a small team of Primary Prevention Nurses within Locala.

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Due to the nature of the service being outreach-only and with limited resource, it was decided it should initially target communities in Kirklees with the worst health and deprivation, who are at greatest risk of vascular disease. Therefore, the service is currently not universally available for the whole 40-74 population within Kirklees.

When the service was commissioned a target of 7000 (1750 per quarter) Health Checks was set for 2011/12. This was agreed as a sensible number based on the budget and resource available at the time.

However, as part of the national formal monitoring return, the PCT was required by the SHA to sign-up to delivering Checks for 18% of our eligible population, which was calculated at 4542 per quarter.

We have already informed the SHA through formal performance channels, that NHS Kirklees will not meet their expected target of 4542 within the current service provision.

Significant underperformance was highlighted during the 2011/12 Integrated Performance Measures Return (IPMR). Quarter 1 reported 240 Health Checks provided, against an NHS Kirklees target of 1750.

In comparison to other PCTs within the Yorkshire and Humber region, NHS Kirklees are ranked 10th out of 13 PCTs. Three PCTs in the region still have no service and all reported zero.

During the first quarter, the service has been targeting communities within the Dewsbury, Batley, Ravensthorpe and Huddersfield Central areas, and has endeavored to build links and foundations in these communities to reach the target population.

There have also been huge efforts in marketing and embedding the service through advertising and canvassing with large employers and within close-knit communities. As a result, momentum is starting to build weekly and the service is becoming more well-known and established.

The service now offers regular health checks in mosques, leisure centres, libraries and other community centres, as well as targeting large employing companies and sports stadiums in order to attract a higher footfall. However, some venues are not as successful as others and some clinic slots are going un-used. Locala are reviewing the current venue choices and their marketing plan, to try and encourage more people into the service.

Patient feedback so far has rated the service very well in areas of it meeting expectations, being accessible, prompting people to follow-up areas of risk with their GP practice and people recommending the service to family/friends. The majority of people seen so far, heard about the service either through newspaper adverts, via their employer/work colleagues or through the library.

Locala understand that they need to spread messages about the service further and would welcome feedback around this to incorporate into their marketing plan.

Where risk factors have been identified as a result of a health check, the service has been actively referring people onto their GP practice for further investigations and other services where they can get help to reduce their risk of vascular disease in the future and make the necessary lifestyle changes. So far there have been:

16 referrals to Weight Management

37 to GP

134 to Practice Nurse

17 to Physical Activity Programme

2 to stop smoking clinic

Performance has been discussed at a recent Contract Management Group meeting and Locala have been asked to produce an action plan around how they intend to increase numbers.

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Risks and Issues

One key risk is that communications and engagement needs to continue to be a focus for this outreach-only service as there is a need to continually embed links, create opportunities and build trust to successfully encourage people into the service. This is very time-consuming and resource intensive for such a small-scaled service.

Although we are confident that we will see numbers starting to increase during 2011/12, it is unlikely that we will hit the target at the end of year one.

National guidance suggests that the future commissioning of NHS Health Checks will be the responsibility of Public Health when they move into the Local Authority, and this needs to be considered in any medium and long-term planning.

NHS Wakefield

Services in Wakefield are offering the health check to a significant number of people and have grown momentum in doing so over a number of years however; patients are choosing not to have the checks in 50% of the cases.

The delivery of the NHS Health Checks commenced in Wakefield in 2007/08, the numbers of eligible people was approximately 130,000. This figure included hypertensive patients as this group of patients have the biggest risk factor for cardiovascular disease; therefore to reduce their risk would be the greatest impact in reducing morbidity and mortality. The number of eligible patients excluding hypertension (DH exclusion for the 2009 programme) is approximately 100,000.

The NHS Health Checks were launched nationally in 2009, by March 2011 Wakefield had delivered 45,000, a health equity audit in 2010 demonstrated that Wakefield had delivered the health checks without increasing inequalities in health, the numbers of health checks delivered in deprived areas was equal to the numbers in affluent areas.

There have been 10 training sessions delivered to practitioners across Wakefield to ensure that there is an understanding of the programme and a standard delivery model. The Health Trainers were included in the training sessions to ensure they have the basic understanding of assessing cardiovascular risk and are able to signpost clients to their local GP practice for a formal assessment and any treatment options. The Health Trainers will support the clients to make healthy lifestyle choices, for example weight management and stop smoking.

Standard operating procedures and a contract specification were updated in March 2011 to ensure providers of the service were aware of the service delivery components and the targets set.

