THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST

Board Paper - Cover Sheet

DateNovember 2016 / Report Title
Business Delivery & Performance Report / Agenda Item:
A5 (ii)
Lead Director
Report Author / Louise Robson
Jo McCallum
Classification / NHS Unclassified / NHS Protect / NHS Confidential
Purpose (Tick one only) / Approval / Discussion / For Information
Links to Strategic Objectives / To put patients and carers at the centre of all we do and to provide care of the highest standard in terms of both safety and quality
To continue to be recognised as a first class teaching hospital, counted amongst the top 10 in the country, which promotes a culture of excellence, in all that we do.
Links to CQC Domains/
Fundamental Standard(s) / The BD&P Report is relevant to all the CQC domains but particularly the “good governance”, “person centred care” and “display of ratings” domains.
Identified Risk? (If yes, risk reference) / 2745 - Failure of Trust-wide Performance Standards
Additional risks on service-specific Risk Registers
Resource Implications / A number of resource implications within Directorates to meet both planned activity levels and key operational standards
Legal implications and equality and diversity assessment / E&D implications in relation to a number of issues included in the paper
Benefit to patients and the public / To ensure patients receive an excellent standard of care and promote a cycle of continuous improvement
Report History / Routine BD&P report to Board
Next steps / To closely monitor and promptly escalate any risks/issues

Service Quality & Performance Report

April - November2016

Healthcare at its very best - with a personal touch

Service Quality & Performance Report / December 2016
  1. EXECUTIVE SUMMARY

1.1.This report outlines a level of detail regarding the Trust’s performance for the period April 2016 to November 2016. This summary pulls out the key issues and implications.

1.2.It is hoped that Directors find the report useful, informative and straightforward to follow. Feedback is always most welcome

  1. INTRODUCTION

2.1.This Business Delivery & Performance Report is reporting the period April 2016 to November2016. The format and content of the report will continue to evolve, but it is hoped that Directors find the style of reporting useful, informative and straightforward to follow.

2.2.The remainder of the report sets out the activity and key targets the Trust has to deliver in 2016/17. The report will also specify financial penalties where they apply.

2.3.NHS England’s Final Standard Contract 2017/18-2018/19 sees little change to the content of national performance indicators. However, the arrangements in respect of financial sanctions will vary depending on whether a provider is granted funding from the general element of the Sustainability and Transformation Fund (STF) and agrees an annual financial control total.

2.4.The Appendices give a more detailed breakdown of some of the performance, for example, performance by Directorate and/or site level and additional activity such as critical care, maternity and chemo/radiotherapy. However the report itself will include key figures and graphics to demonstrate the Trust’s position and where possible, how it compares to other providers. As always, feedback is most welcome.

  1. TRUST WAITING TIMES

3.1.Directors’ Summary

3.2.This section details the Trust’s performance against 18 Weeks, Cancer and Diagnostics standards. As the issues with compliance are increasingly complex, the position is summarised below:

  • The Incomplete (92%) 18 Weeks target was achieved Trust-wide during November 2016.
  • The Admitted (90%) 18 Weeks metrics were achieved Trust-wide during November 2016.
  • Whilst the Non-Admitted (95%) performance has yet to be finalised, the Trust is expecting to achieve the standard at a Trust level.
  • The Trust met all of the Cancer standards with the exception of the 31 day subsequent treatment for drugs in October 2016;
  • Whilst the Trust achieved the 6 week diagnostic standard in November 2016, sustaining compliance remains very challenging.

3.3.18 Weeks Referral to Treatment (RTT)

3.4.Table 1 shows the Trust performance by specialty for the 18 weeks targets in November 2016:

  • 92% of incomplete pathways are under 18 weeks
  • 95% of non-admitted patients are treated within 18 weeksLocal
  • 90% of admitted patients are treated within 18 weeksMonitoring

