ANNUAL REVIEW 29JULY 2014

Self-Assessment

CONTENT

Section 1: Progress against Action Points arising from Annual Review 2012-13 / 3 - 5
Section 2: Everyone has the best start in life and is able to live longer, healthier lives / 6 – 10
Section 3: Healthcare is safe for every person, every time / 11 – 13
Section 4: Everyone has a positive experience of healthcare / 14 – 23
Section 5: Best use is made of available resources / 24 - 27
Section 6: Staff feel supported and engaged / 28 – 31
Section 7: People are able to live well at home or in the community / 32 - 37

Section 1: Progress against Action Points arising from Annual Review 2012-13

ACTION / SUMMARY OF PROGRESS
Continue the programme of work underway to achieve and sustain delivery of the suite of waiting times targets and standards for unscheduled and scheduled care / Progress in relation to the 18 Weeks Referral to Treatment Time (RTT)standard, Treatment Time Guarantee (TTG) and A & E 4-hour waiting times target is detailed in Section 4.This section also includes performance information in relation to access to the stroke unit.
Improve performance in relation to the 62 day cancer target / Work continues to streamline all pathways particularly where elements of treatment are delivered outwith Fife.Mechanisms have been refined to escalate patients at risk of breaching.Despite this capacity challenges remain within Urology and Lung preventing consistent performance in these tumour groups.Further detail is provided in Section 2.
Sustain performance against all Health Improvement, Efficiency, Access and Treatment(HEAT) targets and standards / Progress is outlined within all sections of this document
Continue to review, update and maintain robust arrangements for controlling Healthcare Associated Infection (HAI) / Progress in relation to HAI standards and targets is outlined in Section 3.Work with HPS to develop local initiatives for hospital and community SABs has continued. Standard IC Precautions including Hand Hygiene have been promoted, monitored and reported throughout the year.
Respond promptly and effectively to all of the issues raised in Healthcare Environment Inspectorate (HEI) and OPAH inspection reports / An Inspection Co-ordinating Group, which meets every two weeks, oversees the development and implementation of Action Plans resulting from HEI and OPAH Inspection Reports.The Director of Acute Services, Associate Medical Director and Nurse Director all attend this meeting to closely monitor progress.
A watching brief is maintained over HEI and OPAH reports from other Boards to ensure that NHS Fife is aware of, and can address, any issues that arise nationally.Further information is provided in Section 7.
Work proactively in communicating with patients and patient groups effectively so that they are given the right information at the right time / NHS Fife’s clinical strategy makes specific reference to giving patients choices and information.This sets the standard and expectation for staff across the Board area.
There are robust mechanisms in Fife to enable us to inform, engage and consult with the public and our wider community. Health and Belief in dialogue is one example where we pro actively engage with our local communities about health issues that matter to them.This model of working has been spread to our equality and humans rights work.
Continue to ensure that local staff feel supported and engaged, in particular, in taking forward work on embedding an open and transparent management culture / A programme of open sessions with staff has taken place throughout the year with the operational senior managers leading these. The Director of HR and Employee Director have been holding drop in ‘listening’ sessions in wards and departments across Fife where staff are invited to share their views. Staff have been involved in developing the Strategic Framework including NHS Fife’s Vision, Mission and Values.
Continue to work with planning partners on the integration agenda, and to ensure that local staff are fully engaged and involved in this process / A significant programme of work has been progressed with a number of work streams supporting the implementation of the partnership arrangements. Most importantly, a communication and engagement plan has been produced ensuring we engage and consult with staff, patients and service users and local communities. A number of staff events have taken place across Fife targeted at front line health and social care staff with workshops and joint discussions focussing on sharing information, learning and shaping the future arrangements.
Maintain focus on improving performance on delayed discharges; reducing overall length of delays and bed days lost / Performance fluctuated during the year. The Partnership has recently experienced a particularly challenging period. Improved working around assessment of care needs with our Council partners was evident leading to new developments in care and assessment in the form of the integrated discharge hub, and short term assessment and rehabilitation (STAR) beds. Details are outlined in the unscheduled care plans in Section 4. Joint analysis work undertaken locally has identified a significant challenge in reducing the overall number of patients in delay on a sustainable basis. The majority of delays are as a result of the Local Authority commissioning capacity, and the characteristics of demand for more complex care packages in home settings. The weekly review undertaken by the LocalManagement Groups (LMGs) is beginning to resolve some more complex cases, and there has been an overall reduction in the number of bed delays associated with patients categorised as Adults With Incapacity(AWI).
Work proactively to ensure financial balance in 2013/14 and to deliver services which are affordable and sustainable. You should also keep the Health and Social Care Directorates informed of progress in implementing the local efficiency savings programme / Progress is outlined in Section 5.

