Fife NHS Board – ActivitySECTION B

NHS FIFE

Report to the Board26 February 2013

ACTIVITYREPORT

1AIM OF THE REPORT

This report provides a snapshot of the range of activity that underpins the achievement of key National Targets and National Standards, such as Waiting Times, A&E Attendances and Delayed Discharges. To allow for comparison, previous years’ activity has been included where appropriate.

2TREATMENT WAITING TIMES

2.1Introduction

Reporting on performance against Waiting Times standards and legal guarantees can be considered under the main headings of:

  • Treatment Time Guarantee (applicable to patients for whom elective inpatient or day case treatment has been agreed)
  • Referral to Treatment (applicable to patients who have been referred for an Outpatient Consultation and who then require some diagnostic and/or hospital treatment)

With all Waiting Times, it is important to note the situation where patients may be ‘unavailable’ to accept offered dates for outpatient or inpatient treatment. A study of ‘unavailability’ was completed by Audit Scotland in late 2012, and the findings showed that NHS Fife were consistent and fair with their management and reporting of ‘unavailable’ patients. The NHS Fife figures in comparison to Scotland overall are given in Section 2.4.

2.2Treatment Time Guarantee

From 1st October 2012, Health Boards are required by law to provide Inpatient or Day Case treatment within 12 weeks of agreement on treatment, the Treatment Time Guarantee (TTG). This applies for patients listed for treatment from that date onwards. The guidance on management of Inpatient and Day Case Waiting Times and Waiting Lists in the context of this new guarantee is outlined in our Patient Access Policy.

Local management information showed that there were 2,115 patients who had been treated within their TTG by the end of December, and that no qualifying patients had waited more than 12 weeks. for treatment.

2.3Referral to Treatment

NATIONAL STANDARD: 90% of planned/elective patients to commence treatment within 18 weeks of referral

A patient journey may comprise 3 specific stages following referral – Outpatient Consultation, Diagnostics and Treatment. The elapsed time specified in the National Standard covers all stages, and the NHS Fife performance against this over the last year is illustrated in Chart 1.

Chart 1 – 18 Weeks Referral to Treatment

NHS Fife has consistently exceeded the standard during the last year.

Local management information for the months of October 2012 through to January shows that performance has continued to fall slightly, but has remained above the 90% standard in each month.

A more detailed report on activity within the individual stages of the pathway is provided in the following sub-sections.

2.3.1Outpatient Consultation

Chart 2 shows the number of patients waiting for a new outpatient consultation, at all sites and from all referral sources, with monthly figures from April 2010 in a bar-chart formand the annual trend from March 2011 in line form.

Chart 2 – New Outpatients Total Waiting (All Sites)

The 12-month total has risen from 116,931 to 151,399 over 22 months, an increase of 29%.

Chart 3 shows the trend in outpatient referrals and attendances at acute hospitals (from all referral sources) since March 2011.

Chart 3 – Outpatient Activity (Acute Hospitals)

New outpatient attendances have increased by around 2%, Review outpatient attendances by around 3% and referrals by around 5%.

As a component of the overall patient journey, Health Boards are expected to maintain a standard of having no patients from any referral source waiting over 12 weeks from referral to first outpatient appointment. Chart 4 illustrates how the number of breaches has increasedduring the last 9 months.

Chart 4 – Outpatients Waiting Over 12 Weeks from Referral

InDecember, there were 9,607 new outpatient attendances and 90.8% (8,720) of these waited 12 weeks or less from referral to appointment.

Additional activity is being undertaken to try to bring this back in line with the standard. A plan is also being prepared identifying the gap in capacity to meet demand, and the additional resources required to meet this demand. Work is also underway as part of the Improving Elective Flow programme to reduce demand and improve utilisation of outpatient capacity.

2.3.2Diagnostics

Again as a component of the overall patient journey, Health Boards are expected to maintain a 6-week maximum waiting time standard for the following 8 key Diagnostics tests:

  • Upper Endoscopy
  • Lower Endoscopy
  • Colonoscopy
  • Cystoscopy
  • MRI Scans
  • CT Scans
  • Non-obstetric Ultrasound
  • Barium Studies

Chart 5 illustrates the difficulty in achieving this over the last year.