The numbers of clients who have been offered an NHS Health Check is on track to delivering the 4.5% offered each quarter (18% annually). The offered code is a recent addition to the template and it is excellent that there have been over 11,000 coded by the end of quarter 2.

The numbers of patients who have had a health check delivered is approximately 50% of the offered which is an achievement. Total Health Checks is over 50,000 (quarter 2 2011/12.)

As we have delivered the NHS Health Checks for almost 4 years it is now more challenging to achieve the ones who remain in the 5 year rollout. We are planning a review of the Equity Audit to understand if there are any gaps in service provision in January 2012. If there are any gaps we will consider alternative modes of delivery to achieve the target.

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3.14 HRS04 – QIPP Savings

The underperformance highlighted is with NHS Kirklees.

The overall QIPP savings are expected to be achieved. The majority of the individual QIPP

plans are expected to deliver the required level of savings. However, there is a risk that

£1.5m of plans may not be fully achieved at the end of the year which is mainly due to

slippage in implementing the agreed plans. The bulk of this risk, £1.4m, rests with secondary

care related schemes. This is being offset by additional running cost efficiencies, meaning

that the overall levels of efficiencies are expected to be delivered.

We are working with GP Commissioners to strengthen the delivery of secondary care

efficiencies in a number of ways. This includes linking QIPP priorities to the PBC Incentive

Schemes and QoF targets, as well as working with them to identify new areas of efficiencies.

We are also working with them to help deliver the mental health efficiencies.

3.15 HRS06 – Non Elective FFCEs

The underperformance highlighted is with NHS Kirklees. – Issues predominantly with MYHT.

April May June July August September October

Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual

3461 3574 3451 3548 3424 3554 3442 3618 3178 3578 3426 3497 3504 3702

NHS Kirklees are closely performance monitoring this measure and although non elective activity was only slightly above trajectory in April (3.26%) with a downward trend showing in May (2.8%), there has been an increase in June (3.8%), July (5.1%) and August (12.5%), on variance to trajectory, and this is showing an adverse impact on the YTD position. However, at this stage, there is confidence that the year-end plan figure will be achieved.

3.16 HRS07 - Total waiting at the end of the month on an incomplete RTT pathway

The underperformance highlighted is with NHS Kirklees and NHS Wakefield District – issues predominantly with MYHT.

This 18 Week RTT supporting measure is being closely performance monitored and managed by the PCTs simultaneously with the overall 18 Week RTT activity programme. Although actual activity is showing above planned trajectories, there is confidence at this stage that the year-end plan figures will be achieved.

Refer above to 18 Weeks RTT commentary.

3.17 SRS11 – GP Written Referrals

The underperformance highlighted is with NHS Calderdale and NHS Kirklees.

The PCTs are activity working with their Primary Care contractors to understand current referral patterns and are closely performance monitoring this 18 Week RTT supporting measure and although actual activity is showing above planned trajectory, there is confidence at this stage that the year-end plan figures will be achieved.

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3.18 SRS12 – Other Referrals for a First Outpatient Appointment

The underperformance highlighted is with NHS Kirklees and Wakefield District.

There has been a significant increase in the number of other referrals to MYHT under specialty 340 Thoracic Medicine in 2011/12 which has been raised with the Trust via the Contract Monitoring Group (CMG). We have specific restrictions in the contract regarding Consultant to Consultant referrals for unrelated conditions which the Trust have informed us is adhered to but the data on this specialty would seem to contradict that. MYHT have been asked to investigate this issue and we are currently awaiting a response from them.

3.19 SRS13 - First Outpatient Attendance Following GP Referral

The underperformance highlighted is with NHS Kirklees and NHS Calderdale.

3.20 SRS14 – All First Outpatient Attendances

The underperformance highlighted is NHS Kirklees and NHS Calderdale.

NHS Calderdale

FOT is higher than plan for 2011/12 – the assumptions in the profile developed for this year need to refreshed to ensure a more accurate plan is developed for 2012/13. Triangulation with contracting data indicates NHS Calderdale is not overtrading with the volume and expenditure on outpatient appointments, both 1st and follow up.

All other activity levels for NHS Calderdale remain broadly in accord with the plans established for 2011/12. It should also be noted that the rate of growth in GP referrals is also decreasing which will impact on demand for outpatient attendances.

3.21 SRS15 – Elective FFCEs

The underperformance highlighted is with NHS Kirklees.

This 18 Week RTT supporting measure is being closely performance monitored and managed by the PCTs simultaneously with the overall 18 Week RTT activity programme. Although actual activity is showing above planned trajectories, there is confidence at this stage that the year-end plan figures will be achieved.

