Board of Directors Meeting

Board of Directors Meeting 23 rd July 2014 (BDA/14/26) part Performance Report Monitor Key Indicators Status: A Paper for Information History: Amanda Pritchard Chief Operating Officer Page 1 of 10

Performance Report Monitor Key Indicators July 2014 Paper written by Martyn Dorey, Head of Planning & Performance, Hannah Coffey, Director of Operations (Hospital Services) and Amanda Pritchard, Chief Operating Officer 1. Introduction This paper provides a narrative highlighting Trust performance against key Monitor performance indicators, taking into consideration performance history (where relevant), our current performance and an analysis of issues, actions and associated risks. An Integrated Performance Report is being developed through the Quality Committee, which will include a broader range of indicators and analysis of performance at directorate level from October. 2. Overview In Q1 we have achieved 11 of the 14 Monitor Key Performance Indicators, subject to completion of data validation and submission of the final position at end of July. 3. A&E Waiting times 3.1. Background The Trust struggled to deliver consistently against the A&E waiting time standard during 2012/13. It is important to note that current Trust performance is as a result of significant local clinical leadership combined with strong executive and operational focus in 2013/14 to understand and address the root causes of poor performance, as well as a commitment from the entire organisation to prioritise emergency pathways accordingly. Enormous effort has gone into ensuring there is a robust structure and escalation process in place to make sure the department can identify and address issues proactively to ensure ongoing robust delivery of quality standards. 3.2. Current & Future Performance The Trust has comfortably achieved Q1 performance for A&E and Urgent Care attendances, which will be the 5 th consecutive quarter achieved. As Table 2 illustrates, this performance is exceptional given the performance of many other Trusts across London (and the country). Table 1 Waiting times for A&E and Urgent Care Attendances Performance Target Q 1 2013/14 Q 2 Q 3 Q 4 Q1 2014/15 Target: 95% A&E patients wait less than four hours. 95.6% 95.3% 96.5% 96.4% 96.5% Table 2 A&E Performance (Q1) Top & Bottom 5 London Trusts During the quarter the Trust has achieved the 95% standard every week for total A&E plus Urgent Care attendances, and there have been just 2 weeks where the standard for A&E attendances alone (i.e. the sickest patients) has not been achieved. This has been due in the main to junior doctor sickness in the department, particularly over night and at Page 2 of 10

weekends. The team has worked hard to ensure cover is in place at critical operational times, including staffing over and above establishment, but this has not always been possible. However, on these occasions the department has responded very proactively when risks have been identified, and have worked hard to ensure performance bounces back after one or two consecutive days of sub 95% performance. 3.3. Actions & Risks The Trust is starting to plan for the winter period now, working with local commissioners in order to ensure we have robust plans in place in advance of the winter period. The commissioners priorities are: Further development of the Enhanced Rapid Response service to support discharge and admission avoidance; Increased mental health service support to A&E; Alcohol services - we already have the Lambeth Alcohol Recovery Centre, but might enhance the operating days/hours; Social services 7 day working; Early supported discharge support from voluntary sector; A&E triage and diversion - we already have this in place, but might need to enhance, including additional PALS support for patients needing appointments at alternative services Our priorities will also include consideration of the following, some of which will require additional financial support. Decisions will be made in August to ensure that developments can be delivered in time, including recruitment of sufficient workforce: Provision of escalation adult beds at St Thomas' Hospital, including critical care; Children's escalation beds at Evelina, including some PICU; Enhanced A&E and Urgent Care Centre related escalation staffing support, including GPs and emergency nurse practitioners; Extended 7 day therapy support to emergency medical wards to reduce length of stay; Extended Pharmacy support to wards and departments to support early discharge. We will follow a similar process to previous years in developing our winter plan, which will include seeking outline proposals from clinical directorates in order to ensure we pick up innovative new ideas in addition to those set out above. 4. Referral to treatment waiting times (RTT) 4.1 Background In 2011 the Trust had a significant backlog of patients waiting over 18 weeks for admitted care. Over an 18 month period, the Trust put considerable effort into reducing this from 2953 to a sustainable figure of circa 600, based on Trust activity levels at that time. The Trust has consistently achieved the national targets since October 2012 up to and including Q1 2014/15: Table 3 RTT waiting times Page 3 of 10

