Agenda Item 12.2(i)

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Performance Recovery Update

Public Board Meeting

March 2018

Presented for:

Update on position statement presented to January Board for the following standards:

Emergency Care Standard

Cancer Waiting Times

RTT/ 18 weeks

Cancelled Operations not rebooked in 28 days

With Update for 6ww Diagnostics position for January.

Presented by:

Professor Suzanne Hinchliffe, Chief Nurse and Deputy Chief Executive

Author(s):

Clare Smith, Director of Operations (RTT)

Sajid Azeb, Assistant Director of Operations (ECS)

Angie Craig, Assistant Director of Operations (Performance and Diagnostics)

Mike Harvey, Assistant Director of Operations (Cancer)

Previous Committees :

None

Key points

1. To provide the Board with an updated position of LTHT’s current performance for the Emergency Care, Cancer, RTT, Diagnostics and Cancelled Operations national operational standards

For Information

2. To provide an update on the action plans and their progress towards achieving recovery of those standards.

For Information

3. To highlight risks to LTHT’s performance. For Discussion

Trust Goals

The best for patient safety, quality and experience

The best place to work

A centre for excellence for research, education and innovation

Seamless integrated care across organisational boundaries

Financial sustainability

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Index

Section Page number

1. Performance summary 2

1.1 Emergency Care 3

1.2 Referral to Treatment 3

1.3 Cancer Waiting Times 3

1.4 Cancelled Operations not rebooked in 28 days 4

1.5 6ww Diagnostics 4

2. Publication Under Freedom of Information 5

3. Recommendation 5

4. Authors 5

5. Appendices (detailed performance overviews): A - Performance overview B - Emergency Care C - Referral to Treatment D - Cancer Waiting Times E - Cancelled Operations not rebooked in 28 days F - 6ww Diagnostics G - Overall performance predicted position

6 6 9

14 17 22 23 25

1. PERFORMANCE SUMMARY

August 2017

Performing Achieving STF trajectories Non-Performing

Responsive • 2 Week Cancer Waiting Times • 31 Day Cancer Waiting Times -

First treatment • 31 Day Subsequent Surgery

Cancer Waiting Times • 31 Day Subsequent

Radiotherapy and Chemotherapy Cancer Waiting Times

• Outpatient Measures

• Emergency Care Standard • 62 Day Cancer Waiting Times

(October) • Referral to Treatment

• Diagnostic Test Waiting Times

• Cancelled Operations

• Delayed Transfer of Care and Repatriations

• Ambulance Handover

Safe • Incidence of CDI • Incidents

• Incidence of MRSA • Electronic Discharge Advice

Notes (eDANs) • Venous Thromboembolism

(VTE) Risk Assessments

Effective • Mortality Indicator Reporting • 30 Day Emergency

Readmission Rates • Harm Free Care

Caring • Complaints

Well-Led • Patient Satisfaction: Friends and Family Test

• People

Other • Length of Stay • CQUIN delivery

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1.1 Emergency Care Standard Performance

LTHT achieved the required STF trajectory for April, June and Q1 with a formally reportable position for Q1 of 90.54% against a trajectory of 90%. The Trust achieved the trajectory for Q2 with the inclusion of all MIUs as reported in the NHSI daily SitRep. The Q3 target of 90% was not achieved. The reported position from 1st October 2017 included all MIUs and Accelerator Zone/ performance as agreed across all WYAAT Trusts following the NHSI letter of 13th October which was intended to ensure greater consistency of reporting and comparisons both locally and nationally. However, in January 2018 further guidance was received that has made the position regarding systems reporting less clear. Discussions have taken place with NHSE regarding the new requirement, and in the interim January 2018 data has been resubmitted for LTHT. For more detail, please see Appendix B.

1.2 Referral to treatment Standard (RTT/ 18 weeks) Peformance

In May, June, Q1 and July 2017 LTHT delivered against its NHSI STF RTT trajectory. The Trust did not sustain this position although performance improved in November from October, achieving the highest performance year to date. This was again not sustained in December to February due to winter pressures and elective capacity restrictions. To mitigate the impact of the significant restrictions on in patient and day case activity following the NHSE directive, CSUs have, where possible, redirected Consultant time to clinics, leading to a decrease in the non-admitted backlog of patients waiting over 18 weeks and an increase in the admitted backlog of patients waiting over 18 weeks. This has resulted in the backlog being maintained in a relatively steady state, with the result that the overall waiting list size has been reduced by 3% (1485 patients). There are no monies payable on achievement of the STF trajectories for RTT in 2017/18; however, CSUs remain committed to regaining overall Trust compliance. For more detail, please see Appendix C.

1.3 Cancer Waiting Times Performance

2017/18

Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Q1 Q2 Q3

Formally Reported

(until 30/09/17)91.71% 88.29% 91.80% 87.69% 87.71% 86.73% 90.54% 87.38%

LGI 93.40% 91.05% 92.86% 87.91% 90.23% 90.39% 88.47% 88.76% 81.71% 80.60% 79.60% 92.39% 89.48% 82.28%

SJH 87.11% 80.78% 87.76% 83.59% 81.02% 77.54% 77.85% 66.57% 59.55% 53.48% 56.89% 85.15% 80.78% 52.94%

WGH 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Trust + All MIU's

(Reported for Q2)93.51% 90.84% 93.63% 90.45% 90.33% 89.63% 88.99% 92.62% 90.14%

Accelerator Zone-

Reported position

from 01/10/17

94.33% 92.02% 94.47% 91.68% 91.00% 91.48% 90.40% 87.77% 83.03% 82.21% 81.75% 93.57% 91.43% 87.15%

