NHS Nottingham City

1. NHS Nottingham City Performance Report February 2011

2. Introduction The performance management report provides members with highly visual information relating to key performance indicators, demonstrating performance to date and highlighting areas of concern. The format of the report is based on exception reporting. The main operational targets or Key Performance Indicators are summarised with brief comments alongside. Only if an indicator is below target will it be highlighted and reported in detail in the performance exception section. The presentation of this report now reflects the use of the Performance Accelerator toolkit and website which continues to be developed to help performance management. The indicators are now grouped based on Access, Infection Control and Immunisation. The slides show performance both for the latest period – usually monthly, and also for most indicators - the year to date. This performance report also includes a report on performance with respect to NHS Nottingham City contracts with Nottingham University Hospitals NHS Trust, Nottinghamshire Healthcare Trust, Nottingham NHS Treatment Centre, and CitiHealth - the Provider Unit for community services in Nottingham. Members are advised that due to the timing of receipt of performance information and production of this report it is possible that more timely information will be available at the time of the meeting which will be provided as a verbal update if required. Proposal Recommendations Members are asked to: Comment on the actions taken to improve performance, and endorse proposals to increase performance in the high risk areas. Richard Hobbs Performance Manager February 2011

3. SUMMARY TABLE: MAIN OPERATIONAL TARGETS OR KEY PERFORMANCE INDICATORS

4. SUMMARY TABLE: MAIN OPERATIONAL TARGETS OR KEY PERFORMANCE INDICATORS continued Key to symbols: Green means on target or over-performing, amber means under-performing by less than 5%, and red means under-performing by 5% or more. means an improvement on previous reporting figure means a deterioration on previous reporting figure

5. Performance Exceptions 5

6. Accident and Emergency • The network performance is calculated by using figures from local walk in centres along with the accident and emergency at Nottingham University Hospitals. As patients at walk in centres are usually seen within 4 hours the principle cause of under performance is at Nottingham University Hospitals • The performance in December At Nottingham University Hospitals fell well below the 98% target (subsequently revised to 95%) at 92.7%. This was due to the increased demand due to the winter weather and flu cases. The latest year to date figure stands at 97.3%. The median wait to be seen in A&E is being recorded and reported as required in the Revised Operating Framework 2010-11. As a result of the pressures detailed above, this rose to 2 hours 23 minutes in December – the highest figure in the year to date. • The Emergency Department Change Programme is trialing new ways of working within the Emergency Department to improve the flow of patients. Capacity has been increased within the primary care service that works alongside the Emergency Department from the beginning of September and NHS Nottingham City is starting to work with GP commissioning clusters on improving access to same day appointments / advice within general practice.

7. Ambulance service Category A targets • This East Midlands Ambulance Service target states that 75% of Category A calls (defined as “immediately life-threatening”) should receive an emergency response within 8 minutes, and 95% should receive a response within 19 minutes. • In June 2010 East Midlands Ambulance Service was served with a Performance Notice by NHS Derbyshire County as Lead Commissioner for the Ambulance Trust contract, due to the failure to meet the 8 minute target and the Category B target (see next slide). As a result an action plan was prepared which was a mix of short and long term operations and control actions. Although the benefit of these actions can be seen in improvements in the figures for Category A calls in August and September, the performance in October slipped below 75% and this continued further in November and December with the poor weather affecting both the number of calls and response times. The chart to the left shows the performance. The year to date performance stood at 72.4% with performance in December at 59.6%. • The chart to the right shows category A calls responded to within 19 minutes, and the actions from the action plan have again led to improved performance in August and September to meet the 95% target, but again this slipped back from October onwards. The adverse weather conditions in December saw performance for the month at 86.1% to leave the year to date position at 94.1%. • In 2011-12 there will be changes to introduce clinical quality indicators for ambulance services (see next slide for more details) but the 8 minutes and 19 minutes targets for Category A calls will continue as existing commitments.