Performance Target Q 1 2013/14 Q 2 Q 3 Q 4 Q1 2014/15 Target: 95% patients treated within 18 weeks RTT (non-admitted) Target: 90% patients treated within 18 weeks RTT (admitted) Target: 92% incomplete pathways within 18 weeks RTT 96.6% 96.3% 95.7% 95.8% 96.0% 92.7% 92.3% 91.4% 91.1% 91.5% 93.7% 93.6% 93.0% 93.5% 92.9% 4.2 Current & Future Performance The pace of growth in demand for our services has exceeded our activity levels particularly in the last three months and, despite best efforts to increase activity, the waiting list of patients waiting for treatment has grown (see graph of total waiting list below). Monitor and NHS England have invited us (and all trusts) to submit a plan to deliver additional activity aimed at reducing backlog so that referral to treatment time performance can be recovered nationally, and additional funding has been made available to support this effort. This is linked to plans to improve operational resilience, particularly for the winter. We have agreed a plan with commissioners and Monitor to step up activity throughout Q2, and focus this additional capacity on backlog reduction. This will result in our admitted performance falling below the standard of 90% within18 weeks over this period as we seek to treat higher numbers of longer waiting patients. However, on the basis of current modelling we would expect to return to a compliant RTT position from Q3. The current situation is partly a consequence of success in becoming a more popular choice to referrers and patients, which is in line with the Trust strategy to grow its services, but the pace of growth in demand for our services has exceeded our activity levels in recent months and despite best efforts to increase activity we now have a backlog of patients waiting over 18 weeks for admitted care of over 1,200 compared to the ideal sustainable level of between 500 and 800. Two specialties have contributed disproportionately to the queue of patients waiting over 18 weeks; Page 4 of 10

Paediatric ENT has a challenging set of constraints, with increasing capacity and limited alternative providers and we are in discussion with commissioners to agree a way forward; Urology has a growing pressure on capacity for urgent cancer care and with neighbouring services struggling it would appear that additional patients are choosing to come here; we are hopeful that it is feasible to ease this pressure through outsourcing of routine cases. 4.3 Actions & Risks The risk to RTT performance was noted in our 2 year Operational Plan submission to Monitor in April and plans are in hand to increase outpatient and admitted activities by at least 10% on the current run-rate to avoid any further build up in the queue and then to deliver more non-recurrently in order to reduce the waiting list to a more sustainable size, and in particular to reduce the numbers waiting over 18 weeks. Analysis of the current waiting lists gives assurance that the clinically urgent cases are being treated appropriately and it is the routine cases that are waiting longest. There are a number of risks that we are mindful of in pursuing this approach, in particular operational deliverability (especially over the summer), inherent limitations of modelling assumptions, further unexpected increases in demand above current levels, and limited options for referral management. However, we have very tight weekly monitoring arrangements in place to mitigate these risks and are in regular dialogue with commissioners to ensure we have a joined up approach. Our lead commissioner has been very supportive of our plans, noting that this will cause the Trust to fall below the standard for admitted treatment in Q2 and has made it clear that this action is being taken at their request. Monitor has confirmed that it does understand the Trust s plan, which is in response to its request, and whilst it does not intend to suspend its Risk Assurance Framework, it will take this into account in determining our governance rating for Q2. 5. Diagnostic Waiting Times 5.1 Background The national standard for Diagnostic waiting times is that no more than 1% of patients should wait more than 6 weeks for their test. This is measured at the end of every month and should mean that no more than about 50 patients would be waiting more than 6 weeks. The Trust has never achieved this standard and whilst there has been some improvement in recent months (as can be seen in the graph below), current performance is still not in a position where we can have confidence in sustainably achieving 1% or below. Page 5 of 10