NHSI STF trajectory 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 82.00% 84.00% 90.00% 90.00% 90.00%

MONTHLY

(national

reporting

period)

62 days 2ww referral to Treatment

Apr-17

May-17

Jun-17

Jul-17

Aug-17

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Q1 17/18

Q2 17/18

Q3 17/18

Overall performance

72.8% 78.5% 77.1% 78.9% 83.4% 74.9% 75.2% 75.0% 76.7% 83.5% 76.5% 79.2% 75.5%

Internal and by day 38

performance 78.8% 87.0% 84.8% 85.3% 89.1% 80.2% 81.4% 82.9% 84.1% 89.2% 84.1% 85.0% 82.7%

NHSI STF Trajectory

74.9% 77.5% 81.1% 81.3% 82.7% 83.1% 82.6% 82.7% 81.0% 80.2% 78.1% 82.3% 82.1%

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Overall reported performance was 76.7% for December 2017 and 83.5% for January 2018, an improvement since November. The STF trajectory has been achieved for November, December and January when the LTHT internal and by day 38 performance position is considered, with continued improvement being demonstrated from the September 2017 position.

The current shadow breach reallocation process has had a positive impact on LTHT performance of 2.4% for January (formal national reporting due to commence July 2018 following guidance issued by NHSE in February 2018).

LTHT has continued to perform on all other CWT standards from April 2017 to date, with the exception of the overall 62 day performance standard and the 62 day screening standard (not achieved September - November). The 14 day urgent GP referral standard has not achieved for January due to the large number of patient choice deferrals over the Christmas and New Year period, with performance restored in February to date, although issues with snow at end of February and early March will impact on March performance. For more detail, please see Appendix D.

1.4 Cancelled Operations not rebooked in 28 days

This is a zero tolerance NHS contract standard. Following good progress in reducing levels of cancelled operations breaches not rebooked within 28 days, the position significantly deteriorated in 2017/18. Early Q3 data did indicate signs of improvement but this was then signifcantly impacted with December bed pressures. As expected the unvalidated January data showed further deterioration in 28 day performance, with recovery showing in February and early March. For more detail, please see Appendix E.

1.5 6ww Diagnostics Standard Performance

The Trust reports diagnostic waiting times for 15 modalities against a national standard of 99% of patients waiting less than six weeks from point of referral to test at the month end. The Trust achieved and maintained the Diagnostic standard of 99% since September 2016, with the number

Apr-17 May-17 Jun-17Q1

17/18Jul-17 Aug-17 Sep-17

Q2

17/18Oct-17 Nov-17 Dec-17

Q3

17/18Jan-18 Feb-18

2014/15 = 132 2015/16= 82 2016/17 = 277

Cancelled Ops

not rebooked in

28 days

24 15 15 54 19 19 19 57 7 17 44 68 59 40

Patients whose operations is

cancelled on or after the day of

admission should be offered another

binding date within 28 days (at LTHT

or funded at a provider of the patient's

choice)

Apr-17 May-17 Jun-17Q1

17/18Jul-17 Aug-17 Sep-17

Q2

17/18Oct-17 Nov-17 Dec-17

Q3

17/18Jan-18 Feb-18

Performance (%)99.57 99.76 99.75 99.70 99.77 99.77 99.85 99.80 99.86 99.82 99.34 99.68 97.90 99.82

Patients

Waiting 6

Weeks or Over

(at Month End)

51 31 32 114 29 29 18 76 17 22 75 114 255 21

6ww

Diagnostic

Standard

<1% of Patients

to have waited

over 6 weeks for

basket of 15

tests at month

end

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of 6ww diagnostics breaches continuously falling from a high of 79 in January 2017 to the lowest 17 reported in October 2017. December 2017 and early January 2018 data indicate significant increase in the number of 6ww diagnostics month end breaches, this was mainly due to challenges in echo cardiology service and impact of cancelled diagnostic daycases. Through supporting actions in place Trust performance

has been restored in February. For more detail, please see Appendix F.

2. PUBLICATION UNDER THE FREEDOM OF INFORMATION ACT

This paper will be made available under the Freedom of Information Act 2000.

3. RECCOMMENDATION The Board is asked to receive this report of Performance within LTHT.

4. NAME OF AUTHOR(S):

Clare Smith, Director of Operations (RTT)

Sajid Azeb, Assistant Director of Operations (ECS)

Angie Craig, Assistant Director of Operations (Performance and Diagnostics)

Mike Harvey, Assistant Director of Operations (Cancer)

Date of paper: 22/03/2017

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5. APPENDICES A. PERFORMANCE / FLOW OVERVIEW The impact of our inability to flow patients out from LTHT has continued throughout the year, with patient acuity remaining high, becoming particularly acute in December,January and February. This has remained problematic despite the actions that are in place with partners as part of the Leeds Delivery Plan. The continued pressure has had a detrimental effect on the Trusts overall ability to achieve planned levels of elective activity, with the contingent detriment to our financial position. The main factors contuing to affect the outflow from LTHT are:

Demand for IP beds outstripping capacity due to medical outlier and medically optimised patients still in the bed base.

Timeliness of patients discharge from LTHT and the increased number of stranded patients (patients with a >7 day length of stay).

Community bed provision.

Medically Optimised Patients (MOFD previously MFFD)

In January we began validating the daily MOFD position via the Winter Room, giving a more robust / live picture. This showed a sharp increase in January and February on the previous 2 months snapshot positions. This data fits with the information available later in this paper which identifies a significant increase in the occupied bed days associated with patients with long lengths of stay. Delayed Transfers of Care (DTOC) The DTOC numbers for the officially reported position have seen a slowly rising trend from December 2016. The overall number does not include delays associated with community nursing assessment processes which are not captured as DTOC.