8. Ambulance service Category B targets • This East Midlands Ambulance Service target states that 95% of Category B calls (defined as “serious but not immediately life-threatening”) should receive a response within 19 minutes. • The chart below for Category B performance shows a gradual deterioration from April to November with a larger fall in December due to adverse weather conditions. Performance for the month was at 75.9% The year to date figure is at 89.5%. The service are focussing their efforts and resources on delivering the 8 minute response time target for the most serious calls for an ambulance response.  It appears that as a result of this performance against the 19 minutes response time target has deteriorated both for them as a whole and for NHS Nottingham City.  The efforts to secure delivery of the 8 minute response time target across the East Midlands means that the 19 minute response time target is unlikely to be delivered across the East Midlands and may also not be delivered within NHS Nottingham City. • On 17 December 2010 the Secretary of State announced that this indicator would be replaced for 2011-12 by 11 clinical quality indicators which would apply to all ambulance calls. It is intended that they will give a better indication of patient care and experience. Timeliness will still be an important factor but will be supplemented with additional outcome and service measures.

9. Choose and Book • This target measures the percentage of GP referrals that use the Choose & Book system. The performance in September fell again to 79% - the lowest figure for 12 months. Some practices have stopped using Choose & Book since the Board endorsed the decision to stop the Local Enhanced Service which meant that practices were no longer paid for using the system. • We are working with Nottingham University Hospitals Trust to put together an audit of paper referrals received, ideally at a speciality and GP practice level. It is hoped this may identify trends in paper referring that we will be able to address e.g. GP uncertainty about locating clinics on Choose & Book, any link to slot unavailability, link to the need for them to use proformas. We are also working with a number of our community services in order to implement Choose & Book including physiotherapy services. • Fortnightly meetings continue to be held with our local providers, managing their performance against the 0.04 national best practice ratio for slot issues. These meetings allow us to identify and address the problem areas, and since August 2009 both providers have significantly brought down the slot issues experienced by GPs, and therefore more bookings are successfully going through Choose and Book. Greater communications through twice-monthly e-mails and support from clinical leads are designed to encourage performance to the 90% target level. We are actively working with GP commissioning clusters to promote Choose & Book as the preferred method of appointment booking.

10. Chlamydia Screening • There is a Vital Signs indicator to reduce the prevalence of Chlamydia through a comprehensive programme of screening of the 15-24 year old population.  NHS Nottingham City has built a sustainable infrastructure of multiple providers that enables access to Chlamydia screening seven days a week, supported by appropriate marketing.  Most screening is carried out through the National Chlamydia Screening Programme, but additionally screening in other settings contributes towards the target, and these are both shown in the chart below • For 2010-11, the target is 35% of relevant population or 24,500 screens. • The chart below shows the performance for April to December which cumulatively stood at 17,106 screens. Following three months of increased activity there was a sharp fall in the number of tests in December which is due to the student population being away for part of the month and adverse weather conditions affecting some providers. The number of screens in December 2010 was above that achieved in December 2009 but below the requires target , and is 88% of target for the year to date. • Core providers continue to be monitored monthly against their refreshed action plans, and refreshed trajectories are being performance managed. Additional activity has been commissioned from the independent provider.

11. Healthcare associated infections - Clostridium difficile (c diff) • NHS Nottingham City is measured against the number of c diff infections acquired at Nottingham University Hospitals Trust. The target for 2010-11 equates to 186 cases - averaging 15.5 cases per month. The chart below left, shows the monthly performance to January which was below trajectory for the fist time in the current financial year but is 33 cases or 21% over for the year to date. The target for the year has now been exceeded. NHS Nottingham City is the coordinating organisation for performance management of Nottingham University Hospitals Trust with regard to healthcare associated infections and is actively working with their infection control team, meeting on a monthly basis to review performance. • In view of the continuing high level of cases, colleagues in Nottingham University Hospital Trust, have done an extensive assessment to identify the causes of the issues so that an appropriate action plan can be put in place. The current actions in progress are outlined on pages 12-13. • There is an additional target of the number of NHS Nottingham City patients with a confirmed case of c diff. For April to December together there were 126 cases against a trajectory of 88 –January’s figure is not yet available (chart below right). The number of these cases will generally track the numbers at the trust, and the same measures will be responsible for improving both targets.