Table 1: 18 Weeks Compliance by Speciality - November 2016

RTT Specialty (C) / Non-Admitted (>95%) / Admitted (>90%) / Incompletes (>92%)
100 - GENERAL SURGERY / To be updated / 94.6% / 95.7%
101 - UROLOGY / 96.9% / 97.9%
110 - TRAUMA & ORTHOPAEDICS / 78.5% / 81.2%
120 - EAR NOSE & THROAT / 88.9% / 95.2%
130 - OPHTHALMOLOGY / 95.2% / 98.3%
140 - ORAL SURGERY / 73.7% / 94.8%
150 - NEUROSURGERY / 88.5% / 97.4%
160 - PLASTIC SURGERY / 91.4% / 92.1%
170 - CARDIOTHORACIC SURGERY / 100.0% / 97.5%
300 - GENERAL MEDICINE / 100.0% / 93.8%
301 - GASTROENTEROLOGY / 100.0% / 96.3%
320 - CARDIOLOGY / 90.0% / 94.0%
330 - DERMATOLOGY / 85.9% / 94.6%
340 - RESPIRATORY MEDICINE / 100.0% / 96.0%
400 - NEUROLOGY / 100.0% / 95.3%
410 - RHEUMATOLOGY / 100.0% / 96.2%
430 - CARE OF THE ELDERLY / 100.0% / 99.6%
502 - GYNAECOLOGY / 88.3% / 93.8%
X01 TOTAL / 89.7% / 93.1%
TOTAL / 90.2% / 94.1%

3.5.Directors will note that the Trust met the overall Incomplete and Admittedtargets in November 2016. From a national perspective, the RTT Incomplete target has not been achieved for some time, with October performance at 90.4%. Chart 1 shows the position across England; the dark blue line shows how rapidly waiting times have grown over the last 12 months whilst the pale blue lines show that Trusts are responding by treating the longest waiting patients.

Chart 1: 18 Weeks Compliance by Speciality - November 2016

3.6.Although the Incompletes target was achieved overall, there was a specialty level breach in Trauma and Orthopaedics (689). In total, the penalty will amount to a fine of £206.7k for November 2016 (Table 2). Whilst Newcastle Gateshead CCG committed to reinvesting the spinal penalties in this year’s contract agreement (based on the recommendations of the Spinal Task & Finish Group), they recently confirmed they do not have the funds to reinvest the Quarter 2 penalty at this moment in time.

3.7.As previously reported, the Trust submitted a mitigation paper for the true ‘T&O’ element of the penalty asking for reinvestment of £322.8k. The Trust is currently awaiting formal feedback from the CCG Executive Team.

Table 2: 18 Weeks Compliance within T&O - November 2016

RTT Specialty (C) / Total PTL / Backlog / % / Excess Breaches / Penalty
110 - TRAUMA & ORTHOPAEDICS / 3797 / 597 / 84.28% / 294 / £88,200
108 - SPINAL SURGERY ORTHOPAEDICS / 1763 / 479 / 72.83% / 338 / £101,400
10801 - SPINAL SURGERY NEUROSURGERY / 823 / 123 / 85.05% / 58 / £17,400
Combined / 6383 / 1199 / 81.22% / 689 / £206,700

3.8.Whilst the Admitted target was achieved overall, there were 7 areas where the standard was breached at a specialty level(this is the highest number of specialities breaching in over 20 months); Trauma & Orthopaedics, Dermatology, ENT, Oral Surgery, Neurosurgery, Dermatology and Gyneacology totaling 123 excess breaching patients (a reduction of 4 since last month which is attributable to Dermatology).

3.9.Appendix 4 shows the geographical spread of breaches for November to further clarify for Directors where issues lie. In almost all cases, services experiencing breaches have developed action plans to achieve compliance and in most cases, they are providing additional capacity to treat patients. Table 3demonstrates the RTT penalties incurred April to November2016.

Table 3: RTT Penalties

Indicator / Penalty per breach / Jul-16 / Aug-16 / Sept-16 / Oct-16 / Nov-16
Incomplete Penalty / £300 / £184.8k / £185.1k / £247.5k / £256.5k / £206.7k
Agreed Reinvestment / 0 / 0 / 0 / TBC / TBC
Penalty Total £ / £184.8k / £185.1k / £247.5k / TBC / TBC

3.10.Following the significant increase in the RTT backlog as reported in September 2016, the backlog has continued todecrease with a reduction of293in November2016 (Table 4). Further analysis will be undertaken to better understand the significant shifts in backlog.