From February 2017, DTOC had continued this rising trend and although a reduction was seen in November and December 2017, this again began to rise in January and is expected to fluctuate throughout Q4 due to wider system pressures.

115 121 130

152

124

149

180 180 176

157 158 162 170

192 198 182

159

134

196 211

0102030405060708090

100110120130140150160170180190200210220

Medically Optimsed for Discharge

The MOFD audit prior to January has been based on a snapshot. From January this has been validated through the winter room

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For February 2018 there were 1,843 lost bed days, which equates to 66 beds lost per day to DTOCs. This is still at a level that has a significant impact on bed availability and patient flow and shows an increase when compared to February 2017.

*The “patient or family choice” category includes patients whose families are choosing homes or waiting for home managers to assess patients. As of 17th January 2018 there are no delays in this category attributable to LTHT.

Community bed provision The current level of Nursing, Elderly Mentally Inform (EMI) and Residential community bed provision across the Leeds economy, coupled with timeliness of patient discharge continues to impact on LTHTs ability to discharge patients from the bed base. The largest category of delays continues to be Code G - NHS patient or Family choice. This code includes patients who are:

Actively seeking care home placement (patients / family reviewing care homes or awaiting care home assessment and decision of acceptance)

1825

1992

1722

1922 1899 1949

2532

2127 2075

2337 2319

1848 1760

2124

1843

1700180019002000210022002300240025002600

Number of Delayed Transfers Of Care

Number of DTOC Linear (Number of DTOC)

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Delayed Transfers of Care - Lost Bed Days by Delay Reason

I - NHS Housing pts not covered by NHS & Community Care Act H - NHS Disputes

G - NHS Patient or Family Choice F2 - SS Community Equipment / Adaptions

F1 - NHS Community Equipment / Adaptions E - SS Care package in own home

D2 - SS Care Home Placement Nursing D1 - SS Care Home Placement Residential

C - NHS Further Non Acute NHS Care Incl ICT & Rehab B - SS Public Funding

A2 - SS Completion of Assessment A1 - NHS Completion of Assessment

February comparative positions

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Discharge date planned (care home accepted, patient waiting to transfer)

Awaiting a package of care but have declined an offer of a transitional bed whilst the package is sourced.

Awaiting Housing but have declined an offer of a transitional bed

Family meeting to confirm plans. We are continuing to experience challenges with the timeliness of care homes assessment of patients as well as homes declining patients as they feel they are unable to meet their needs. Community bed availability remains unable to meet the demand which means that patients are continuing to wait in hospital following referral. In addition, due to these capacity constraints we are not able to utilise the discharge to assess functionality of the service. The situation is being closely monitored by commissioners and is a key element of our Winter Room (from mid December 2017). Outliers

The number of outliers on Adult Wards (as at daily 8am snapshot) has seen an increase of 960 bed days over the course of February 2018 when compared to the February 2017 position. This equates to an average of 174 outliers per day. The highest daily recorded outlier number this year to date was 239 captured on 09/01/2018. Stranded Patients Proportion of Non-elective Bed Days by Length of Stay (LoS) Band – Q4 2016/17 to Q3 2017/18

3,913

4,873

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7,000

Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18

Outliers on Adult Wards (Sum of 8 am snapshots) For Month

Outliers on Adult Wards…

27038

29090

53.2% 53.9%

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60.0%

70.0%

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30000Stranded patients

Leeds Teaching Hospitals NHS Trust Stranded patients Excluding C01, J11, J14, J16, HEA, BIL, J30, andTransplant PatientsLeeds Teaching Hospitals NHS Trust % Stranded patients Excluding C01, J11, J14, J16, HEA, BIL, J30,and Transplant Patients

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The graph above demonstrates the increase number of bed days attributable to extended LoS patients. In Q3 2017 approximately 55% of beds were occupied by patients with a LoS greater than 29 days. This is a significant increase when compared to Q4 2016 when the number of bed days occupied by patients with a LoS of more than 29 days was less than 40% of total bed days.

The increase in the amount of stranded patients within the LTHT bed base can be seen above. For comparison between January 2017 and January 2018 we can see an increase of 2,052 patients. This equates to an additional 66 patients per day. In December 2017 there were an average of 829 stranded patients per day in the LTHT bed base. In January 2018 this average is 938 per day (excluding all known long stay patient wards - C1, J11, J14, J16, Heather, Bilberry, J30 and Transplant patients.)

. B. EMERGENCY CARE

B.1 Comparative national position Non elective pressures became acute during December, January and February. It is clear that the admitted breaches remain the major factor for the deterioration in the overall ECS performance position. This is particularly noticeable at the SJUH site which is down 4.8% in comparison to the same period in the previous year (April - Feb).

Silver Command processes have been enacted almost daily from the beginning of December to date, with LTHT remaining at OPEL 3 Escalating throughout the majority of this period. The Winter Room commenced on the 11th December 2017 and has continued to work to try and address patient delays and accelerate discharge. This was supplemented by a two day MADE event on 20th and 21st February 2018.

B.2 Underlying Issues There continue to be pressures on outflow from A&E and associated beds / systems due to the underlying issues as previously described in section A.1 Until these issues are addressed on a system wide basis, performance against the ECS standard within LTHT will remain compromised, despite efforts made internally to reduce admissions and deliver on other ambulatory care options.