Section 2: Everyone has the best start in life and is able to live longer, healthier lives

Reducing Health Inequalities

NHS Fife works in partnership through the Fife Community Planning Partnership to address health inequalities.The Fife Health and Wellbeing Alliance (FHWA) leads the partnership and bases its programme around a three year plan(Fife’s Health & Wellbeing Plan 2011-14).The plan works around three themes of promoting action with individuals and families, communities and through influencing organizations and their ways of working.It has 10 outcomes that monitor progress of the plan.A Health Outcome theme report mapping SOA outcomes to actions is considered by the Fife Partnership annually where high level outcomes are related to programmed activities.The Alliance also co-ordinates the contribution of other Fife thematic partnerships; economic, environmental, employment, children and early years and community safety to improving health inequalities and the Alliance in its turn contributes to the three high level objectives in the 20-year Fife Community Plan of reducing inequalities, improving economic performance and sustainability.
The Alliance uses a small budget of under £1million, comprising the Health Improvement Fund from NHS Fife and around 15% of the Fairer Scotland Fund from Fife Council plus the Choose Life Fund to promote change through innovative projects seeking to redesign services to address health inequalities.An example of which is the Vulnerable In Pregnancy project working with the most disadvantaged mothers in Fife.
This year the Alliance contributed to the Audit of Community Partnership Working and is currently participating in an assessment by the Improvement Service to identify more effective ways of delivering its programme.
The Alliance is aligning its forward planning with the changes of health and social care integration in respect of wider health and wellbeing outcomes and engaging with local community planning in small areas and promoting targeted demonstration projects for target communities.

Prevention

In partnership with the Fife Community Planning Partnership and in line with the Christie Report, a review of preventive services took place in January.From this event a broad based Prevention Plan is in development which will provide a common focus for shared engagement on prevention outcomes, strategies and action plans.
NHS Fife Board has a number of specific initiatives targeted on prevention, examples being; the Infant Mental Health (Flourishing Infants) programme, Health and Wellbeing Looked After Young People work, the Family Health Programme and the Vulnerable in Pregnancy work.The Board also delivers on national prevention focused strategies such as Childsmile, BBV and Sexual Health Strategy and the enhanced immunisation programmes.In this incoming year a new focus will be on measuring and addressing the health inequalities of those with Learning Disabilities and providing local delivery of the health related aspects of the new Keys to Health Strategy.
Each Community Health Partnership (CHP)in Fife has a Health Improvement Team that focuses on local community planning and takes a key role in the delivery of National HEAT targets. There have been notable successes in the smoking cessation target overall and in its coverage of persons in the most disadvantaged Scottish Index of Multiple Deprivation (SIMD) quintiles.
NHS Fife leads a number of multiagency thematic groups which have an emphasis on preventative activities on topics such as Mental Wellbeing, Tobacco Issues, Health and Homelessness and the preventative aspects of the Detecting Cancer Early programme.Active NHS participation also occurs at a partnership level around employability, environmental sustainability and community safety where prevention and early intervention lie at the core of the agenda.
Through the Health Promoting Health Service workstream there is now a structure of reporting on preventive and promotive health activities both in the hospital and community settings.
NHS Fife is aiming towards achievement of the Silver Health at Work Award this year and is driving forward many initiatives to promote staff wellbeing and reduce sickness absence in a proactive manner.