3.22 SRF12 – Proportion of GP referrals to first outpatient appointment booked using Choose and Book (CAB)

The underperformance highlighted is across NHS CKW.

NHS Calderdale

The utilisation of Choose and Book in Calderdale continues to remain one of the highest across the region.

Data from April 2011 indicates that 75% of the patients whose referral requests were made via Choose and Book are „converted‟ into an outpatient appointment. SHA figures show the monthly conversion rate. Conversion means that the patient made a phone call or booked an appointment online (in surgery, at home, library, etc) which turns their Unique Booking Reference Number into an outpatient

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appointment at the hospital of their choice. The Choose and Book indicator nationally has always concentrated on the percentage of converted UBRN‟s. The remaining 25% of referral requests were not converted. This is because patients may have chosen not to make an outpatient appointment.

The national average for Choose and Book Utilisation stands at 52%.

The 2010/11 local LES indicated that Calderdale practices referred 96% of GP referrals to services which were available via Choose and Book. The remaining 4% were referrals which were sent via paper but could have been sent electronically via Choose and Book. The local LES focuses on practice utilisation, and continues in 2011/12. The figures for the national indicator and LES differ as one looks at URBN conversions and the other the utilisation of the system. The conversions have limitations as this fully reliant on patient behaviour. Also, only first outpatient, Consultant led services are included in the figures.

Both Choose and Book and Choice feature in the priorities of the new Government via the 'Liberating the NHS' White Paper, and the Operating Framework. Although no specific national target was specified for 2011/12, the SHA has introduced an aspiration of 70% for local health economies.

All Consultant Led CHFT services on C&B are directly bookable. This allows patients to book their first outpatient appointment at the GP practice, online via health space or by telephoning the Choose and Book Appointment Line. Feedback from GPs is positive.

Actions Taken:

The „Optimising Electronic Referrals', West Yorkshire wide project, sponsored by WYCOM aims to help make further improvements where the national Choose and Book programme had not yet succeeded. NHS Calderdale is part of this project. Making improvements to the local secondary care provider has proved successful as CHFT now offer Advice and Guidance (A&G), currently at no cost. Advice and Guidance allows one clinician to seek advice from another. The GP can attach documents to the advice request - diagnostic results, scanned images (e.g. ECGs) or correspondence related to the patient. The CHFT clinician is then able to review the request, add attachments if required and send a response back to the GP. The following A&G specialties are available at CHFT:

Rheumatology, Elderly Medicine, General Medicine, Paediatrics, Pain Management, Ophthalmology, ENT, Dermatology, Gynaecology, Haematology, Orthopaedics, Oral and Maxillofacial, and Respiratory Medicine.

Respiratory Medicine – Tuberculosis, Gastroenterology and Viral Hepatitis.

All Calderdale GP‟s are committed to using C&B to refer where possible.

Keighley Road Practice declined the Electronic Booking LES in May 2011. They have a known router issue that affects all their e-transactions including Choose and Book. They have chosen not to resume use of C&B until the router problem is resolved.

The additional OER challenge is the target of 90% conversion rate for each PCT by 31 March 2012. As figures seem to be stagnating we are looking at other possibilities to achieve this. CHFT will shortly review all services that are not yet going through C&B (cancers, TOP‟s, etc...) to manage the process to put them onto C&B and improve utilisation, and give the GP a consistent way of referring.

The main aim is to ensure that CHFT adopt all aspects of directly bookable services to the optimum level. This will support both patients and clinicians to be the preferred method of sending referral letters. As a result Choose and Book performance will increase.

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The Choose and Book Team remain in contact with all practices offering support, training and addressing and submitting recurring issues to relevant parties.

NHS Kirklees

Performance for Kirklees continues to be below both National and Regional Average, standing at 44% (provisional figure) for November 2011. We are working with practices in both North Kirklees and Greater Huddersfield to get a better understanding of C&B usage from practice clinical systems as the centrally-available data can be misleading because of exclusions and is therefore not supporting practice engagement. The C&B team continues to meet with practices, especially those with low utilisation rates to resolve issues and increase use of C&B worklists as part of daily routine. Both CCGs are engaged with the C&B team and leading/supporting this work.

At a high level, C&B usage is higher in Greater Huddersfield (as evidenced by referrals into CHFT) than in North Kirklees (as evidenced by referrals into MYHT). Across Kirklees 68 out of 71 practices are currently using C&B but many practices use it occasionally rather than regularly and in other cases some referrers within a practice use C&B whereas others don‟t.

A range of issues at MYHT are contributing to reduced uptake, including: slot availability, limited clinical leadership and engagement, range of services available on C&B.