27038

29090

23000

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25000

26000

27000

28000

29000

30000Stranded patients over 7 days

Leeds Teaching Hospitals NHS Trust Stranded patients Excluding C01, J11, J14, J16, HEA, BIL, J30, andTransplant Patients

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A&E Attendances A&E attendances at the SJUH and LGI sites between April 2017 to February 2018 were 194,807 against 194,035 in the same period last year - an increase of 772. The majority of this increase has been seen within Q3 and Q4 of the current year.

During this period we continued to experience significant variation in daily attendance patterns, seeing the busiest day for the current year of 754 patients attending our departments on the 14th December 2017. Overall for February there were: • 16,148 attendances at LTHT A&E departments • 8,018 attendances at the 3 Minor Injury Units supporting LTHT (Wharfedale, St Georges

and Shakespeare Street) • 3,990 patients were seen acutely in assessment areas at LTHT outside A&E • 5,609 emergency admissions to LTHT (All CDU, Assessment, Admissions) • 17,576 IP and Day case discharges from the Trust, of which 10,100 were non elective

patients When compared to the December and January positions, A&E attendances have fallen slightly, with MIU and assessment area attendances increasing (by 707 and 817 respectively). Discharges during January increased by 2,986 but this was still not sufficient to significantly improve flow / bed capacity. During February, overall discharges once again were reduced although those for non-elective patients increased by 3,733.

Admissions There were 41,178 non-elective admissions from A&E into the main bed base between April to February 2018. This represents an overall reduction in admissions via A&E of 973 year to date in comparison to the same period last year when we admitted 41,178 patients. There were 78,980 total non-elective admissions (A&E plus assessment areas excluding CDU) from April to February 2018. This again is a reduction of 966 admissions year to date, equivalent to a 1.2% improvement in comparison to the same period last year when we admitted 79,946 patients. The Trust has demonstrated a reduction in its acute admissions due to the continued work to operate the strengthened ambulatory care and admission avoidance models, including the Frailty unit fully established from 6th November 2017 on a Monday - Friday basis. During

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A&E Attendances & Non-Elective Activity Excluding CDU Patients Sent Directly Home

A&E Attendances Non Elective Admissions

Linear (A&E Attendances) Linear (Non Elective Admissions)

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November and December 2017, 308 patients were managed through the unit with 210 (68%) being discharged back to their normal place of residence. The operational hours of the unit have now extended to open 7 days to further improve admission avoidance Waits within A&E

The reducing trend in bed requests via A&E shown in the graph above further demonstrates this admission avoidance progress. The unusual peaks in May 2016, October 2016, March 2017 and May 2017 have been reviewed and are not thought to be related to half term issues (as raised at the March F&P committee). The number of patients waiting within A&E post decision to admit had continued to increase, although has reduced somewhat in February compared to the January 2018 peak. The graph above shows the number of patients who waited more than 4 hours (trolley wait patients) in A&E post decision to admit. The number of patients who remain in A&E awaiting a bed from September to February 2018 is significantly above that for the same period in 2016/17. In February 2018, 1,625 patients waited greater than 4 hours post TCI compared to 1,078 in February 2017. The number patients who have waited 8-12 hours has seen a significant increase; in December it was 21 a day, January 29 per day and February 27 per day compared to 3 per day in first 6 months of the year. This continues to have a direct impact on the congestion within the A&E department and LTHTs ability to achieve compliance against the 4 hour standard and is reflective of the on-going bed pressures which result in high levels of outflow delays. Despite these increased pressures, there have been no 12 hour trolley waits to date.

B.3 Recovery Actions

The reason for deterioration in performance is due to exit block from the A&E department in line with our inability to discharge patients from our wards. We can demonstrate a significant increase in the number of patients who have long lengths of stay (LoS) which is mainly associated with those patients who require some form of on-going health and social care intervention in the community to enable their discharge. The increase in LoS is demonstrated in the following graphs:

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Actions undertaken We developed the Leeds A&E Delivery Plan:

A system-wide plan, which incorporates and is aligned with NHS England’s 9-point plan;

Operational Pressures Escalation Levels (OPEL) Framework has been developed, supported by system-wide ‘SitRep’ calls that have commenced to provide a consistent approach in times of pressure;

Action on A&E Programme has been undertaken, with the support of NHS Improvement, in which projects such as the frailty service have been piloted.

In addition other initiatives in place are as follows:

GP in A&E – Since November 2017, we have had GPs in A&E on both sites routinely

commissioned by CCG (provided by LTHT as part of a pilot previously) for 12 hours per day 7 days a week. GPs have seen and treated approximately 1,400 patients per month, and have achieved more than 98% compliance with the 4-hour standard.

Ambulatory Care – The Joint Acute Medical Assessment area (JAMA) was relocated from J27 into

A&E in January 2017, and the service was extended to 7-days a week. Co-location has allowed more patients to be seen through assessment / ambulatory pathways. In December 2017, 419 patients were managed through the ambulatory care pathway, and only 44 (10.5%) were subsequently admitted.

– We have increased Joint Oncology Assessment area (JONA) capacity from 4 to 6 cubicles, which has allowed more patients to be managed through the unit.

– A Frailty Unit opened in November 2017 at the SJUH site, and we extended its opening hours from January 2018 to 9am-6pm, 7-days a week.

To improve inpatient flow:

We have been ring-fencing capacity in the AMS CSU since last August.

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– Acute wards J46 and J47 - we are trying to restrict the number of outliers to no more than 6 lodgers per ward. This allows for a significant proportion of new acute admissions to be cared for across JSAU, J46 and J47. This has minimised delays in the timely review of patients and also reduces the length of time it takes to do the acute surgical round. It has also significantly reduced delays for patients requiring transfer from A&E.

