1 AIM OF THE REPORT NHS FIFE Report to the Board 24 February 2015 ACTIVITY REPORT This report provides a snapshot of the range of activity that underpins the achievement of key National Targets and National Standards, such as Waiting Times and Delayed Discharges. To allow for comparison, previous years activity has been included where appropriate. 2 WAITING TIMES: 18-WEEKS REFERRAL TO TREATMENT NATIONAL STANDARD: 90% of planned/elective patients to commence treatment within 18 weeks of referral A patient journey may comprise 3 specific stages following referral Outpatient Consultation, Diagnostics and Treatment. The elapsed time specified in the National Standard covers all stages, and the NHS Fife performance against this over the last year is illustrated in Chart 1. Chart 1 18 Weeks Referral to Treatment NHS Fife consistently exceeded the standard until September last year, when performance fell to 89.2%. Local Management Information for each month of the final quarter of 20 suggests that performance has fallen further but has now stabilised. It is anticipated that improvement work relating to both Diagnostics and Outpatients Waiting Times will bring monthly performance back above 90% by the start of FY 2015-16. A more detailed report on activity within the individual stages of the pathway is provided in the following sub-sections. Activity Report V1.0 Page 1 of 17
2.1 Outpatient Consultation Chart 2 shows the number of patients waiting for a new outpatient consultation, at all sites and from all referral sources. Chart 2 New Outpatients Total Waiting (All Sites) From April 2012, the waiting increased month-on-month (with a few exceptions), rose sharply at the start of 20 but began to fall at the end of the year. The number waiting at the end of December was 16,625, 23% higher than at the end of 2013. Chart 3 shows the trend in outpatient referrals measured on a monthly and rolling 12- month basis, since March 2012. Chart 3 Outpatient Activity (Acute Hospitals) While there have been monthly (basically seasonal) variations, the total 12-month figures have only varied by around 4,000 (approximately 4%) over the period. There is, however, evidence of a consistent upward trend from the middle of 20. Activity Report V1.0 Page 2 of 17
As a component of the overall patient journey, Health Boards are expected to maintain a standard of having no patients from any referral source waiting over 12 weeks from referral to first outpatient appointment. Performance against this is illustrated in Chart 4. Chart 4 Outpatients Waiting Over 12 Weeks from Referral The number of patients waiting over 12 weeks at the end of each month has been above 400 for most of the last 2 years and rose sharply at the start of 20-15. At the end of December, 2,426 patients had waited over 12 weeks for their first appointment, just under 200 less than reported at the previous Board Meeting. The over 12 weeks figure equates to around 15% of the total number waiting. A more detailed analysis of demand for Outpatient Services, along with a Recovery Plan, was provided for the December Board Meeting. Progress is being monitored each month by the Acute Services Management Team, and there has been evidence of improvements in some specialties. The Board will receive an update early in FY 2015-16. Activity Report V1.0 Page 3 of 17
2.1.1 Outpatient Unavailability The most recent figures for Outpatient unavailability (and a breakdown of reasons) are illustrated in Charts 5 and 6. Chart 5 New Outpatient Unavailability Chart 6 New Outpatient Unavailability (by Reason) NHS Fife has consistently reported a lower % of unavailable patients than the Scotland average. At the end of September 20, only 120 out of 16,154 Outpatients waiting for an appointment were categorised as unavailable, with 99 of these being unavailable for social reasons. The National External Audit on Waiting Times, completed during 2012, confirmed that NHS Fife managed lists appropriately. Activity Report V1.0 Page 4 of 17
2.2 Diagnostics Again as a component of the overall patient journey, Health Boards are expected to maintain a 6-week maximum waiting time standard for the following 8 key Diagnostics tests: Barium Studies Non-obstetric Ultrasound Computer Tomography (CT) Scans Magnetic Resonance Imaging (MRI) Scans Imaging Imaging Imaging Imaging Upper Endoscopy Lower Endoscopy Colonoscopy Cystoscopy Endoscopy Endoscopy Endoscopy Endoscopy Chart 7 shows the total number of patients waiting for one of the above tests at the end of each month, and the number who had waited more than 6 weeks. Chart 7 Diagnostics, Patients Waiting (Total and Over 6 Weeks) At the end of December, there were 5,298 patients waiting for a Diagnostics test, 1,083 of whom had waited more than 6 weeks. The total number has fallen by 10% since the last Board Meeting, but the number of 6-week breaches has remained at virtually the same level. This was due to a reduction in capacity over the festive period. Chart 8 provides a breakdown of the number of patients waiting, by test and length of wait (in 2-week blocks). There are currently no patients waiting for Barium Studies, so this is excluded from the chart. Activity Report V1.0 Page 5 of 17
