Board Report – Performance September 2009 Produced by Business Intelligence (Performance)

1. Board Report – Performance September 2009 Produced by Business Intelligence (Performance)

2. Cleanliness and HCAI The was only one case of MRSA recorded in July for Western Hospitals Trust. Cases have fallen month on month to a total of 10 for July against a DH target of 8,compared to 18 cases this time last year. Numbers for August show 2 cases of MRSA. Trust and Community attributable show a fifty percent split. Work continues with West Sussex Trusts through the HCAI Task Force. Brighton Trust shows 12 cases against a target of 10. 7 Hospital acquired, however the PCT is only measured against the Host Trust so BSUH and SASH are for information only. Lead: Mona Walker – Interim Director of Quality

3. Cleanliness and HCAI There were 32 cases for July against a DH trajectory of 50 and a stretch target of 45. This demonstrates the lowest number of cases in a month since the start of the year. From a year to date point of view we have 163 cases against a DH target of 210 and a stretch target of 179. This is an improvement on last year when we were 22 cases above DH target. Community cases have also decreased and for the first time this year is showing green against stretch trajectory of 2 cases. SASH is the only provider who are above stretch trajectory-by one case, however this does not affect the PCT target as we are only measured against the Host trust. Lead: Mona Walker – Interim Director of Quality

4. Emergency Care Category A with 8 minutes response time by District for July – target 75% The cumulative position has dropped below the 75% target for the first time this. The 75% target has not been met for 3 consecutive months and for the first time this month, SECAmb as a whole has dropped below the target. In order to have achieved the 75% target:- Chichester – require to achieve50 additional responses <8mins for July and 142 cumulatively Horsham – require to achieve47 additional responses <8mins for July and 173 cumulatively Mid Sussex – require to achieve43 additional responses <8mins for July and 109 cumulatively West Sussex – require to achieve43 additional responses <8mins for July and 16 cumulatively The number of Wards in the lower performing categories (<25% and 25-50%) has increased by 50% since last month (from 24 to 36) – the decrease is replicated within the 50-75% category. From the month 10 board update last year, an update was given that listed a number of schemes which would improve the ambulance response times for Category A within 8 minutes. Having monitored the response times since then a significant improvement has not been made at Ward level. A short report on the key action points will be agreed with SECAmb and an update will be provided next month. Ward level analysis can be found in Appendix 1.

5. Emergency Care Category B with 19 minutes response time by District for July – target 95% Both cumulatively and monthly, the 95% target has not been achieved. Underachievement has occurred for 4 consecutive months.

6. Waiting times There were 15 breaches of the 6 week diagnostic wait in July. These consisted of the following: Portsmouth Hospital – 1 patient was an ECG delay and this was due to capacity, St Georges Hospital Colonoscopy – 1 patient breached as Consultant was on annual leave and no locum was arranged for cover Great Ormond Street (1 patient) and UCL (2 patients) MRI breaches due to capacity- to be rectified by end of the month UCL – (1 patient) sleep studies awaiting confirmation from patient Park Surgery – 8 patients waiting 6-7 weeks was a capacity issue and will be raised via contracting. 1 patient waiting 11-12 weeks is patient choice. These issues are still being raised with the practice through a variation to the contract. Lead: Bianca Kokkolas, Head of Performance and Programme Management

7. Waiting times SASH – T&O patient Patient cancelled on original date. Ward did not pass on information and patient was booked and discharged on IT system and therefore was removed from waiting list. This is the third month in a row where SASH have breached due to administrative errors. This has been raised with their host commissioner, Surrey PCT and awaiting response. Lead: Bianca Kokkolas Head of Performance and Programme Management

8. Sexual Health – Chlamydia screening Agreement has now been reached as to the funding of the programme, and the contract variation with Western Sussex Hospitals Trust has been prepared. A formal letter has been drafted and will be sent to the Trust for them to sign off. The trajectory for achievement of this target has not yet been agreed but there will be a meeting at the end of Sept to agree this. The IT system for the collection of data has been ordered and the Trust await delivery. Lead: Paul Woodcock Public Health Programme Manager

9. Childhood Immunisation

10. Childhood Immunisation DTaP/IPV/Hib age 1 is almost on target. Hib/MenC age 2 uptake is within 2.1% of the target and MMR age 2 is within 1.4% of the target. Although there has been a marked increase in uptake during the last quarter, considerable improvement is required for DTaP/IPV age 5 which is 6.4% below target. An immunisation action plan has been developed using NICE guidance. The immunisation coordinator is consulting with practice managers, GP locality groups and the head of children’s services. A data reconciliation project is also in progress to improve the accuracy of records. Lead: Nick Kendall

11. Cancer Waiting Times The change to the counting methodology we knew would have an impact and we are continuing to see this effect. Acute trusts report a specific problem in patients refusing the offered appointment within the 2 weeks. This then has a knock on effect throughout the pathway. The PCT has taken remedial action in writing to all GPs in West Sussex and explaining the constraints on trusts surrounding 2ww referrals and the need to ensure that patients understand they are on an urgent pathway. Via local cancer action groups we are also taking a local perspective and for Worthing have instigated some audits around referrals, which our GP lead will be looking at with the trust to identify any trends or particular problem areas. Lead: Alison Hempstead

12. Appendix 1 Focused Wards: Cat A (8 min) Calls Wards with <60% Cat A (8 min) Response Rates in 08/09 - Arising 09/10

13. Appendix 1 (continued)