Integrated Quality and Performance Report

1. October 2014 Report Using Best Intelligence : Nationally verified data and data from providers at Month 5 – August 2014 Integrated Quality and Performance Report

2. Contents • Executive Summary 3 • Quality 4 & 5 • Serious Incidents 5 • Un-Planned Care & Long Term Conditions 6 to 10 • NHS 111 7 & 8 • Long Term Conditions Update 9 & 10 • Planned Care 11 to 13 • Social Care 14 • Mental Health 15 & 16 • Learning Disabilities 17 • Adult Safeguarding 18 • Children’s & Young People’s Services 19 to 21 • Medicines Management 22 to 24 • CCG Benchmarking 22 & 23 • Communications & Engagement 25 & 26 • Glossary for Indicators 27 to 33 Month 5 Report This is the month 5 (August 2014) report as this is the latest month for which most nationally verified and provider data is available. Some services can be tracked more frequently and where more recent performance is known it may be included or commented on in the report.

3. Executive Summary

4. Quality Dashboard The dashboard will show indicators that can be tracked across the year to enable understanding of our provider performance for key quality indicators. More details on the indicators can be found in the glossary at the end of this report.

5. Serious Incidents: Reported by Trust Themes The RUH report a mix of incidents which is good practice and to be expected from a medium size acute trust. No themes have been identified as the incidents are reported from a wide range of services within the trust. Incidents include falls, safeguarding, equipment issues and Healthcare acquired infection. As expected from a community provider, the largest percentage of incidents reported by Sirona are pressure ulcers, then falls. Learning and Actions Impact of the RUH rapid spread pressure ulcer reduction programme is evidenced in the fact that no grade 3 or 4 incidents have been reported in the last two months. The CCG has funded Sirona to implement a similar programme across their services and within care homes. This begins in January 2015 The CCG is facilitating a multi-agency falls collaborative group to share learning and good practice across agencies. As new incidents remain under investigation, the detail and outcomes have not been included in this report. Please note: Serious Incidents are considered in detail at the CCG Serious Incident, Complaints and Safeguarding Committee with reports to Quality Committee.

6. Unplanned Care Performance The provider splits are the total Trust figures not just for BaNES patients. More details on the indicators can be found in the glossary at the end of this report.

7. NHS 111 Update The NHS 111 service supports the delivery of urgent and emergency care by directing patients to the right service first time with clinical assessment and referral taking place within the same telephone call. The service is commissioned locally but to a national specification to ensure a consistent approach to quality across the country. In order to support further transformation of urgent and emergency care, NHS England with the support of CCGs, has produced new NHS 111 commissioning standards (June 2014). We will work closely with Care UK to implement these standards within realistic time scales, recognising that recruitment of staff will continue to be the current priority. The service continues to experience challenges around recruitment and retention of Health Advisors and Clinical Advisers which, at weekends in particular, contributes to delays in call handling, higher than necessary ambulance dispatch rate, delays in warm transfer (transfer from health to clinical advisor) and call back. Care UK has implemented a new model of call forecasting and rota management which aims to better meet demand. This model has greater recognition of staff satisfaction and retention and is complemented by a rolling programme of recruitment. Commissioners will continue to monitor the outcome of this programme closely. Commissioners are developing a project to improve the quality of Special Patient Notes (SPNs) which provide the call handler or clinician with knowledge and additional information specific to a patient to facilitate making informed decisions about treatment. Commissioners have agreed to provide additional project support to develop the Directory of Services (DOS), on which NHS111 relies to direct patients appropriately to health providers. We will share the support of a small regional team with our co-commissioners.

8. NHS 111 Results The NHS 111 service has been working through a recovery plan including a new approach to recruitment and retention of health care advisors and clinical advisors (see previous slide). The outcomes of this work can be seen with the improved call handling since mid August. There are still issues with weekend performance, % calls warm transferred to the clinical advisors and the disposition of patients to the emergency department and 999 – ambulance service. All NHS 111 data is joint for BaNES and Wiltshire.