– J43 has been designated as an inpatient elective ward to allow capacity for continued cancer / urgent elective cases.

– We have continued to protect the use of David Beavers Day Unit (DBDU) and Joint Admissions Lounge (JAL), which has allowed us to maximise day case activity.

Inpatient bed capacity: – Increased capacity by opening 52 beds on the Heather and Bilberry Wards at

Wharfedale, for MOFD patients, in January and March 2017. – Increased capacity by 9 beds over the 2018 winter period through transferring J16

to J11, releasing staff from Wharfedale to support. – Created an additional 7 beds on J27 as a result of the relocation of JAMA to A&E – An additional 30 beds on J30 for MOFD patients. This ward is managed by our

partners, Villa Care (who also run Heather and Bilberry Wards) and this has enabled us to release nursing staff into our acute wards

– Opened up J31 and J32 as MOFD wards in January 2018, again staffed by Villa Care, adding a further 47 beds into the system.

– Created an additional 8 beds for medical patients on J24 which will be handed back to allow normal elective operating from March 2018.

– Increased L28 to a 7-day ward, adding a further 20 beds. As of the 12th Feb 2018 the area has reverted back to a 5.5 day 23 hour / day-case facility.

– Utilised wards C02 and C03 at Chapel Allerton Hospital to help with acute pressure being experienced on the SJUH and LGI site. As of the 12th February 2018 we have returned these areas back to their normal functionality.

– Extended many of our 5-day into 7-day opening e.g. J43, L14, DBDU

Inpatient Flow: there are a number of initiatives we’ve introduced recently to improve flow across the system, including:

– New cross-city Daily Operational Processes, linking together the partner organisations in Leeds

– New OPEL framework to enable easier escalation – Established a ‘Winter Room’ in Gledhow Wing – Instituted a daily teleconference at 22:30 for key on-call managers and directors to

help ensure plans are in place for the night.

Improving Discharge – Leeds Integrated Discharge Service:

– Bringing together resources from within the hospital and community to cover A&E, assessment areas and 9 wards across the Acute Medicine CSU to help avoid admission and expedite hospital discharges.

– Funding has been approved through the iBCF to expand the service across an increased number of wards at SJUH site and to allow expansion on to the LGI.

– Daily MOFD review with escalation through to partners via the winter room.

– Discharge Lounge: – Improved utilisation, when compared to its previous location. Delays in

EDAN continue to be the main driver of discharge lounge usage – Introduction of a ‘Discharge by 12’ target number for each CSU (the

number of patients who can be discharged by midday).

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Multi Agency Discharge Event (MADE) was facilitated by NHSI on the 20th and 21st February 2018. The learning from this event will be combined with outputs from the Perfect Week and the Winter Room themes to allow an action plan to be developed ahead of winter 2018/19.

C. REFERRAL TO TREATMENT LTHT reports the number of failing specialties/ specialties under pressure (ranging from 6-8) as well as the overall Trust performance position. In December we reported 7 failing specialties as Dermatology did not achieve for the month. The number has remained at 7 failing specialities in January; however, whilst Dermatology has recovered Neurosurgery has dropped performance; this was anticipated in view of the level of cancellations experienced. C.1 National Comparative Position When compared to other units nationally, LTHT’s position has slightly improved again from previous reports despite LTHT’s on-going bed pressures (December 2017 latest available national comparison data).

* Dec 2017 is latest national benchmarking data

C.2 Underlying Issues In Q 3 of 2017/18 delays in discharging medically optimised patients continued to result in the cancellation of a number of RTT patients, with subsequent impact on elective plans to reduce the number of patients waiting over 18 weeks for treatment. At the start of Q4 the impact of stranded patients in the LTHT bed base was compounded by heightened winter pressures and the NHSE directive leading to the Trust cancelling all cases that were not cancer or clinically urgent (including day cases on both the SJUH and LGI sites, and all inpatient activity on both the Wharfedale and Chapel Allerton sites).

External pressures Patients waiting more than 40 weeks for treatment are in our most pressured areas, namely: Paediatric Urology, Paediatric Dentistry, Paediatric ENT, Adult Spines and General Surgery / Urology.

During Q1 2017/18, LTHT agreed mutual aid support to the Manchester Paediatric Cardiology service, with NHSE support, to the level of 65 patients per month. In June 2017 we received 140 patients due to their pressing backlog position. This assistance has been kept under

65%

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90%

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100%

Trusts

Peer comparison: % of patients on incomplete RTT pathways waiting no more than 18 weeks, December 2017

LTHT Peers Other Trusts England Target

Source: NHS England

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reguar review during 2017/18 to assess the impact at LTHT on Childrens and Radiology services as there is currently no formally agreed end point.