5.2 Current & Future Performance The numbers of patients waiting over 6 weeks has reduced from over 300 last year, and in particular the number waiting for endoscopy is much lower. There are 3 diagnostic tests which comprise the majority of the patients waiting over 6 weeks and are being addressed so that we can achieve the national standard reliably: BRAVO endoscopy (30 patients at beginning of July waiting over 6 weeks): this involves the patient swallowing a capsule which films the patient s intestines. It is a test prescribed for some patients following other investigations. The capacity for this is limited by the equipment available, which has recently been increased, and the workforce available to review the films and report on the test. Plans are in hand to increase capacity so that the queue for this test is reduced below 6 weeks. Paediatric sleep studies (16): the demand for this study has grown because it has been found to be helpful in planning treatment for certain conditions. The capacity is limited principally by the availability of rooms (as well as equipment and staff). Plans are in hand to increase capacity, but projections show that it will still take many months to achieve a maximum 6 week wait because of the delay in new staff starting and the increasing demand on this service. Urodynamics (15): this test requires a complex combination of staff skills, rooms and equipment and any variability in access to this capacity currently results in patients waiting more than 6 weeks. A number of actions are in hand to ensure that consistent access to the required capacity is in place. 5.3 Actions & Risks The actions described above are expected to ensure we remain below 2% of patients waiting over 6 weeks, but will not achieve 1% sustainably until the end of 2014 when the benefit of the actions described above should have been fully realised. Page 6 of 10

6. Cancer Waiting Times 6.1 Background The Trust has consistently achieved 6 of the 8 cancer standards in recent months (subject to final validation of data and submission to Monitor at end of July), with the exceptions relating to 62 days referral to treatment and 62 days from screening to treatment. Table 4 Cancer waiting times Performance Target Q 1 Q 2 Q 3 Q 4 Q1 to date Target: 85% cancer patients treated within 62 days from GP Referral 75.3% 76.4% 74.0% 78.3% 78.9% Internal Referrals 84.8% 84.0% 82.8% 88.5% 86.7% Target: 90% cancer patients treated within 62 days from screening Target: 96% cancer treatment started within 31-days from decision to treat Cancer: Subsequent treatment within 31days: 94% Surgery Cancer: Subsequent treatment within 31days: 98% Chemotherapy Cancer: Subsequent treatment within 31days: 94% Radiotherapy Target: 93% urgent cancer referrals seen within 2 week waits Target: 93% breast symptomatic referrals seen within 2 week waits 90.0% 80.0% 88.9% 83.3% 84.0% 97.1% 97.8% 95.0% 96.6% 97.4% 98.4% 96.6% 89.7% 98.0% 94.5% 98.4% 99.0% 99.1% 98.3% 99.6% 96.9% 95.2% 98.0% 97.0% 96.7% 95.6% 94.5% 95.0% 94.4% 96.3% 93.4% 96.8% 93.6% 93.7% 95.3% The target for 62 days treatment from screening is extremely difficult to achieve as it involves very small numbers of patients (less than 10 per month). However, every effort is made to continually learn and apply improvements to processes. A huge amount of work has gone into understanding the drivers for 62 days from referral to treatment performance and putting actions in place to improve it, both for internal 62 day performance, and on external performance with other referring trusts, which is much more challenging. Significant progress has been made to improve internal performance against the 62 day standard and the Trust is on track to achieve over 86% for internal referrals in quarter 1 and also achieved the standard for the last quarter. The most substantial risk to the overall achievement of the standard is late referrals from other trusts, particularly in Lung/Thoracic and Urology. If a referral is received within 42 days with diagnosis completed, it should be possible to start treatment within the standard. The London Cancer Alliance has agreed a system for the fair reallocation of breaches referred after day 42, but this does not apply to trusts outside London. If we applied this system to all our referrals then overall performance against the 62 day standard would have been achieved in both the last two quarters, with 86.3% in Q4 and 85.5% in Q1 Page 7 of 10