9. Long Term Conditions Update 1 Dementia The Dementia Support Worker service which has been provided by the Alzheimer’s Society since February 2014 is embedding well and referrals have been steadily increasing. Excellent links with RICE and a variety of voluntary sector organisations have been developed to ensure people with dementia and their carers receive high quality information, advice and support tailored to their specific needs. The dementia diagnosis rate in BaNES has not significantly changed and is 47.23% against a target of 66%. Against this target, BaNES is the worst performing CCG in the South West so to ensure all patients with a dementia diagnosis have been recorded appropriately in their primary care record, the following actions are being taken: • A data quality exercise comprising of: • Practice Support Pharmacists checking that patients prescribed dementia drugs are appropriately coded. • Practices being asked to check that the patients diagnosed by RICE are coded appropriately. • Practices being asked to review patients coded as having memory problems or similar but not given a diagnosis that results in them being included on the QOF dementia register. • The Dementia Care Pathway Group has been briefed on the national focus on dementia diagnosis and encouraged to promote the benefits of a diagnosis to service users. • A meeting with RICE and Dr Nick Cartmell (NHSE Intensive Support Team for Dementia and Associate Clinical Director, Strategic Clinical Network (Dementia) South West has been held to discuss reasons for low diagnosis rate and action plan for improvement. • Nationally, NHS England has developed an Enhanced Service which funds practices £55 for each extra patient on the QOF dementia register at the end of March 2015 compared to October 2014.

10. Long Term Conditions Update 2 Bladder and Bowel Service The new community Bladder and Bowel Service has been provided by Sirona in partnership with the RUH since 1st October. However, the transition from Somerset Partnership NHS FT has been extremely difficult and Sirona have struggled to recruit specialist staff. This has impacted on the delivery of the new service specification but Sirona have a transformation plan for the service and regular meetings will be held to monitor progress. Stroke The latest SSNAP (Sentinel Stroke National Audit Programme) audit results for April – June 2014 show that performance has remained at a similar level to the previous quarter. The main challenge continues to be admitting patients to the stroke unit within 4 hours and if this could be met, improved performance on other indicators such as swallowscreen assessments would follow. The RUH have an action plan in place and are reviewing levels of therapy and nursing staff but are expecting performance around speech and language therapy to improve in the next quarter as a result of a new SaLT joining the team.

11. Planned Care Performance The provider splits are the BaNES patients for RTT 18 weeks. More details on the indicators can be found in the glossary at the end of this report.

12. Planned Care Update 1 18 week Referral to Treatment (RTT) Targets Performance against the 18 week targets for BaNES patients is on a downward trend leading to increasing waiting lists and backlogs in some specialties. RUH The RUH have reported significantly increased referrals in 2014/15 in ENT, Gastroenterology, Cardiology and Dermatology. CCGs are working with the Trust to fully understand the reasons for these increases some of which relate to national campaigns such as the ‘Be clear on Cancer’ and to agree clinically led action plans at specialty level to manage demand within the capacity available. The increase in referrals along with, reduced planned care capacity due to the impact of urgent and unplanned care pressures and consultant / locum vacancies have resulted in increasing waiting times for some patients. (As at Month 6, the YTD contract position for the RUH was an over-performance in the order of £760k for Non Elective Inpatient activity, set against an under-performance of £839k for Elective Inpatient activity). The CCG has set up an RTT Working Group which is focusing on ensuring a full understanding of the waiting time position and performance against targets. This group is currently focusing on the challenges that have been identified by the RUH and are seeking assurances that action plans are being developed and put in place at specialty level and that implementation and progress is being monitored. Wiltshire and Somerset CCG’s are represented on the group and an invitation has been extended to the Area Team for Specialised Commissioning. UHB The rationalisation of services in Bristol last year left UHB with backlogs in services that were transferred to them. Along with urgent and unplanned care pressures this highlighted RTT pressures several months ago and UHB put in place a recovery plan aimed for specialty level performance to be on target by March 2015. UHB have recently signalled that some specialties will take longer to recover and are working with the lead commissioners to agree an updated recovery plan.

13. Planned Care Update 2 18 week Referral to Treatment (RTT) Targets - continued NBT NBT have a specific issue with Spinal surgery that has been reported previously. More details on this can be found in the dashboard. NBT also have other specialties performing below target. They are working with their lead commissioners to set trajectories and plans for recovery by March 2015. The exception to this is Spinal Surgery where their current recovery plan extends to 2016, however, this is still under discussion with lead commissioners (Specialist Commissioning and South Gloucestershire CCG Referral to Treatment (RTT) Additional Activity Plans Nationally it was recognised over the Summer that the pressure on planned care has been building and will potentially impact on the ability of Acute Trusts to deliver their RTT targets for patient access to care under the NHS Constitution. A scheme has been put in place by NHS England to fund Acute Trusts to deliver additional activity over the Summer and Autumn period. The CCG has worked with RUH to submit plans for this funding and work is now ongoing on to deliver the plan and monitor the results.