Chart 8 Diagnostics, Patients Waiting Breakdown The test with the highest number of patients waiting was Ultrasound (2,295). It is a challenge to improve and sustain waiting times for Radiology against increasing demand. Chart 9 illustrates how demand has increased over the last 3 years. Chart 9 Radiology Referrals This shows that referrals have increased by 36%, from an annual figure of 54,741 to 74,504, with a particularly big increase for CT Scans (17,670 to 25,288, a rise of 43%). Activity Report V1.0 Page 6 of 17
A Diagnostics Recovery Plan focusing on Ultrasound, MRI and Endoscopy is in place and being implemented. The number of patients waiting is reducing and although this slowed in December it is anticipated that the actions in the recovery plan will enable the delivery of a maximum 6-week waiting time in early summer. Progress is being monitored each month by the Acute Services Management Team. 2.3 Inpatient / Day Case Treatment Chart 10 shows the number of patients waiting for Inpatient / Day Case treatment. Chart 10 - Total Inpatients & Day Cases Waiting There was a general downward trend in patients waiting for treatment between the middle of 2013 and 20, but the figure started to increase again during the second half of last year. At the end of December, the number waiting was 2,663, just under 10% higher than at the end of 2013. As a component of the overall 18-Week Referral to Treatment Standard, Health Boards are expected to have no patient waiting more than 9 weeks for agreed elective surgery. Chart 11 illustrates the NHS Fife performance against this standard. Activity Report V1.0 Page 7 of 17
Chart 11 Inpatients Waiting Over 9 Weeks At the end of December, there were 235 patients on the Waiting List who had waited more than 9 weeks for treatment, 97 more than at the end of 2013. Over half of the breaches (132) were in the Trauma & Orthopaedics specialty. The Capacity Plan agreed in 2013 funded new posts to maintain and sustain performance by ensuring capacity matched demand. Where posts remain unfilled, additional activity has been undertaken to address the gap between capacity and demand. The Improving Elective Flow programme also supports service improvement in this aspect of the service. 2.3.1 Inpatient / Day Case Unavailability The most recent figures for Inpatient/Day Case unavailability (and a breakdown of reasons) are illustrated in Charts 12 and 13. The figures include only those patients who are covered by the Treatment Time Guarantee. Activity Report V1.0 Page 8 of 17
Chart 12 Inpatient/Day Case Patient Unavailability Chart 13 Inpatient/Day Case Patient Unavailability (by Reason) The % of unavailable patients in NHS Fife has been consistently lower than the Scotland average. At the end of September, 281 patients out of 2,349 on the Inpatient / Day Case list were categorised as unavailable, with 216 of this number being unavailable through patient choice and 65 being unavailable for medical reasons. Patient choice covers a variety of reasons, including a small number of patients who wish to be treated by a named Consultant or within their own Health Board Area. Activity Report V1.0 Page 9 of 17
3 WAITING TIMES: TREATMENT TIME GUARANTEE Health Boards have a duty placed on them to deliver the Treatment Time Guarantee (TTG) under the Patient Rights (Scotland) Act 2011 (the Act). The Act establishes a maximum 12-week waiting time for the treatment of all eligible patients who are due to receive planned treatment delivered on an Inpatient or Day Case basis. The performance of NHS Fife during the last year is shown in Table 1. Table 1 Patients Treated under the Patient TTG In the 12-month period ending September, 99.7% of patients receiving treatment (16,316 out of 16,369) did so within 12 weeks of treatment being agreed. This % is unchanged from the 12-month period ending June. Local management information for each month of the final quarter of 20 shows that the number of breaches has remained at a low level. 4 CANCER WAITING TIMES NATIONAL STANDARD: 95% of all patients referred urgently with a suspicion of cancer will begin treatment within 62 days of receipt of referral. NATIONAL STANDARD: 95% of all patients diagnosed with cancer will begin treatment within 31 days of decision to treat. The most recent published performance is for the quarter ending September 20. It includes patients who go through cervical, colorectal and breast screening programmes. 4.1 62-Day Referral-to-Treatment NHS Fife s performance against this standard was an achievement of 89.5%, lower than that for the South East Scotland Cancer Network, SCAN (94.6%) and for Scotland as a whole (93.5%). The NHS Fife performance equates to 162 patients out of 181 starting treatment within 62 days of receipt of an urgent referral. NHS Fife s performance is shown in Chart, while Table 2 shows the performance broken down to individual specialties. Activity Report V1.0 Page 10 of 17