Table 4: 18 Weeks Backlog by Directorate – November 2016

Directorate / Backlog / Change from previous month / Backlog Direction
Cancer Services / 0 / -2 / 
Cardiothoracic Services / 215 / -21 / 
Children’s Services / 73 / -8 / 
Clinical Genetics / 8 / 2 / 
Dental Hospital & School / 167 / -25 / 
ENT / 295 / -19 / 
Internal Medicine / 281 / -16 / 
Musculoskeletal Services / 1147 / -215 / 
Neurosciences / 294 / -24 / 
P.O.D. / 449 / 62 / 
Peri-op and Critical Care / 94 / 30 / 
Renal Services / 41 / 7 / 
Surgical Services / 298 / -32 / 
Therapy Services / 21 / -13 / 
Women’s Services / 156 / -19 / 
Trust Total / 3539 / -293 / 

3.11.The contract specifies a zero tolerance on over 52 week waiters and the Trust maintained this target inNovember2016. The legally binding contracts also require a quarterly reduction in over 36 week waiters by specialty. There is no penalty stipulated in the contract but it is good practice to achieve this standard.

3.12.Chart 2showsthat the over 36 week waiters inNovember reduced by 21 from October. This is largely due to an increased focus on this within the Trust and new patient-specific actions to reduce the number of long-waiters.

Chart 2: Over 36 week waits (All Specialties) Trend

3.13.As shown inTable 5, Newcastle was ranked first in the Shelford Group for RTT Incomplete performance in October 2016 and is comfortably above the England average of 90.4%.

Table 5: RTT Performance NuTH vs Shelford & England

3.14.Table 6 shows the number of patients waiting to be seen for a first appointment by length of wait (all current patients regardless of appointment status). The accompanying Chart 3shows that the total number of patients waiting for a first appointment hasdecreasedand is 2,855 patients belowlast months position which is the largest drop this fiscal year.

Table 6: Weeks from Referral to First Seen – 2016/17

Chart 3: Outpatient Waiters (All Specialties) Trend

3.15.Table 7 shows the top 5 Directorates/Specialties (based on volume of patients waiting for a first outpatient appointment). Most of the specialtiesare showing an decrease in total outpatient waiters since last month.

Table 7: Top 5 – all patients awaiting a 1st Outpatient Appointment

3.16.Diagnostic Waits

3.17.TheTrust met the 99% diagnostic target in November2016 for the first time since March 2016, achieving 99.01% (Table 8). Although the Trust was compliant, there are still significant pressures within key diagnostic tests and routine meetings and action plans continue.

Table 8: Diagnostic Breaches (15 Key Diagnostic Tests)

Jul-16 / Aug-16 / Sept-16 / Oct-16 / Nov-16
Number of Breaches / 110 / 163 / 139 / 118 / 90
Number of ‘Excess’ Breaches / 13 / 72 / 53 / 29 / 0
Penalty / £2.6k / £14.4k / £10.6k / £5.8k / -
Number of Patients Waiting / 9,637 / 9,039 / 8,552 / 8,802 / 9,108
Compliance / 98.9% / 98.2% / 98.4% / 98.7% / 99.01%

3.18.The Trust-wide action plan(Table 9) is being routinely monitored and meetings are continuing with Directorate Managers to agree medium and long term trajectories. Furthermore, the diagnostic action plans, 7 day services audit and diagnostic service improvement plan are being reviewed in tandem to ensure a joined up approach.

Table 9: Diagnostic Action Plan

Issue / Progress 01.12.16
1) / MRI /
  • New RVI scanner has been successfully commissioned and is operational (still recruiting to posts)
  • New Neuro scanner due for install and handover in December (estimated), already reduced GA capacity
  • Equipment at FH ageing - risk

  • Continued outsourcing
  • Providing additional waiting list initiatives in-house.

  • Additional Radiographers recruited but would require additional 2 years training to operate MRI scanners

  • Agreeing short, medium and long term solutions with Cardiothoracic Directorate

2) / Cardiac ECHO – /
  • Locum Physiologist in post.
  • WLI continuing.
  • Outsourcing to Spire.
  • Demand Capacity work ongoing

3) / Paediatric Sleep Study /
  • New equipment operational

  • Capacity identified on acute paediatric ward
  • Alternative home sleep study provided in a small number of cases
  • Risk of bed availability due to Winter pressures

  • Bank staff use

  • Locum Physiologist in post required for backlog and to maintain service
  • Business case for sustainability

4) / Urodynamics - /
  • WLI sessions
  • Consultant commenced in August.
  • Locum Consultant in post to cover short term
  • Consultant returned from sickness.
  • Nurse consultant appointed start date in January 2016.
  • Nurse practitioner working independently.