14. Social care performance Cumulative indicators reset to zero at the beginning of 2014/15. More details on the indicators can be found in the glossary at the end of this report.

15. Mental Health performance More details on the indicators can be found in the glossary at the end of this report.

16. Mental Health - Update Primary Care Talking Therapies In general we are beginning to see a gradual improvement in performance in the service. This is directly attributed to settled management of the service being achieved. Whilst performance against the national target for entering treatment is still below target we have seen an improvement in performance this month, in this and first therapeutic contact data. Changes in the way that clients are entered into and maintained on the client database have been implemented in order to better capture all the client activity, enabling full monitoring for access to different levels of service. Recovery rates, following a dip in June and July are also improving. Specific monthly performance oversight of the service - in addition to the main AWP performance meetings - will continue for Q3. CQC review of mental health in-patient services - update The full report from CQC on AWP services was released on September 10th and was accompanied by a quality summit involving commissioning organisations, AWP and CQC to agree their commitment to ongoing quality improvements. The requirement to move as quickly as possible on a new build for in-patient services in B&NES was confirmed as a priority. To this end work is advancing on discussions with the RUH and engagement with stakeholders. It has been acknowledged that any rebuild would require the current single ward facility for people with a functional illness to be changed into a 2-ward facility in order to manage quality and maintain patient and staff safety. AWP have been requested to provide a full business case regarding the resource implications of future changes.

17. Learning Disabilities performance More details on the indicators can be found in the glossary at the end of this report.

18. Adult Safeguarding performance More details on the indicators can be found in the glossary at the end of this report.

19. Children and Young People’s Update 1 Child and Adolescent Mental Health Service: Section136 Agreement has been secured until March 2015 with Bristol CAMHS commissioners, Bristol (CCHP) CAMHS provider and BaNES (OHFT) CAMHS provider for young people requiring a Mental Health Assessment at the new place of safety in Southmead Hospital. This builds on previous interim agreement. Reciprocal arrangements have been agreed re CAMHS input for the new Keynsham Police Custody Suite. The ‘all age’ Place of Safety protocol led by AWP is still in draft form and work continues with all partner agencies. The Mindfull on-line Counselling pilot and a CAMHS ‘self –referral’ pilot for older adolescents is due to be launched from November 1st. Community Paediatrics Update The final Royal College Peer Review of Community Paediatrics report has been received. It confirms that the Sirona Community Paediatrics service is of high quality but is currently under resourced. Additional recurring funding has been identified by the CCG and was conditional on the independent report confirming the need for additional funds. A paper will be presented to the Joint Commissioning Committee to support the recurrent investment. Children and Young People’s Plan (CYPP) 2011-14 update The Year 3 (13/14) review of the CYPP 2011-14 was completed and signed off by the Children Trust Board in September 2014. The review, against the 5 priority areas ,demonstrated positive delivery against all the priority areas. The review report is available to select from here on the B&NES council website : http://www.bathnes.gov.uk/services/children-young-people-and-families/strategies-policies-planning/children-and-young-peoples (The report is on the documents section on the right side of the page.)

20. Children and Young People’s Update 2 CQC Review A review of health services in safeguarding and looked after children services in Bath and North East Somerset took place between 9th – 13th June 2014. The review focused on the experiences and outcomes for children within the geographical boundaries of the local authority area and the performance of health providers serving the area including Clinical Commissioning Groups (CCGs) and Local Area Teams (LATs). The final CQC report has now been published. Health Provider organisations are in the process of compiling action plans in response to the recommendations made in the report. These action plans will be submitted for approval to the CQC by 17th October 2014. The CCG will scrutinise the Provider action plans via the existing quality and performance monitoring arrangements.