Other points that may be contributing to low utilisation and for which plans are being developed/implemented:

Some NK GP‟s still believe that the Named clinician function does not work on Choose and book and are therefore not using the system. The C&B team continues to give demonstrations and confirm via newsletter that it does work.

Many NK practices believe that the appointments system is bad at MYHT so there is no point using C&B. If a patient chooses to go to Dewsbury, for example, and the practices find no appointments available via C&B, they tend to send in a paper referral – thinking it is easier to get an appointment allocated

o GP Link is used to communicate C&B information, changes, and new services. Anecdotally this is not proving a popular or effective route of sharing C&B information. As a result, relevant information is missed and needs to be repeated. The C& B team holds non-nhs email address to communicate information which is proving successful.

Many practices do not believe that Consultants use or have access to the Choose and Book system, but this is not the case. Practices sometimes feel as there is no point in taking time and effort to use the system when a Clinician is not at the other end to respond. At CHFT, a mixture of Consultants and Senior nurses review referral letters. At MYHT, the majority of Consultants review referral letters. It could be that when referral letters are missing, practice receive phonecalls from clinic nurses and admin staff, therefore practices believe that that is the level of seniority their letters are dealt with.

Systmone practices have never been able to send more that 4 items with any referral letter via Choose and Book. This has been a major problem, especially for services such as Ophthalmology, where partial reports have been sent and Consultants either reject or request more info to be faxed in. Systmone will be upgraded so that practices can send a maximum of 5 megabytes and not restricted to 4 items. Practices are currently being informed of this.

A large number of GP‟s are still not using the Choose and Book system themselves. Anecdotal comments received from consultants are that they are convinced that if admin were not using the system, patients would be allocated to correct clinics. This could also highlight a Directory of service issue.”

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NHS Wakefield

The volume of referrals through CAB on a monthly basis continues to be high in 2011/12 with Q2 being the highest quarter of referrals so far recorded, and November being the highest individual month with 5,529 referrals being made through the system.

PCT Monthly Utilisation

The table below demonstrates Wakefield‟s % utilisation compared to the Yorkshire and Humber (Y&H) region and PCTs who are part of the Optimising Electronic Referral (OER) programme. It demonstrates that from April 2011 NHSWD continues to exceed both the National and Yorkshire and Humber (Y&H) average. Current performance continues to be over 60% and the PCT has a plan agreed with the Strategic Health Authority (SHA) to try and lift this to between 80% and 90% by year end – though this will depend on a number of external factors improving such as MYHT slot availability and issues regarding the way utilisation is calculated.

Monthly Utilisation

0

10

20

30

40

50

60

70

80

90

100

Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

Month

Perc

en

tag

e u

tilisati

on

Bradford and Airedale Teaching Calderdale Kirklees Leeds Wakefield Y&H National DH Target

Appointment Slot Issues at MYHT

Appointment Slot Issues (ASI‟s) at the Trust continue to be an outlier within the region and nationally with the latest week‟s figures showing slot issues in 20% of cases when compared to a national target of 4%. This is now being considered monthly at the OER Board meeting. Slot availability is also affected by the 18 week backlog position that the trust is working hard to reduce and will be difficult to resolve whilst a backlog remains.

It is important that this is resolved as it negatively impacts on patient experience and the view of

referring clinicians on the system

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3.23 SRF14 – Information to Patients

% of patients with greater control of their care records

The underperformance highlighted is across NHS CKW.

In Kirklees we have a small number of practices utilising certain parts of the functionality in respect of this indicator:

Some practices allow patients to request repeat medications; and

Some allow patients to book appointments on the internet.

No practices as yet provide patients with

Direct access to test results;

Direct access to Letters; and

Direct Access to Full patient record. The PCT, via the IT lead and the data quality team is increasingly beginning to raise the patient access agenda at Practice Managers meetings, The SystmOne User group, and with the CCG‟s IT clinical leads and will continue to provide support to enable the further roll out of this type of functionality.

4. Workforce Metrics: CKW Cluster

Section Authors: Laura Smith, Assistant Director of Workforce and Liz Selfridge, Workforce Analyst. Section 4 of the report is from the Human Resource and Organisational Development (HR&OD) Shared Service and provides the Cluster Executive Team with the latest key workforce metrics from NHS CKWD‟s constituent PCTs.

Workforce metrics can be a good barometer for an organisation. Significant peaks, troughs or deviation from plans can represent an area requiring further investigation or assurance.

The metrics presented here focus on staff in post, sickness absence and turnover, dating back to April 2010.

Unless otherwise stated, all information derives from the NHS Electronic Staff Record (ESR).