Chart 5 – Diagnostics Waiting Over 6 Weeks

At the end of December, 738 patients had waited more than 6 weeks for a Diagnostics test, 402 for Imaging and 336 for Endoscopy.

Table 1 provides a breakdown of patients waiting for the months of November and December.

Table 1 – Diagnostics Tests Waiting Times Breakdown

Between November and December, the total number of patients waiting for a Diagnostics Test decreased by 20%, to its lowest level since November 2011. Of the 3,547 patients, 2,556 (72%) were waiting for Imaging Diagnostics (MRI, CT and Ultrasound).

The longest wait for a Non-Obstetric Ultrasound examination, a significant problem for many months, has reduced considerably, and no patient is currently waiting more than 5 weeks for this test.

Action is continuing to address the rising number of breaches for a Colonoscopy or MRI scan.

2.3.3Inpatient / Day Case Treatment

Chart 6 shows the number of patients waiting for Inpatient/ Day Case treatment, dating back to April 2009, with monthly figures shown in a bar-chart form and the annual trend in line form.

Chart 6 - Total Inpatients & Day Cases Waiting

The ‘spike’ in January 2012 is coincident with the move to the new wing at VictoriaHospital and winter pressures, and the rolling12-month figure has been generally stable.

This final part of the patient journey is the focus of the Treatment Time Guarantee, but as a component of the overall 18-Week Referral to Treatment Standard, Health Boards are expected to have no patient waiting more than 9 weeks for agreed elective surgery.

Chart 7 illustrates the NHS Fife performance against this standard since April 2010.

Chart 7 – Inpatients Waiting Over 9 Weeks

At the end of December, there were 180 patients on the Waiting List who had waited more than 9 weeks for treatment.

2.4Patient Availability

The most recent figures for Inpatient/Day Case unavailability (and a breakdown of reasons) are illustrated in Charts 8 and 9, below.

Chart 8 – Inpatient/Day Case Patient Unavailability

Chart 9 – Inpatient/Day Case Patient Unavailability (by Reason)

NHS Fife has consistently reported a lower % of ‘unavailable’ patients than the Scotland average.

Within Fife, ‘unavailability for social reasons’ accounts for around two-thirds of the overall unavailability cohort.

The most recent figures for Outpatient unavailability (and a breakdown of reasons) are illustrated in Charts 10 and 11, below.

Chart 10 – New Outpatient Unavailability

Chart 11 – New Outpatient Unavailability (by Reason)

NHS Fife has consistently reported a lower % of ‘unavailable’ patients than the Scotland average.

Within Fife, ‘unavailability for social reasons’ accounts for more than half of the overall unavailability cohort.

3CANCER WAITING TIMES

NATIONAL TARGET: From the quarter ending December 2011, 95% of all patients referred urgently with a suspicion of cancer to begin treatment within 62 days of receipt of referral.

NATIONAL TARGET: From the quarter ending December 2011, 95% of all patients diagnosed with cancer will begin treatment within 31 days of decision to treat.

Performance against the 62-day target was first published for the quarter ending March 2010, while performance against the 31-day target was first published for the quarter ending June 2010.

Published information includes patients who gothrough cervical, colorectal andbreast screening programmes.

The most recent published performance for both 62-day and 31-day targets, which are now National Standards,is for the quarter ending September 2012.

3.162-Day Referral-to-Treatment

NHS Fife’s performance against this target was an achievement of 92.1% The figure for the South East Scotland Cancer Network (SCAN) was 92.9% while the figure for Scotland as a whole was 94.0%.

The NHS Fife performance equates to 197 patients out of 214starting treatment within 62 days of receipt of an urgent referral.

NHS Fife’s performance is shown in Chart 12, while Table 2 shows the performance broken down to individual specialties.

Chart 12 – Cancer 62-Day RTT Performance

Table 2 – Individual Cancer Specialty Performance (62-Day RTT)

The NHS Fife performance has been below the standard in each of the last 5 quarters, mainly due to breaches in the Colorectal and Lung specialties, where there have been difficulties with Consultant capacity.

Reviews have taken place, to prioritise and escalate patients at risk of breaching, while discussions have been held with a view to enhancing endoscopy capacity both locally and across the South-East Scotland and Tayside (SEAT)region.