  1. Cancer Waits

4.1.Due to the timing of submissions, cancer data runs one month behind the majority of performance data, this paper therefore reports the October 2016 position. Appendix 1 shows the Directorate cancer compliance. All breaching services are flagged to ensure that Directors have full view of the high risk areas.

4.2.The Breast Symptomatic Two Week Wait target and the 2WW Suspected Cancer target continue to be achieved. Most tumour groups in the 2ww suspected cancer standard experienced fewer referrals with the biggest decrease in Skin referrals; breaches equated to 5.8% of the total referrals. There were no reported capacity issues and all breaches were reported as patient choice. There was no change in the numbers in the Breast Symptomatic Target. The projected outturn for 2WW Suspected Cancer referrals 2016/17 shows an overall increase of 4% in comparison to 2015/16.

4.3.The 62 day target for October was achieved at 87.2% against the 85% standard. Whilst performance is nationally reported at Trust level, internal reporting by tumour group showed those falling considerably below the 85% standard were Lung (69.7%), HPB (66.6%) and Head & Neck (62.5%). Sarcoma also featured with 1 patient treated in the standard who breached, giving them a 0% compliance. These and a number of other tumour groups remain a cause for concern.

4.4.Across NESCN, 3 of the 9 Trusts, Sunderland (84.3%), South Tees (75.1%), and Durham & Darlington (82.9%), failed the 62 day standard for October. The national average was reported at 80.9%.

4.5.The Trust achieved the 90% screening standard for October, reporting performance at 96.3%.

4.6.The Trust achieved the 31 day standard to first treatment for October at 99.3% against the 96% standard. Treatment numbers were at their lowest since April 2016. The projected outturn for 2016/17 shows no increase in the patient numbers in this standard.

4.7.The Subsequent treatment target for Radiotherapy and Surgery were achieved. However, the Subsequent Drug Treatment failed the standard reporting performance at 96.6% against the 98% standard. There were 5 breaches of this standard, 3 recorded as patient choice and 2 due to patient fitness. This standard is repeatedly challenging and efforts are being made to ensure that administering of drugs is captured in a robust and timely way.

4.8.Looking forward to November 2016, data is currently being validated but reports show all cancer standards are on target to achieve. The position for 62 day standard is currently 88% against the 85% standard. Root Cause Analyses are underway to better understand the reasons for breaches which are predominantly in Lung, HPB and OG.

4.9.The Corporate Cancer Team continues to work with all tumour groups to establish robust processes to support the new breach re-allocation guidance. The national IT system will not be available until April 2017 so in the interim providers must work together to implement local solutions for reporting. A breach re-allocation policy has been drafted by the Cancer Alliance with input from all stakeholders.

4.10.As reported previously, the “Backstop” policy requires review and weekly reporting to the CCG of any long waiters (patients classified as waiting 104 days or more). Table 10 shows the most recent position. Patients are often delayed because of medical fitness or diagnostic uncertainty. In all cases, the patients are being actively tracked and clinical teams are aware of their pathway status. The pathway of any patient who has waited more than 104 days to be treated is reviewed by the Trust Cancer Clinician and assessed for harm. Since implementation in October 2015, none of the long wait patients have been identified as ‘coming to harm’.

Table 10: Cancer Patients waiting >104 days

Tumour Group / Number of Patients Waiting with Decision to Treat / Number of patients Waiting Without Decision to Treat
Breast / 0 / 0
Gynae / 0 / 2
Head & Neck / 0 / 0
HPB / 0 / 1
Lower GI / 1 / 1
Lung / 1 / 1
Sarcoma / 0 / 2
Skin / 0 / 1
Upper GI / 2 / 2
Urology / 1 / 1
Total / 5 / 11

4.11.The Corporate Cancer Team continues to review and discuss cancer pathways with each Directorate to ensure that cancer remains a high priority. Areas that continue to be a cause for concern are endoscopy, radiology (particularly breast radiology) and elements of the pathology service.