Chart Cancer 62-Day RTT Performance Table 2 Individual Cancer Specialty Performance (62-Day RTT) All bar one of the breaches were in the Colorectal, Lung and Urology specialties, where staffing and capacity issues continued to be a major challenge to NHS Fife. In order to improve performance, the following actions are being taken: Working with Lung clinicians and cardiothoracic surgeons in NHS Lothian to ensure optimum referrals are made into the service Working with the Urology team and service manager to improve waits to investigations and surgery Holding weekly cancer waiting times meetings to monitor progress 4.2 31-Day Decision-to-Treat to Treatment NHS Fife s performance against the 31-day standard was an achievement of 96.1%, below that for the SCAN (98.0%) and also for the whole of Scotland (96.7%). The NHS Fife performance equates to 274 patients out of 285 beginning treatment within 31 days of the decision to treat. Activity Report V1.0 Page 11 of 17
NHS Fife s performance is shown in Chart 15, while Table 3 shows the performance broken down to individual specialties. Chart 15 Cancer 31-Day DTT Performance Table 3 Individual Cancer Specialty Performance (31-Day DTT) All patient breaches in the last quarter were within the Urology specialty, but overall performance has remained above the 95% standard for more than 4 years. 5 DRUG & ALCOHOL SERVICES WAITING TIMES NATIONAL STANDARD: 90% of clients will wait no longer than 3 weeks from referral received to appropriate drug or alcohol treatment that supports their recovery Performance information is shown in Chart 16. Activity Report V1.0 Page 12 of 17
Chart 16 Referral to Treatment Waiting Times The NHS Fife Referral-to-Treatment performance has been above the standard in each quarter since it became effective in March 2013. This applies to the joint Drugs and Alcohol measure as well as the two services individually. 6 DELAYED DISCHARGES NATIONAL TARGET: No people will wait more than 28 days to be discharged from hospital into a more appropriate care setting once treatment is complete, from April 2013; followed by a day maximum wait from April 2015 Table 4 summarises monthly activity over the last year. Total Delayed Discharges at Start of Period Exclusions at Start of Period Jan Table 4 Delayed Discharges Monthly Activity Feb Mar Apr May Jun Jul 97 103 113 110 101 121 118 130 118 126 122 139 110 33 32 32 31 41 25 26 29 30 30 33 29 30 Reported to ISD 64 71 81 79 60 96 92 101 88 96 89 110 80 Aug Sep Oct Nov Dec Jan 15 OUT - patients discharged, placed, deemed unfit or excluded IN - patients now deemed fit for discharge Total Delayed Discharges at End of Period Total Delays in Acute Total Delays in CHP 58 56 68 65 58 71 67 76 62 64 62 84 67 64 66 65 56 78 68 79 64 70 60 79 55 46 103 113 110 101 121 118 130 118 126 122 139 110 89 21 20 23 28 38 36 48 38 35 51 49 32 29 82 93 87 73 83 82 82 80 91 71 90 78 60 Activity Report V1.0 Page 13 of 17
The total number of patients in delay was 89 at the January census, against 103 a year ago. This includes Code 9 (Complex Needs) and Code 100 (Reprovisioning/Recommissioning) patients (exclusions). After exclusions, the number in delay was 62, a decrease of 18 compared to December and 9 less than at the January 20 census. Chart 17 illustrates the trend in this figure as well as showing how delays are broken down in 2-week periods. Chart 17 Delayed Discharges, by Length of Delay Targeted work in December, led jointly by the Director of Acute Services and the Director of Health & Social Care Integration, has led to an improvement in the position. The number of patients in delay for more than 2 weeks was 35, just over half the figure reported at the last Board Meeting. Despite this welcome reduction, it remains unlikely that we will achieve zero delays over 2 weeks by April. The vast majority of delays continue to be attributable to the completion of preassessment and assessment of home care and residential care and the commissioning of packages of care. 6.1 Delayed Discharges Mental Health Patients In the second half of 20, 107 patients in delay were categorized as Mental Health and 16 of this number remain current. Of the remaining 91 patients, 25 were subsequently removed as unfit for discharge, and the outcome breakdown for the other 66 patients was as follows: 1 patient died 6 patients were discharged home 7 patients were discharged home with homecare 52 patients were placed in a variety of settings Activity Report V1.0 Page of 17