4.1 CKW Workforce Metrics:

4.1.1 Staff in post

The table below shows the quantity of staff in post across NHS CKW Cluster at 30 November 2011:

PCT Headcount FTE

NHS Calderdale 150 136.0

NHS Kirklees 252 222.3

NHS Wakefield District 269 241.6

CKW Cluster Total 671 599.9

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The graph on the following page shows the change in number of full time equivalent (FTE) staff

employed in the CKW cluster since April 2010.

Please note that these figures have been adjusted to remove all Provider directorate staff from the

outset; but they do contain any Commissioner staff who latterly TUPE transferred to other organisations

with Provider directorates. This factor largely accounts for the significant drop in FTE numbers between

March 2011 and April 2011.

The dotted green line indicates the expected trajectory of the workforce during 2011/12. The trajectory,

which was set at the start of the year, is based on assumptions about the rate of turnover and rate of

recruitment, but does not take into account imminent departures from the recent Voluntary Redundancy

/ Early Retirement Scheme or TUPE.

599.9 593.3

500.0

550.0

600.0

650.0

700.0

750.0

800.0

850.0

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

CKW FTE

2010-11 2011-12 Trajectory

FTE numbers peaked in June 2010 at 807.3 FTE and have since dropped to 599.9 FTE. This

represents a decrease of over 25%.

The reduction in the workforce during 2011/12 has to date followed our expected trajectory; however the

impact of autumn 2011‟s voluntary schemes will see a sharper than predicted drop in numbers during

the remainder of the financial year, with a likely outturn at 31 March 2011 of approximately 575 FTE.

4.1.2 Turnover

In this context, turnover refers to the quantity of staff leaving the organisation.

The table below shows the number of leavers and the 12 month rolling turnover for each PCT up to

November 2011.

PCT Number of leavers in the 12 months to 30 November 2011

12 month rolling turnover rate

NHS Calderdale 28 17.0%

NHS Kirklees 35 12.1%

NHS Wakefield District 36 13.1%

CKW Cluster Total 99 13.6%

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The graph on the following page shows the 12 month rolling turnover in NHS Calderdale, Kirklees and

Wakefield Cluster dating back to 1 April 2010. The dotted line indicates the expected trajectory of

turnover during 2011/12.

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

CKW 12 month rolling turnover

2010-11 2011-12 Trajectory

The rolling 12 month turnover rate has been high for all PCTs. This is due mainly to the introduction of

Voluntary Schemes in each PCT during the 2010/11 financial year, and to a number of TUPE transfers

out of the organisations during the course of the year.

Although the rate of turnover has been dropping since the summer, it is expected to rise again for the

remainder of the financial year as the 2011/12 Cluster Voluntary Scheme departures take effect.

4.1.3 Sickness absence

The expectation of the Yorkshire & Humber SHA in 2011/12 is that Commissioner organisations should

achieve a sickness absence rate of 2.5% or less.

The table below shows the rate and cost of sickness across the Cluster for 2011/12 to date, from 1 April

to 30 November 2011:

PCT FTE days lost FTE days available

Sickness rate Cost of sickness

NHS Calderdale 496.8 33661.3 1.5% £36,692

NHS Kirklees 1262.2 58366.2 2.2% £127,156

NHS Wakefield District 1495.1 59046.5 2.5% £162,368

CKW Cluster Total 3254.1 151044.0 2.2% £326,215

The graph on the following page shows the sickness absence rate across the Cluster dating back to

April 2010. The 2.5% expected rate is marked on the graph in green.

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The graph clearly shows that sickness absence rates are markedly lower during 2011/12 to date than in

the previous financial year. The peaks and troughs of sickness absence during 2011/12 are so far

following a similar pattern to 2010/11.

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

CKW Sickness

2010-11 2011-12 Target (2.5%)

4.2 Conclusion

This report is designed to give the Cluster Executive Team a snapshot of workforce metrics from its own workforce. The report can be adjusted as needed to meet the CET‟s ongoing requirements. HRODSS will continue to work closely with CET members and NHS CKW workforce to deliver expected outputs in internal workforce metrics. 4.3 Recommendation The Cluster Executive Team is asked to receive and note the content of this report.

5. Recommendations

The CKW Cluster Board is asked to NOTE NHS Calderdale, NHS Kirklees and NHS Wakefield District PCTs performance against the key headline and supporting outcomes/measures, together with performance against local identified priorities, and APPROVE the action being taken to address areas of under/over performance.

Report Owner: Peter Flynn, Director of Performance & Commissioning Intelligence Report Author: Natalie Ackroyd, Business Planning and Performance Reporting Manager