A review of the whole lung pathway has also taken place, to determine if there are any further improvements which can be made.

3.231-Day Decision-to-Treat to Treatment

NHS Fife’s performance against the 31-day target was an achievement of 97.5%. The figure for the South East Scotland Cancer Network (SCAN) was 97.9% while the figure for Scotland as a whole was 97.6%.

The NHS Fife performance equates to 307 patients out of 315beginning treatment within 31 days of the decision to treat.

NHS Fife’s performance against the 31-Day DTT target is shown in Chart 13, while Table 3 shows the performance broken down to individual specialties.

Chart 13 – Cancer 31-Day DTT Performance

Table 3 – Individual Cancer Specialty Performance (31-Day DTT)

Performance has been above the target/standard for each quarter since reporting started.

4DRUG & ALCOHOL SERVICES WAITING TIMES

NATIONAL TARGET: By March 2013, 90% of clients will wait no longer than 3 weeks from referral received to appropriate drug or alcohol treatment that supports their recovery

Performance information is shown in Chart 14.

Chart 14– Referral to Treatment Waiting Times

This shows that the most recent NHS Fife Referral-to-Treatment performance has fallen slightly from the previous quarter, but remains ahead of plan and on course to achieve a figure of 90% by the target end date.

Note that the figures for the last quarter (ending September 2012) are provisional and may change slightly in future publications.

5DELAYED DISCHARGES

NATIONAL TARGET: No people will wait more than 28 days to be discharged from hospital into a more appropriate care setting once treatment is complete, from April 2013

Table 4 summarises monthly activity over the last year.

Table 4 – Delayed Discharges Monthly Activity

Feb 12 / Mar 12 / Apr 12 / May 12 / Jun 12 / Jul 12 / Aug 12 / Sep 12 / Oct 12 / Nov 12 / Dec 12 / Jan 13
Total Delayed Discharges at Start of Period / 93 / 110 / 92 / 91 / 110 / 112 / 104 / 104 / 102 / 107 / 95 / 103
Exclusions at Start of Period / 29 / 29 / 28 / 28 / 34 / 37 / 32 / 33 / 29 / 27 / 26 / 29
Reported to ISD / 64 / 81 / 64 / 63 / 76 / 75 / 72 / 71 / 73 / 80 / 69 / 74
OUT - patients discharged, placed, deemed unfit or excluded / 55 / 82 / 58 / 54 / 62 / 67 / 65 / 55 / 64 / 70 / 56 / 65
IN - patients now deemed fit for discharge / 72 / 64 / 57 / 73 / 64 / 59 / 65 / 53 / 69 / 58 / 64 / 36
Total Delayed Discharges at End of Period / 110 / 92 / 91 / 110 / 112 / 104 / 104 / 102 / 107 / 95 / 103 / 74
Total Delays in Acute / 25 / 12 / 13 / 19 / 22 / 17 / 15 / 13 / 11 / 22 / 21 / 14
Total Delays in CHP / 85 / 80 / 78 / 91 / 90 / 87 / 89 / 89 / 96 / 73 / 82 / 60

Activity has been fairly consistent over the last 12 months, with more patients being removed from the list(753) than have been added (734).

Of the total 74 delays in January (before exclusions), 14 were in AcuteHospital beds.

Reducing the total number in delay is a key driver to achieving the National Target, and Chart 15illustrates the trend in this figure as well as showing how NHS Fife is performing against the target.

Chart 15 – Delayed Discharges (as reported to ISD)

After exclusions, the overall number of delayed discharges reported to ISD for Januarywas 49, a decrease of 20 compared to December and the lowest monthly figure for 3 years.The number of patients in delay for more than 4 weeks, however, was 14, 2 more than in Decemberand 12behindthe planned position at this time.

5.1Delayed Discharges – Mental Health Patients

In Calendar Year 2012, 165 patients in delay were categorised as Mental Health, 17.6% of which were adults under 65 years and 82.4% of which were adults aged 65 and over. Of these 165 patients, 34 were subsequently removed as unfit for discharge, leaving 131 of which 110 were discharged.

The discharge breakdown of the 110 patients was:

  • 9 patients moved to continuing NHS care
  • 20 patients discharged home
  • 81 patients placed in a variety of settings

The average waiting time was just under 50 days.