Early Years

Early Years is a core area of priority within Fife’s Children’s Services Plan 2014-17.NHS Fife is a key agency in the partnership for children’s services in Fife which is responsible for delivering this plan.High quality universal and targeted services are needed to support young families and where needed provide additional supportive and preventative services.
Key areas of work include the Early Years Collaborative which is a national initiative using improvement methodology across a range of agencies to identify ways to improve services and engage with vulnerable groups.The Family Nurse Partnership in Fife has recruited its second team of nurses and provides intensive support for first time mothers under the age of 20, from pregnancy to the age of two.This enhances the range of support available including third sector agencies.The NHS in Fife also supports the Family Nurture Approach which provides enhanced opportunities for learning and development in targeted areas.

Health Improvement Targets

H3: Achieve agreed completion rates for child healthy weight intervention programme over the three years ending March 2014
NHS Fife delivered 1,123 interventions between April 2011 and March 2014, 6% above the target. This was achieved by the Child Health Team working closely with families and schools on both 1-1 and class-based programmes. They also effectively targeted the two most deprived SIMD areas (where over 600 interventions were delivered).
H6: NHSScotland to deliver universal smoking cessation services to achieve at least 80,000 successful quits (at one month post quit) including 48,000 in the 40% most-deprived within-Board SIMD areas over the three years ending March 2014
NHS Fife recorded 4,389 successful post-1 month quits in the 40% most-deprived SIMD areas between April 2011 and March 2014, 24% above the target. Success was a result of improved working between CHPs, reduction in lost-to-follow-up numbers and more activity in community pharmacies.
All NHS Boards to maintain the standard of 90% or more of clients will wait no longer than 3 weeks from referral received to appropriate drug or alcohol treatment that supports their recovery
Having achieved the initial treatment target by March 2013, NHS Fife sustained this throughout 2013/14. The high level of performance, against an increasing demand, was due to close working with third sector agencies by the Alcohol & Drug Partnership(ADP).

Cancer Waiting Times Standards

A9 KPM1: From the quarter ending December 2011, 95 per cent of those referred urgently with a suspicion of cancer to begin treatment within 62 days of receipt of referral
NHS Fife faced significant challenges in sustaining the 62-Day Referral-to-Treatmentstandard during the year, with particular difficulties in the Lung and Urology specialties. There were difficulties around patient pathways, theatre capacity and Consultant shortages.

A9 KPM2: From the quarter ending December 2011, 95 per cent of all patients diagnosed with cancer to begin treatment within 31 days of decision to treat
In contrast to the 62-Day standard, NHS Fife met the 31-Day Decision-to-Treat-to-Treatmentstandard consistently throughout the year. Weekly Cancer Waiting Times Meetings helped to identify and escalate potential breaches.

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Detect Cancer Early

The National Detect Cancer Early (DCE) initiative is now in its third year. Campaigns have been launched in breast, lung and colorectal cancers with a target of 29% of patients presenting with these cancers presenting in the first stage of the disease by 2014/15.
Preliminary data suggests that there has been an increase in all three cancers with Fife running slightly ahead of trajectory. It is expected that the target will be met.
Challenges relate to clarity on the ongoing level of available resource to support DCE and recruitment into necessary posts. Decisions are also awaited on what cancers will be added to the list of priorities specifically targeted by DCE.