The average waiting time excluding Code 100 patients was 48 days. There are no particular issues with the provision of nursing or residential home for older adults and funding arrangements are generally approved within a reasonable timescale. There have been patients delayed because the care package requested has been difficult to source. Finding suitable accommodation for those patients who are under 65 years of age and have complex needs continues to be particularly challenging for our service. Those who require specialist units, residential care and supported accommodation often have to stay in hospital longer than necessary. The funding of the Under 65 age group is decided at a different meeting from the over 65s and the outcome of this meeting is generally fed back to the ward staff from Social Work colleagues. Patients who have been identified as having complex needs and requiring specific care packages can also be in hospital longer than necessary due to shortage of appropriate housing. The problems remain with the Guardianship process with it taking many months to complete from start to finish. There have been particular delays due to Legal Aid applications. At the end of 20, there were 16 patients remaining in delay, 1 of whom was coded 100 (commissioning/reprovisioning) and 8 of whom were aged under 65 years. The Re-Design Programme resulted in 17 patients being discharged in 20, as follows: 1 patient was discharged to his/her own tenancy, with support 13 patients were discharged to supported accommodation in Glenrothes and Dysart with SAMH providing the support. 3 patients were discharged to residential accommodation in Newburgh 6.2 Delayed Discharges Patients with Learning Disabilities As part of the final discharge of the long stay patients from Lynebank Hospital to the community, it has been agreed that delayed discharges for people with learning disabilities should be reported to the Board although they are not part of the requirement for reporting to the Scottish Government. The Board asked to see the information to ensure appropriate pace of discharge for people with a learning disability in conjunction with colleagues from Fife Council Social Work Services. There are currently 9 patients who are delayed, 3 of whom have jointly-developed discharge plans and are awaiting suitable accommodation within the community to be identified. Of the remaining 6 patients, 2 have no accommodation or care provider. Accommodation and a package of care has been identified for one patient, and a discharge date in February has been agreed. Activity Report V1.0 Page 15 of 17
For the final 3 patients, the newly commissioned service and accommodation for these patients finally opened in December. There continues to be concerns however in relation to recruitment of staff and the service has therefore only been partially opened. These issues are currently being addressed by the provider and it is hoped that 2 patients will be discharged in February and the final patient in March. 7 EMERGENCY ACCESS 7.1 4-Hour Waiting Time Performance In the whole of 20, 95.1% of patients at NHS Fife A&E / Minor Injuries Units were admitted, discharged or transferred for Accident and Emergency treatment within 4 hours of arrival. This against 96.1% for the whole of 2013. Chart 18 illustrates monthly and rolling 12-monthly performance between December 2013 and December 20. Chart 18 4 Hour A&E Target Performance Achieving a consistent monthly performance is key to meeting the 95% (stretch 98%) standard stipulated by the SGHSCD. The Local Unscheduled Care Action Plan (LUCAP), which is an initiative being run over 3 years, describes the changes being implemented by NHS Fife. The final year is 2015-16. 7.2 A&E Attendances A&E attendance at all NHS Fife sites since March 2011 is shown in Chart 19, in both bar chart (monthly) and line (12-month rolling) format. Activity Report V1.0 Page 16 of 17
Chart 19 A&E Attendance (all NHS Fife sites) Attendances have varied historically, with peaks during the early Summer months and troughs in the Winter months. The annual attendance trend is illustrated in Table 5, which also shows the population changes between 2011 and 20. Table 5 Total A&E Attendance, 2010/11 to 2013/ In the 3-year period, attendance increased by 1.8% while the NHS Fife population increased by 0.5%. The population increase in patients aged 75 and over, the age bracket most likely to require treatment at A&E, was 2.9%. DR. BRIAN MONTGOMERY Interim Chief Executive 17 February 2015 Activity Report V1.0 Page 17 of 17