Issues with the Genetics service provision have also become a challenge for RTT delivery due to reduced staffing. Whilst plans are in place to address this, it is expected to take a protracted period of time (circa March 2018) as is dependant on staff recruitment and the scarcity of those staff nationally. All issues are regularly discussed with NHSE and local Commissioners via appropraite contract meetings to ensure all options are explored to support and allevaite if possible the current LTHT position, although alternative options have not been easy to identify to date

52 week breach position LTHT has now reported seventy seven 52 week breaches, following a two year period from the last reported breach. The formally reported breaches by month are:

July 2 breaches

August 2 breaches

September 1 breach

November 1 breach

December 4 breaches

January 22 breaches

Nationally, for December (latest comparison data available) there were 13 Trusts who reported a total of eight hundred and fourteen 52 week breaches, of which LTH was ranked 11th with four reportable breaches (highest single Trust reported position was 242, with the 10th ranked trust reporting 18). In February 2018 there have been forty five 52 week breaches:

21 Colorectal

9 Spinal

5 Plastics

5 Upper GI surgery

5 Urology

Due to the continued increased bed pressures at both main sites, there are currently 116 risks for March (as at 20th March 2018). CSUs are closely monitoring on a patient by patient basis their breach risks, but the routine clinical classification of these patients continues to place them at risk due to bed capacity. Concerns remain with longer term insufficient capacity and flow into Leeds from closed or struggling surrounding facilities:

Spines(long standing regional capacity insufficiency

Neurology (Mid York's)

Paediatric surgery across West Yorkshire (particularly Paed ENT, Paed Urology)

Manchester Paed Cardiology patients volume being higher than first anticipated. Requests were made in November support with Dermatology and Ophthalmology, which in December were increased to include Respiratory Medicine. In January 2018 there was an additional request for support from Mid Yorkshire for their Bariatric service. Additional sessions (in house, Independent Sector and transfer to Harrogate) have continued to be delivered, although not at the level to sufficient to address the long waiters position, with continuing risks for 52 week breach position. This has been further exacerbated by the NHSE elective operating restrictions from mid-December to mid February 2018.

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Impact on elective care The team continue to focus on the delivery of Outpatient activity whilst the ability to deliver Elective activity at planned levels remains constrained. The focus on Daycase throughput YTD has been significantly constrained in January and February following the NHSE requirement to reduce all non urgent or cancer activity in from 22nd December to end of January 2018. Elective procedures remain some 11.4% below planned levels at 2,674 cases and cases behind plan which was being offset by increased Daycase activity at 2,937 cases and 3.4% above plan YTD. The CSU most affected by this reduced elective throughput / shift to daycase overtrading is the Abdominal Medicine and Surgery CSU who primarily operate from the SJUH site.

C.3 Recovery Actions The RTT recovery plan and associated trajectories continue to be monitored closely and are being recast for March due to the impact of the NHSE directive on CSUs’ day case backlog clearance plans. All CSU triumvirate teams receive a letter following their monthly RTT performance meeting with actions agreed being clearly documented.

Key actions to support recovery are:

Full review of booking in order practice which will be monitored via the monthly RTT performance meeting and also CSU Integrated Accountability Meetings

Review of progress against all 1st OP appointment trajectories

CSU submission of 2nd OP appointment trajectories for patients who have waited longer than 18 weeks.

Review of day case trajectories and capacity

Identification of patients suitable for the Independent sector payable at tariff

Due to the significant bed pressures and cancellations of electives January 2018 performance dropped to 88.37% from the high of 89.29% in November 2017, the best performance since June 2016.

The chart below shows a peak of 7,112 patients waiting past 18 weeks at the end of December 2016, with this reducing over the following months to reach 5,630 in November 2017 (a fall of 1,482) but then increasing to 5,839 in December in line with elective operating constraints. Even with the reduction of operating in January 2018 the backlog reduced by 15 patients against the December position, although this has grown slightly in February.

This is due to consultant time being utilised in clinic for outpatient appointments (the admitted backlog has increased by 358 patients and the non-admitted backlog has reduced by 373 patients).

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Through this additional focus on Outpatients who have waited over 18 weeks, from December to January the total waiting list size has reduced by 3% (1,485 patients). This in turn has reduced the overall performance denominator which has adversely impacted on the January performance position. There remains a recognised substantial and significant risk that the continuing flow pressures will have an on-going impact on admitted performance and any planned recovery. D. CANCER WAITING TIMES There is a longer lag in formally reporting cancer performance than all other standards, with February data not formally reported until early April. D.1 National Comparative Position

LTHT performance against the overall 62 day performance metric deteriorated since the August position, but is now recovering, with LTHT December internal performance only slightly below the England average and 85% target, whilst performance for some cancers including gastrointestinal and urological tumours continues to be above the England average, overall performance remains below the national benchmark.

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When the formally reported position for all standards for January is considered, LTHT is above the national average position in all areas apart from that for 2ww (which has recovered in February) as outlined below:

January 2018

LTHT National

2WW (93) 91.9 93.8

Breast symptoms (93) 95.6 91.9

31 FDT (96) 96.3 96.5

31 Subs Drug (98) 100 99

31 Subs RT (94) 100 96.2

31 Subs surgery (94) 95.1 93.6

62 Days 2ww ref to tx (85) 83.5 81

62 Days Screening to tx (90) 93.3 87.7

62 Days Clinical Upgrade (85) 69.1 87

31 days’ rarer cancer (85) 100 86.5

D.2 Underlying Issues There are 2 keys elements to cancer performance, Internal LTHT performance and that for

patients transferred to LTHT for treatment during their 62 day pathway (inter-provider transfers).

As an average LTHT treats in the region of 160-180 accountable cases per month on a 62 day

pathway. This means that to achieve 85% compliance we have a tolerance of 24-27 accountable

breaches.

Over the last year, we have had an average of 34 breaches per month. Therefore, the challenge in 2018/19 is to reduce 5 internal and 5 late referred breaches to reach a sustainable position. For the late referred cases, this would mean LTHT receiving / the 6 main referring units sending 10 more patients per month (1-2 each), by day 38 than they currently do.