Section 3: Healthcare is safe for every person, every time

Clinical Governance Systems

Clinical Governance systems continue to evolve and in the last year there has been particular focus on systems to deal with adverse events from reporting through review to learning from experience.Fife’s systems have been positively evaluated against NHS Healthcare Improvement Scotland (HIS) standards.The approach to Clinical Governance (CG) has been influenced by a growing focus on quality and quality improvement and the Board’s recently established Quality, Safety and Governance Group working through the NHS Fife Quality Delivery Plan has provided the necessary focus and context.
Healthcheck
Overall accountability for quality begins and ends with the Board.All Board members should have the personal responsibility to assure themselves that the organisation is as effective, safe, andperson centred as it possibly can be.This assurance can be gathered partially from using and understanding the summary on the quality and safety position of the organisation presented in Healthcheck.
Healthcheck is a set of key high level indictors deemed appropriate by NHS Fife to provide a summary on the quality and safety position of NHS Fife. Supportive text is provided alongside the indicators to aid understanding.Atevery Board meeting alongside the Healthcheck indicators, the Board hears a story from a patient and staff member relating to either an incident that caused harm and/or poor quality of care. This was presented to the Board in December 2013 and has been to subsequent meetings in February and April 2014.Each Board meeting has informed the further development of Healthcheck and the stories.
Currently in development is an assessment tool to assess the impact of Healthcheck which designed to create the foundation for future dialogue amongst the Board members and organisational leaders, and to determine which areas require further work in order to ensure Healthcheck is successful.

Patient Safety

Patient Safety remains the primary consideration of clinicians and the workstreams of the Scottish Patient Safety Programme (SPSP) have been complemented by local work focussed on applying the SPSP methodology to activities not covered by the formal programme.There has been a significant impact within community hospitals.The formal programme has regrouped around four areas, the acute hospital, women & children, mental health and primary care.Local arrangements are being revised to take account of this and to embed safety as an operational consideration.NHS Fife continues to feature in national activities and has gained plaudits for work in a number of areas within patient safety.

Safe Care

The provision of safe care is determined by a combination of factors including culture, clinical practice and environment.A number of activities in relation to the patient safety programme, HAI and certain performance targets all contribute to safety.Improving performance against the measures some of which are absolute and some of which are proxy would indicate improvements in safety of the care provided by NHS Fife.
Delivery against HAI standards has been monitored and supported through inspections by HEI colleagues.
CameronHospital was inspected in September 2013 and the report described knowledgeable and confident staff working together to deliver safe care and improve the patient experience.The Chief Inspector (who accompanied the HEI team) was quoted as saying “This is the very first CommunityHospital we have inspected and overall, we have been satisfied with our findings”.Some areas for improvement were identified and addressed via an Action Plan with two Requirements and two Recommendations.All elements of the Action Plan were completed by April and this was reported back to the Inspectorate.

Healthcare Associated Infection(HAI)

T11 KPM1: Further reduce healthcare associated infections so that by 2014/15 NHS Boards’ staphylococcus aureus bacteraemia (including MRSA) cases are 0.24 or less per 1000 acute occupied bed days
NHS Fife fell short of the previous HAI Sabs target, and consequently has a greater challenge to meet the lower target by March 2015. At the end of March, the rate of infection per 1,000 acute occupied bed days was 0.38, slightly ahead of plan but still requiring a significant improvement during the final year. Continuing support from Health Protection Scotland (HPS) Epidemiology and Infection Control experts was valuable in identifying new initiatives which will support SAB reduction in Fife but we are still to resolve the issue of ‘community’ infections, which continue to account for over half of hospital cases.

T11 KPM2: Further reduce healthcare associated infections so that by 2014/15 NHS Boards’ rate of Clostridium Difficile (C Diff) infections in patients aged 15 and over is 0.32 cases or less per 1000 total occupied bed days
NHS Fife has consistently exceeded the C Diff target for a number of years, and is confident that the current infection rate will remain significantly below the target level. At the end of March, the infection rate was 0.21 cases per 1,000 total occupied bed days, this excellent performance being attributable to high levels of hygiene and close monitoring of antibiotic prescribing.

Section 4: Everyone has a positive experience of healthcare