6.2 Current & Future Performance Q1 62 day treatments and breaches by specialty are set out in the table below. There are about the same number of internal and external treatments but there are 2.5 times as many patients referred from other hospitals waiting longer than 62 days, mostly because they do not reach diagnosis and decision to treat quickly enough. 64 of the 77 external breaches were referred after day 42 and 58 were referred from SE London providers: before 42 after 42 South East London 12 46 58 Other Trusts 1 18 19 13 64 77 6.3 Actions & Risks In response to the analysis of key issues at external trust and pathway level, the focus of the last six months has been on strengthening internal clinical engagement at tumour group level and harnessing this to support engagement with externally referring trusts, either by offering support to review pathways, or by offering capacity where we can assist. This has included writing to Trust Chief Executives to highlight where a referral has been received after day 62. The Director of Operations continues to chair a weekly meeting to monitor cancer waiting times and there are early indications of a risk to 62 day waiting times in the summer months arising from a combination of clinical complexity and patient choice in the holiday period. We will continue to make every effort to mitigate this risk by focusing on individual patient pathways. In addition to this, the Trust Cancer Committee has been revamped, which will bring together performance, pathway and service transformation work, and provide support and challenge where required at tumour level. The Director of Operations, Trust Cancer lead and Deputy Medical Director are meeting with each specialty to review the internally generated best practice checklist, as well as focus on internal and external priorities highlighted by themes identified in root cause analyses. Reviews of Urology and Lung have already been undertaken. In addition, improvements are being delivered in consistent turnaround of imaging and histo-pathology diagnostics. Page 8 of 10

The Trust has appointed an interim Cancer Programme Manager who has been able to take forward our action plan to improve our internal processes, but more significantly, to progress the joint work between clinical teams within South East London hospitals in each tumour group. This work has progressed under the auspices of a commissioner led group of CCGs and providers following an external (NHS Intensive Support Team) review of South East London cancer pathways. Examples of the work each tumour group is undertaking to improve pathways include: Lung/Thoracic ensuring timely access to radiotherapy capacity and improving timeliness of referrals beyond SE London; Urology improving the clinical pathway in respect of TRUS and TP biopsy decisions and increasing the staffed theatre time available for robotic surgery; Gynae optimising the scanning and hysteroscopy diagnostic capacity to deliver true one-stop clinics at the beginning of pathway; Breast expansion of one-stop clinic capacity and continual flexing to meet variations in demand; Skin profiling of clinical capacity to meet variations in demand and closer working with plastic surgery to improve continuity between tumour groups; GI Surgery improved turnaround times for endoscopy investigations to enable quicker diagnosis At the last meeting, it was noted that Urology services present a significant risk to the achievement of the 62 day standard. There is considerable work being undertaken by providers to improve Urology services but it is apparent that the benefits of this will not be realised in time to improve patient pathways in Q3. In some other trusts two week wait performance has also dropped below the national standard in recent months and this will result in more late referrals to Guys and St Thomas, which puts additional pressure on the Trust. 7. C Difficile 7.1 Background The Board will be aware that the Trust was set a C Difficile target of 37, a 21% reduction from the previous year due to the way the baseline period was identified and used to set this year s target. The Trust has raised concerns formally but not yet achieved a review of the target which, given the formulae used, should have been set at 43 if Public Health England had used the end of the financial year figures. 7.2 Current and Future Performance We have, however, not been complacent about the risk of C Difficile and continue with all of our actions including a real focus on antibiotic prescribing. Unfortunately there has been a steep increase in positive toxin cases, with 19 to date against 4 in the same period last year. This increase is mirrored across other London Trusts as well. Each case of C Difficile is reviewed to identify if there have been any lapses in care, which if proven will incur a 10,000 fine. To date out of the 19 cases there has been one case where there has been a possible lapse in care. 7.3 Actions and Risks At present we cannot identify any new actions that we can put in place, therefore we have invited Mathew Wilcox who is acting as an expert reviewer to come in and assess our C Difficile action plan and to advise if there is anything else we can do. He will be with us at the beginning of August. Page 9 of 10

8. Conclusion Overall, the Trust has maintained the improvement in performance that was achieved last year; especially in A&E and cancer. However, as set out in this paper, there are a series of actions being taken to ensure A&E performance is sustained and cancer performance is improved, particularly in relation to external referrals. We will see a planned deterioration in our position against the Monitor Risk Assurance Framework in Quarter 2 as a result of the actions we have agreed with commissioners to increase elective activity and focus this additional capacity on our longest waiting patients. This will have the positive benefit of reducing the backlog of patients waiting over 18 weeks and should put the Trust in a position to achieve the referral to treatment targets from Q3 onwards. However, as noted above, there are a number of risks with this approach, not least the likelihood that referrals will continue to increase. We have seen a steep increase in C Difficile cases, with 19 to date against 4 in the same period last year, which is mirrored across other London Trusts. We have invited an expert reviewer to come in and assess our C Difficile action plan in August to advise if there is anything else we can do. Page 10 of 10