Internal Performance

To compensate for an increasing level of late referrals, LTHT performance for internal and patients referred from other providers by day 38 needs to be in excess of 90% to achieve the overall standard. Whilst LTHT is yet to achieve this 90% target, the 85% standard for Internal and by day 38 performance was achieved in Q2. Whilst Q3 performance was slightly below the standard at 82.7%, December performance of 84.1% and January performance of 86.9% signifies an improving trend. In order to further improve performance against the 62 day standard, the cancer management team in February began daily patient tracking list reviews with the Urology, and Lung teams. Following a trail period, showing impact in avoiding breaches, this has now moved to twice weekly and the Colorectal team have been added. This model will be expanded to additional areas as required. The Assistant Director of Operations and Lead Cancer Manager attend weekly conference calls to NHSI and the Alliance to review the progress and impact of this initiative.

Inter-Provider Transfers (IPTs)

As shown in the quarterly analysis below, the total number of patients referred from other providers has increased from an average per quarter of 205 in early 2016/17 to 250 in 2017/18 to date. During this time there has been a decrease in the number of patients referred by day 38 and an increase in those referred after day 38 to LTHT, which continues to present challenges to treat these patients within 62 days.

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The Lead Cancer Managers across the region have commenced a programme of work to proactively manage the increasing number of late referrals. This includes weekly conference calls between Lead Cancer Managers to agree remedial plans based on the challenge of reducing by 10, the number of patients referred in post day 38 (thereby reducing the number of accountable breaches by 5). This work is being supported by NHSI who have had discussions with the referring trusts to ensure their support.

Demand

The chart below illustrates how LTHT performance against the two week wait standard continues to be comparable with peers seeing similar volumes of patients. The 2ww CWTs standard has consistently been achieved, despite referral demand remaining high. For January 2018 however, the standard will not be achieved (due to the volume of patient choice deferrals over the Christmas and New Year holiday period). Performance is expected to be recovered in February.

7 day challenge

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As part of LTHT’s 62 day cancer performance improvement strategy, all teams are endeavouring to see patients earlier in their pathways to allow for faster diagnosis and treatment. The proportion of patients being seen within 7 days is increasing with January and February to date having the highest proportion since April 2017.

As can be seen below the Trust continues to deliver an increasing number of cancer treatments ( including 31 first and subsequent treatments as well as 62 days), with the number of overall cancer treatments delivered in Q3 of 2017/18 reaching the highest level seen to date and an 8% increase on the same quarter in 2015/16.

Cancellations and Continued risks for February and March performance

The impact of cancellations and prolonged acute flow pressures continue to be a challenge. For those cancelled as a result of bed pressures, we have as an average had to cancel approximately 35 patients per month. Not all of these patients will have a confirmed cancer diagnosis (they may have been on a diagnostic pathway) or their admission on the occasion they were cancelled may have been unrelated to their cancer pathway Cancellations on the day only occur in conjunction with review and prioritisation with the relevant clinical teams to ensure patients will not deteriorate as a result of the cancellation. The volume of cancellations is reviewed on a weekly basis by the Lead Cancer Team to ensure plans are in place for all those cancelled. As at the end of January 2018, of all patients cancelled only 2 patients did not have a date, one as a result of patient choice and the second is currently being re-dated (for a procedure unrelated to their cancer diagnosis). The number of patients waiting over 90 days for treatment has reduced significantly from 63 in June 2017 to 49 in February 2018. These long waiting patients remain a mix of

16.2%

18.9%

16.5%

16.6%

15.3%

19.0%

18.3% 16.6%

13.8%

20.0% 25.1%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan 1st -15th Feb

All Referrals: % Seen by Day 7

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clinically complex and late referred cases which are validated on a weekly basis by the clinical teams to ensure progression to treatment at the earliest opportunity.

IPT Reallocated Performance - according to WYAAT guidance Following a recommendation from the Chief Operating Officers the WYAAT Chief Executives agreed to implement the national guidance for breach reallocation across WYAAT. Shadow reporting of the guidance began from 1st September 2017 across WYAAT: For LTHT, for January 2018 this would have had the following impact:

o Formally reported 62 day performance = 83.5% o Breach reallocated position = 85.9% o LTHT only position (2ww then treated at LTHT) = 86.9% o LTHT and referred to LTHT by day 38 = 88.6%

Additional guidance was released by NHSE national team in February 2018, which indicates that a large number of new rules will be now be introduced with significant changes and additions from the original guidance issued in 2016 related to inter provider transfers (IPTs). At present the performance and practical implications of these rule changes are being quantified and LTHT will be seeking clarification of these rule changes and their impact prior to any implementation, the national timescale for which remains extremely tight as it is still planned to begin from the end of Q1 2018/19.

WYAAT Performance and Cancer Transformation Funding During Q4 2018/19 communication was received from the National Cancer team indicating that the 2018/19 Cancer Transformation funding across WYAAT would become contingent on achieving 62 day performance. As we did not achieve 85% performance across WYAAT for Q3 2017/18, they have withheld 25% of the 2018/19 funding (equivalent to circa £1.6 million). This funding may be released if the required performance level is achieved across a period during Q1 and Q2 2018/19 (May to July). In order to achieve this level of performance LTHT will need to continue its internal drive to achieve 90% and be supported by increased numbers of patients being referred to the Trust by day 38 (as discussed at the March WYAAT chairs meeting).

D.3 Recovery Actions

The cancer 62 day recovery plan and associated trajectories have now been re-worked beyond the original deadline of September to ensure focus continues on improving internal 62 day performance.