12. Clostridium difficile continued The challenge to reduce Clostridium difficile infections within Nottingham continues. The many different ribotype strains currently identified is suggestive of a change in the Clostridium difficile epidemiology. There are very few identifications of the previous epidemic ribotypes (001,106 and 027) implying that there is very little direct cross-infection with Clostridium difficile occurring to account for the numbers of infections at this time. Environmental sampling within Nottingham University Hospitals NHS Trust has failed to identify any significant contamination. The actions being taken to address the higher numbers of cases have been reported extensively in the last few months, and many of these are on-going, with Nottingham University Hospitals Trust continue to update their Clostridium difficile action plan. A health economy meeting was held with the Health Protection Agency on 21 December 2010 to support gaining a greater understanding of the suggested change in the epidemiology of the disease. The outcome of this review will direct health economy and organisational response. Conclusions from data presented before include: • Despite the numbers of cases, the current c diff rate per 1,000 bed-days has been maintained. • The number of actual cases, based on the amount of patients and samples tested, is only slightly higher than expected. • There has been a significant reduction in c diff associated deaths since July 2007 when 8 cases were reported. There was only one such death in 2010. • There are only two cases of c diff associated complications reported to date in 2010-11. • There are no increase in c diff outbreaks reported – five in 2009-10 and only one in 2010-11 so far. • The increased positivity rate in the 45-64 age range correlates to the larger number of samples from that age group. • The different number of ribotype strains is more indicative of sporadic infections rather than outbreaks, possibly due to patients being admitted to hospital already colonised with c diff in their gut.

13. Clostridium difficile (c diff) continued A number of actions were agreed from the meeting including: • A comparison of local data with that from University Hospitals of Leicester, NHS Leicester City and NHS Leicestershire County & Rutland. • Discuss proposed c diff epidemiological research with Dr Jonathan Van Tam – Professor of Health Protection. • Analyse the age demographics of samples submitted for c diff testing and the wards requesting tests • Examine the possibility of mapping the social demographics of c diff positive patients.

14. Provider-specific Performance 14

15. Nottingham University Hospitals Trust contract performance – December 2010 Nottingham University Hospitals Trust sends detailed monitoring data monthly to enable the monitoring of the Service Level Agreement. This covers both the monthly and cumulative year to date activity and spend data for each type of procedure, test and group of drugs. The data is divided into 26 points of delivery but these can be further grouped into a smaller number of areas as above. The figures only relate to Nottingham City Primary Care Trust contracted information at the Trust, and show both financial and activity figures. The figures above are cumulative for the nine months to December 2010, and show an over spend of £2.685m which represents 1.9% of the planned costs for the financial year to date. These figures include the activity and spend incurred by the East Midlands Specialised Commissioning Group who are responsible for commissioning specialised services from providers including Nottingham University Hospitals Trust, on behalf of Primary Care Trusts in the region. Ad-hoc covers major items like adult critical care, radiotherapy and chemotherapy treatments, and drugs expenditure including HIV/AIDS drugs. “Other” represents activity such as pathology tests, haematology and other non-tariff specialised services such as bone marrow transplants and disability services.