21. Children and Young People’s Update 3 • Special Educational Needs and Disabilities (SEND) reforms • The CCG/LA have been implementing the SEND reforms as required from September 1st 2014. There are 11 work streams for the year 2 implementation period for the SEND reforms (Sept 14-Sept15). The CCG are represented on a number of work streams including the SEND steering group. Number of key points: • Clear plan in place for new Education, Health and Care Plans (EHC) requests • Clear plan in place for the “conversion” of a range of current SEND statements to EHC plans • Additional capacity created in the LA to support the above • Personal budget and Personal Health budget policies are being developed • The ‘Local Offer’ is under review and to include older adolescents and transitions • Children’s health commissioner attends the SEND and Early Years panels to consider the health needs of children as appropriate. All panels, including the transitions (into adulthood) operational panel, will be reviewed in year 2 • Sirona have been asked to consider the skill mix required for the statutory Designated Medical Officer/ Designated Health Officer role. • A ‘task and finish’ group is being established (alongside the current Disabled Children’s Strategy Group) to determine the CCG/LA governance and partnership requirements to lead SEND post year 2 implementation.

22. Medicines Management – CCG benchmarking 1 BaNES CCG Prescribing Dashboard For those indicators that are worse than National: Indicator 10 – this indicator was previously reviewed through an analgesic dashboard, there has been focus work on opiate patches, but has not been prioritised this year Indicator 12 – BaNES is not a significant outlier, work has been done on this indicator previously, not a priority for this year Indicator 13 – work on this will be included in practice savings plans Indicator 23 - Lots of work is on-going on choice of antibiotics, has been highlighted at GP Forum and work with practices is continuing Indicator 25 – the performance against this indicator shows a sensible steady introduction of these agents into BaNES Areas of improved performance: Indicator 2 - good reduction in overall antibiotics

23. Medicines Management – CCG benchmarking 2 Primary Care Prescribing: weighted cost per Net Ingredient Cost per weighted population unit - BaNES CCG Comparative Data for Q1 2014/15: • 9th lowest of 211 England CCGs, which is in the top 5%. • 5th lowest in the 50 South of England CCGs and lowest in BGSW Area Team & Old South West. • BaNES is in the lowest 12% of deprived CCG areas, so is performing well to be in the lowest 5% of CCGs. • Prescribing growth in this measure year to July 2014 is lower for BaNES (2.14%) than for England (3.41%).

24. Medicines Management Update BCAP Website Launched on new platform http://www.bcapformulary.nhs.uk/ Major improvements: • Easier to navigate (alphabetically by BNF chapter) • Provides a great platform for accessing clinical information for CCG including pathways, guidance and other documents • Easier to access from non NHS systems environments Medicines Optimisation Technician joins team QIPP investment in improved skill mix of the Medicines Team will improve delivery on medicines safety and savings. The role will support the team in updating the formulary on the web and on the TPA systems. Roll out of electronic prescription service (EPS) The first 2 waves of the roll out are now completed: • 2 practices have achieved over 40% of prescriptions sent to pharmacy by e-transmission in September • A further 4 practices achieved 10% e-transmitted prescriptions.

25. Glossary for Indicators Friends and Family Test – Net Promoter Score Methodology The Friends and Family score is a net promoter score and is calculated as: the proportion of respondents who would be extremely likely to recommend (the promoters) minus the proportion of respondents who would not recommend (the detractors) An example calculation (using the example numbers in the table): Proportion who recommend: 114 / 200 (x100) = 57 Proportion who would not recommend: (24+2+6) / 200 (x100)=16 Friends and Family Test Score = 57-16 = 41 Indicator dashboard format: The indicator reports are comparing performance in the latest available period with the target for that period, and performance financial year to date with the year to date target. The results use Red-Amber-Green (RAG) rating to highlight whether the results are on target. There are arrows showing the direction of travel of the results for the latest available period compared with the previous reported period. After the trend line there is a column that shows the direction this arrow needs to move in to be showing an improvement in the results. The trend lines show the last 13 periods results where available, this is aimed at giving a simple idea of how this indicator has been performing in the last year. Some are showing zero for 12/13 results. Each trend line is automatically formatted to fit the data of that indicator so please read in context with the last months results.

26. Glossary for Indicators Quality Dashboard

27. Glossary for Indicators Unplanned Care Dashboard

28. Glossary for Indicators Planned Care Dashboard

29. Glossary for Indicators Adult Social Care Dashboard

30. Glossary for Indicators Mental Health and Learning Disabilities Dashboards

31. Glossary for Indicators Adult Safeguarding