Performance Measures

Cancer: 62 Day: GP/Dentist

Referrals - Target >= 85%

Cancer: 62 Day: Internal and by

day 38 performance

Cancer: 62 Day:

Internal Only

Cancer: 62 Day: Reallocated position

(COO definition)

Apr-17 72.8 78.8 78.4 76.8

May-17 78.5 87.0 85.7 82.3

Jun-17 77.1 84.8 84.7 82.1

Jul-17 78.9 85.3 85.6 81.7

Aug-17 83.4 89.1 88.0 85.4

Sep-17 74.9 80.2 79.2 77.4

Oct -17 75.2 81.4 82.1 77.5

Nov-17 75.0 82.9 81.0 77.8

Dec-17 76.7 84.1 83.3 81.0

Jan-18 83.5 88.6 86.9 85.9

Q1 17/18 76.5 84.1 83.4 80.8

Q2 17/18 79.2 85.0 84.4 81.6

Q3 17/18 75.5 82.7 82.0 78.7

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The Trust is continuing its programme of work following a number of successful bids in partnership with health partners across the city and WYAAT. This will support additional diagnostics capacity to improve timeliness of pathways and patient experience. This includes an expansion of the ACE programme, roll out of Teledermatology across the city, Endoscopy and Cystoscopy nurse training, implementation of a single reporting software system and training scientists within pathology to expand these roles.

E. CANCELLED OPERATIONS NOT REBOOKED WITHIN 28 DAYS

E.1 National comparative position

Nationally in comparison to other units, the LTHT ranking, for patients not treated within 28 days of their last minute cancelled operation has remained relatively static. For Q3 (October to December 2017) LTHT is ranked 134th out of 154 Trusts nationally. E.2 Underlying issues The Trust has consistently found the delivery of the Cancelled Operations not rebooked within 28 days zero tolerance standard challenging due to the attempts to maintain elective activity at maximal levels whilst dealing with the impact of decreased outflow on capacity.

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Q3 data shows a fall in the overall number of last minute cancellations, but a further deterioration in the number last minute cancelled operations not rebooked in 28 days due to significant bed pressures from congestion pressures and restrictions in elective admissions.

A summary of last minute cancelled operation reasons is shown below:

*January and February 2018 figures are partially validated

Patient flow issues (due to run out of theatre time, critical care capacity, scheduling and ward bed capacity) are the key reason for last minute cancellations YTD. In January there was a higher than normal level of sickness across key operating theatre and surgical staff.

E.3 Recovery Actions

Daily oversight of cancellations and escalation to CSU level process remains in place.

The new standard theatre scheduling meeting process and tools are ready to be rolled-out Trust wide once elective bed pressures are reduced. These new tools set a standard way of working and support easier identification of lists where additional cases can be added /equipment and resources are properly optimised.

Bed pressures remain the major issue related to the achievement of this performance standard with any improvement in performance linked to the ECS performance recovery actions and the Planned Care FSB sponsored programme.

F. 6WW DIAGNOSTIC STANDARD PERFORMANCE

F.1 National comparative position When compared to other units nationally, in December 2017 the LTHT has risen in its national ranking position and it was ranked 41 out of 171 Trusts nationally. In December, due to the increased volume of patients waiting 6ww or over at month end and reduction in overall activity, the LTHT is ranked 71:

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F.2 Underlying issues

There has been a general trend in reducing the 6ww diagnostic breaches during 2017, depsite ongoing pressures in a number of specailties:

MRI (equipment replacement with outage of 2 scanners during December 2017/ January 2018)

Paediatric services (due to constraints on paediatric theatres)

At the end of November a number of issue with the Echo service led to a deterioration in there 6ww performance:

A series of spikes in demand for Trans-Thoracic Echo (TTE) and Stress echoes referrals between September and November

Reduced capacity, due to staff leaving compounded by inability to recruit to Band 6 posts (national shortage of cardiac physiologists and echo-cardiographers), with currentl staff undertakin locum or private provider additional hours rather than Trust offered overtime.

A short term shortfall in administrative staffing also contributed to a backlog of request card awaiting registration/ booking, which resulted in an unclear picture of the scale of the breach risk for December 2017 and January 2018.

Prior to this point, the Cardiac echo services had been managing service shortfalls with

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increased overtime whilst trying to recruit. This overtime pick up was much reduced in December and January These ongoing challenges resukted in the Trust not achieveing the Diagnostic standard of 99% in January 2018, for the first time since August 2016. F.3 Recovery Actions There are a number of mitigating actions and long term recovery actions in palce:

An additional agency member of administrative staff was put in place in December to address the card registration and booking issues (with substantive staff levels back in place end of January)

Agreement on enhanced overtime rate for current staff for a short period to incentivise staff to work for LTHT rather than locum or private providers for additional hours. Commenced February 2018.

Short term locum appointed stationed at Wharfedale

Reviewed workforce requirements to introduce more advanced roles (AfC Band 7) as can’t recruit to Band 6 - recruitment plan in place.

Increase the number of band 5 workforce to support other areas to release more senior staff for specialist training and expand the nurse establishment to cover stress echo lists instead of band 6 physiologists

With these actions in place performance recovery was achieved from February, with long term sustainability for the service from June / July once new round of recruitment is complete.

G. OVERALL PERFORMANCE POSITION

Performing Non-Performing

• 2 Week Cancer Waiting Times

• 31 Day Cancer Waiting Times - First treatment

• 31 Day Subsequent Surgery Cancer Waiting

Times

• 31 Day Subsequent Radiotherapy Cancer Waiting Times

• 31 Day Subsequent Chemotherapy Cancer Waiting

Times

• 6ww Diagnostic Test Waiting Times

• Emergency Care Standard

• 62 Day Cancer Waiting Times

• Referral to Treatment (18 weeks)

• 52 week breaches

• Cancelled Operations

• Ambulance Handover