Table 11: Cancer Targets as at October 2016

Cancer / Quarter 1
16/17 / Jul-16 / Aug-16 / Sep-16 / Quarter 2 16/17 / Oct-16
All cancers: 2 week wait (C,M)
(Target 93.0%) / 95.9% / 95.7% / 96.5% / 94.6% / 95.6% / 94.2%
2 Week Wait for Symptomatic Breast Patients (Cancer Not initially Suspected) (C,M)
(Target 93.0%) / 96.4% / 95.2% / 96.4% / 94.1% / 95.1% / 97.0%
All cancers: 1 month diagnosis to first treatment (C,M)
(Target 96.0%) / 97.9% / 98.7% / 98.2% / 98.2% / 98.4% / 99.3%
All cancers: 1 month diagnosis to subsequent treatment – surgery (C,M)
(Target 94.0%) / 96.8% / 96.8% / 97.5% / 93.5% / 95.8% / 96.5%
All cancers: 1 month diagnosis to subsequent treatment – drug (SS,M)
(Target 98.0%) / 100% / 100% / 100% / 98.5% / 99.2% / 96.6%
All cancers: 1 month diagnosis to subsequent treatment – radiotherapy (SS,M)
(Target 94.0%) / 98.7% / 98.7% / 98.4% / 98.0% / 98.6% / 98.5%
All cancers: 2 month urgent referral to treatment (C,M)
(Target 85.0%) / 85.1% / 91.1% / 88.4% / 85.0% / 87.9% / 87.2%
Percentage patients referred from cancer screening service treated within 62 days (C,M)
(Target 90.0%) / 95.2% / 95.6% / 96.0% / 95.5% / 95.7% / 96.3%
  1. EMERGENCY CARE (INCLUDING A&E INDICATORS)

5.1.Directors will note that the Trust failedto meet the A&E 4hr target in November2016at 92.95% (Table 12). Unfortunately, the A&E performance for Type 1 (main RVI ED) missed meeting the standard at 89.16% for the fourth month in a row. Looking forward, Decemberis currently below target at 88% (to 11thDecember 2016), with the Quarter 3 performance at 93.3%. Whilst there has been no real change to the volume of Main EDattendances, the department have reported multiple issues; a higher level of acuity in patients attending ED, staffing pressures, implementation of ‘paper lite’ and bed pressures.

5.2.The ‘A&E Improvement Programme’ continues to progress at pace with a number of new initiatives being developed and piloted. Whilst it is difficult to currently predict the impact on the A&E 4hr performance, the programme is tackling the hospital wide issues, such as timely Consultant review, diagnostic pressures and delayed discharges. There is also a stream to review Paediatrics.

5.3.Recent guidance reported that NHS Trusts will have to report how quickly they are treating patients experiencing mental health crisis in A&E or hospital wards from April 2017 as part of new NHS England standards. Liaison psychiatry is one of nine priority areas as set out in the 2 year planning guidance for 2017-19 and NHS England recently announced a £30m fund which A&E delivery boards could bid against to extend liaison psychiatry services.

Table 12: Emergency (A&E) Indicators

Emergency Indicators / May-16 / Jun-16 / Jul-16 / Aug-16 / Sept-16 / Oct-16 / Nov-16
Percentage of A & E attendances where the patient was admitted, transferred or discharged within 4 hours of their arrival at an A&E department (CCG,M)
(Target: 95.0%) / 94.7%
P’lty
£6.8k / 96.4% / 97.4% / 96.8% / 96.5% / 95.5% / 92.9%
P’lty
£41.6k
Trolley waits in A&E >12 hours (CCG)
(Target: Nil) / 0 / 0 / 0 / 0 / 0 / 0 / 0
All handovers between ambulance and A & E must take place within 15 minutes – Handovers >30 minutes (CCG) (Target: Nil) / 10
P’lty
£2k / 5
P’lty
£1k / 4
P’lty
£800 / 5
P’lty
£1k / 3
P’lty
£600 / 7
P’lty
£1,400 / 5
P’lty
£1k
Handover breaches >60 minutes (CCG) (Target: Nil) / 0 / 0 / 0 / 0 / 0 / 0 / 0

5.4.The Trust reported 5ambulance handover delays in November 2016 (still being validated). These breaches will incur a penalty of £1,000for the Trust.

5.5.The contract also contains a number of local indicators around A&E, with associated figures for items 1-4 located in Appendix 2.

1)Unplanned re-attendance rate - 7 days <5%

2)Left department without being seen rate <5%

3)Time to initial triage/assessment (95th percentile <15 minutes)

4)Time to treatment in department (median <60 minutes)