16. Mortality rates at Nottingham University Hospitals Trust The Hospital Standardised Mortality Rates for 56 diagnoses and procedures at Nottingham University Hospitals Trust are shown below. Hospital Standardised Mortality Rates (HSMR) are an internationally used measure of hospital mortality and are quoted in the UK's Dr Foster Hospital Guide. These cover in-hospital deaths for the diagnoses and in the cases of procedures, mortality within 30 days of the operation. The chart also shows the 95% confidence limits for each month. A green bell is shown when there are statistically significantly less deaths than expected, and a red bell where there are statistically significantly more deaths than expected. Dr Foster mortality figures are adjusted for risk associated with the case mix, that is patient characteristics strongly associated with death which reflect the patient’s risk profile, such as age, sex, deprivation, ethnicity, diagnosis as well as month, method and source of admission. The data for the last 12 months (December 2009 to November 2010) is shown below. This shows that in January 2010 the mortality rate is statistically higher than expected at the Trust. Further investigation shows that : • Nottingham City patients were not the cause of the increased rate, but rather patients from other primary care trusts at the hospital, • the diagnosis group for pneumonia had a higher HSMR than expected in January but not for 2009-10 as a whole, • the January cohort of patients were generally over 80 years of age with many having co-morbidities.

17. NHS Performance Framework • As part of the NHS Performance Framework, the Department of Health have introduced a performance tool in the form of a quarterly assessment that sets a clear definition of success and generates a single assessment of organisational performance. • The assessments cover the domains of Finance, Operational Standards & Targets, Quality and Safety and Patient Experience, and there are categorisations for organisations of Performing, Performance under Review and Underperforming with rules and timescales for intervention where necessary. • In terms of the Operational Standards & Targets domain, we monitor each of the performance indicators and regularly update the tools to ensure that the assessments for Nottingham University Hospitals Trust, East Midlands Ambulance Trust and Nottinghamshire Healthcare Trust are within the Performing category – see pages below. • In addition, we have constructed a similar performance framework for primary care based on key indicators from the Quality Outcomes Framework, the out of hours service and access to NHS dentistry. • In terms of the latest performance assessment for Nottingham University Hospitals Trust below, the overall weighted score is shown as 2.48. A score between 2.1 and 2.4 is deemed by the Department of Health to mean that the organisation is under review for its performance. This score is higher than recently reported. Most of the underperforming indicators are reported on above, but in the case of the others: • 31 day cancer wait for subsequent radiotherapy – performance at 87.6% for April to November. • 62 day cancer wait for referral to treatment following screening – continued low numbers in the breast screening pathway mean that the four breaches in lower gastro-intestinal stand out and lowered the performance score. However the YTD figure is moving upwards and no breaches for last four months. • 62 day cancer wait following referral – no breaches since August, YTD improving at 82.4%. • In relation to the latest assessment for East Midlands Ambulance Service also below, their weighted score is 2.33. For Ambulance Trusts a score of greater than 2 is considered to show a performing trust. However, in view of the fact that the latest year-to-date data for both the Category A calls in 8 minutes and Category B calls in 19 minutes are below the required levels, East Midlands Ambulance Service was been served with a Performance Notice by NHS Derbyshire County as the Lead Commissioner for the Ambulance Trust contract.. • In relation to the assessment for Nottinghamshire Healthcare Trust below, their weighted score is 2.83 which is well above the threshold of 2 for a performing mental health trust. • For the primary care indicators, their weighted score stands at 2.33 which is above the threshold which we have decided ourselves for good performance.