Staff continue to discuss the possibility of earlier discharge with relatives and patients. As a result of this, Multi Agency working has improved.

There are no particular issues with the provision of nursing or residential home for older adults and funding arrangements are generally approved within a reasonable timescale.

Finding suitable accommodation for those patients who are under 65 years of age and have complex needs continues to be particularly challenging for our service. Those who require specialist units, residential care and supported accommodation often have to stay in hospital longer than necessary.

Patients who have been identified as having complex needs and requiring specific care packages can also be in hospital longer than necessary due to shortage of appropriate housing.

Once an application has been lodged for Guardianship, patients are unable to move on until this has been granted. This can take a number of months particularly if the patient challenges the decision.

At the end of 2012, there were 21 patients remaining in delay, 5 of whomwere coded 100 (commissioning/reprovisioning).

The Re-Design Programme resulted in 8 patients being discharged in 2012, as follows:

5 patients were discharged to their own tenancy, with support

  • 1 patient was discharged to supported accommodation
  • 1 patient was discharged to a specialist male unit
  • 1 patient was discharged to residential accommodation

5.2Delayed Discharges – Patients with Learning Disabilities

With the completion of the final phase of discharge from long stay provision at Lynebank, and in line with partnership performance monitoring arrangements, it has been agreed that delayed discharges for people with learning disabilities should be recorded in the same way as the other adult services. They are not, however, recorded in our figures that are reported to the Scottish Government.

There are currently 5 patients who are delayed, with 2 patients of the 7 mentioned in the last report having been discharged in January 2013.

Oneof the 5 remaining patients, one has accommodation and a service provider identified and discharge is planned for February.

The new service for the other 4 patients has undergone a tender process in partnership with Fife Council and a service provider was identified. These patients are the very last of the long stay patients and have extremely complex needs that present major challenges to services. As part of the response to these challenges the accommodation will have to be specially designed and built by the service provider. A suitable site has now been identified in Cowdenbeath, and these patients should be discharged by the end of 2013.

6EMERGENCY ACCESS

6.14-Hour Waiting Time Performance

In the quarter ending September, 98.7% of patients atNHS Fife A&E / Minor Injuries Units (Victoria Hospital – VH, Queen Margaret Hospital – QMH, St. Andrews Community Hospital and Adamson Hospital)were admitted, discharged or transferred for Accident and Emergency treatment within 4 hours of arrival, against a standard of 98%.

Chart 16illustrates monthly performance in the 12-month period to the end of September 2012.

Chart 16 – 4 Hour A&E Target Performance

Following the A&E service reconfiguration in January, when QMH became a Minor Injuries Unit only and VH reverted to a 24-hour, 7-day A&E unit, performance against the Standard has improved significantly. This is largely due to the implementation of anImproving Access andEmergency Flow Improvement Programme, which is optimising patient flow by focusing on 3 distinct areas of the service - Front Door, Acute Admissions and Specialty Flow and Community Flow.

In the most recent quarter, the NHS Fife performance exceeded the 98% standard in each month. However, unvalidated data for the final quarter of 2012 suggests that performance has fallen, reflecting the situation in most Mainland Health Boards as winter pressures increase. The challenge at the start of 2013is to ensure that performance improves again and becomes sustainable throughout the year.

6.2A&E Attendances

A&E attendance for the last 4 years is shown in Chart 17.

Chart 17 – A&E Attendance (all NHS Fife sites)

Attendances have varied historically from month to month, with May usually showing the highest attendance and November/December the lowest attendance. Considering complete Financial Years, attendances from 2008/09 to 2011/12 are summarised in Table 5.

Table 5 – A&E Attendance Annual Variation

The current HEAT target relating to A&E Attendance runs from April 2011 to March 2014, and expects all Health Boards to show a reduction over this period.

In common with most other Mainland Health Boards, NHS Fife reported an increase in attendance during the first 18 months of the target, and this is illustrated in the above table and chart.

Latest performance against the target measure (an attendance rate per 100,000 population) is summarised in Section A of the Board Executive Performance Report.

JOHN WILSON

Chief Executive

19 February 2013

Activity ReportV2.0Page 1 of 15

Performance Management, Medical Directorate