18. Latest 2010-11 Performance Assessment for Nottingham University Hospitals Trust

19. Latest 2010-11 Performance Assessment for East Midlands Ambulance Trust

20. Latest 2010-11 Performance Assessment for Nottinghamshire Healthcare Trust

21. Latest 2010-11 Performance Assessment for primary care indicators

22. NOTTINGHAMSHIRE HEALTHCARE NHS TRUST MENTAL HEALTH – Dec 2010 Graph 1: NHT Activity Levels (% Variance to Plan per month) Graph 1 shows NHT’s under/over performance (against monthly planned activity) as a percentage. Five of the six areas are now performing above the planned activity levels. Children & Adolescents remains below planned activity levels. Due to under-performance of activity in 2009/10, the Commissioner reduced the activity plan for Older People and Drugs & Alcohol for 2010/11.   This change in activity has resulted in Older People presenting a 16.6% over-performance and Drugs and Alcohol meeting activity expectations.   The change in planned activity levels has resulted in the contract as a whole presenting a 10.8% over-performance, however the NHT contract is within a Block, therefore the commissioner will not incur additional costs.  It is imperative that the commissioners understand activity and demands, in order to better prepare itself for when Payment By Results is implemented.  The activity changes have demonstrated that more detailed analysis is required on Older Peoples services in order to better understand performance trends. The above principle was implemented for Children and Adolescents, which has resulted in under-performance. The commissioner will again need to reflect more appropriate activity numbers and these negotiation are taking place with the provider.

23. NOTTINGHAMSHIRE HEALTHCARE NHS TRUST MENTAL HEALTH - DEC 2010 Table A: Activity Levels up to end Dec 2010 Table A shows the number of contacts (either face-to-face in a community setting or an Occupied Bed Day for an in-patient) against plan up to period end (31st Dec). NHS Nottingham City has had 13,282 more contacts than planned (9.3% of contracted activity). This does not incur any additional cost as this contract is managed on a block basis. Work is underway to negotiate the arrangements for 2011/12, taking into account this current performance. Psychiatric Readmission – Exception Report Table B (see over) show NHT’s performance up to December 2010 against the contract targets. Psychiatric Readmissions for Older People is the only target not being achieved. This relates to one patient (which was a clinical appropriate readmission) and therefore was unavoidable.

24. NOTTINGHAMSHIRE HEALTHCARE NHS TRUST MENTAL HEALTH Table B: Summary of performance (Apr 2010 – Dec 2010)

25. Nottingham NHS Treatment Centre The Nottingham NHS Treatment Centre opened on 28 July 2008 and sees patients in a range of daycase surgery and outpatient specialities including dermatology, oral surgery, orthopaedics, digestive diseases and endoscopy, cardiology, respiratory diseases and gynaecology. The final transfer of services from NUH occurred on 26th July 2010 when Endocrinology Outpatients commenced. This is a minimum take contract in which NHS Nottingham City is committed to purchasing an agreed volume of costed activity. The percentage of the value of the contract which NHS Nottingham City patients have used in 2010-2011 is as follows: In financial terms, the utilisation for NHS Nottingham City for November 2010 was £1,461,351 against a contracted £1,466,178 (validated figures). Initial unvalidated figures for December 2010 are £1,417,377 against a contracted £1,443,319. If, at the year-end, the minimum take exceeds 100% then NHS Nottingham City will be required to pay for the excess activity used. The minimum take by value and by value year to date are worked out on a financial year basis, however please note that the financial year for the contract itself runs from August – July. 18 week performance remains excellent at 99.5% for Admitted patients and 99% for Non-Admitted patients. The daycase DNA rate for December was 1.7%, against the threshold of 2%. The Treatment Centre reported that 95% of 2WW urgent referrals were seen within 2 weeks, with patient choice the prime reason for appointments outside 2 weeks. 19 patients chose appointments outside the 2 week period, and one breach was due to human error. Performance against the 62 Day target was 93.1% (5 shared breaches, of which 2 were complex, 2 patient choice, and 1 patient considered unwell). Performance was 97.1% for 31 days. 387 patients were screened for MRSA which represents 100% of patients requiring screening before treatment with no patients found to be MRSA positive, that is they were carriers of, or colonised with MRSA. There were no patient complaints and 6 patient concerns reported in December. Patient satisfaction overall was at 99% (non-admitted) and 100% (admitted) against the 80% target. 25

26. Community Services (CitiHealth) December 2010

27. Community Services (CitiHealth) December 2010 continued

28. Community Services (CitiHealth) December 2010 continued