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Gloucestershire

Health Overview and

Scrutiny Committee

CCG Performance Report

September 2019

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Report Title

Gloucestershire CCG Performance report

Health Overview and Scrutiny Committee – September 2019

Purpose of Report

The performance framework report provides the Committee with an overview of Gloucestershire CCG

performance against the ‘in year’ organisational objectives 2018/19.

A full summary of performance against all national and local standards as reported to GCCG Governing Body

is included, with supporting narrative to inform members of key system actions to support continued

performance or mitigating actions to give assurance where performance is below target or there is outlying

variation across the county.

Is this for information

or decision?

This Report is for information.

Authors

Kat Doherty, Performance Manager, GCCG

Key Issues:

• A&E performance to 4 hour target across Gloucestershire system remains above 90% and is the best performing STP nationally for

July 2019.

• DToC performance has improved in June 2019 to meet the national standard.

• RTT performance for Gloucestershire continues to improve, and 52 week breaches are reducing in line with agreed performance

trajectory.

Recommendations to the Committee:

We recommend that this report be noted.

Financial/Resource Implications:

Financial implications considered in provider contracts.

Contents

1.0 Scorecard

2.0 Executive Summary

2.1 Leadership

2.2 Better Care

2.3 Sustainability

2.4 Better Health

3.0 Better Care

3.1 Performance updates

This document is a highlight report which is presented to give the CCG Governing Body an overview of current

CCG and provider performance across a range of national priorities and local standards.

Whilst inevitably this report focuses on areas of concern it should be noted that Gloucestershire is currently

achieving the majority of the local and national performance standards.

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1.0 Scorecard: CCG Performance Overview

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CCG IAF assessments for 2018/19 were published 11th July 2019.

GCCG was rated “Good” overall.

2.1 Executive Summary – Leadership

This domain assesses the quality of the CCG’s leadership, the quality of its plans, how the CCG works with its partners, and the governance arrangements that the CCG has in place to ensure it acts with probity, for example in managing conflicts of interest.

2.1.1 Staff engagement : Robust culture and Leadership Sustainability (OD Plan)

2.1.2 Probity and Corporate Governance: Full governance compliance

2.1.3 Effectiveness of working relationships in the local system: Effectiveness of working relationships in the local system

2.1.4

Quality of CCG leadership: Review of the effectiveness of culture, leadership sustainability and an oversight of quality assurance.

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Green

2.2 Executive Summary – Better Care

This domain focuses on care redesign, performance of constitutional standards, and outcomes, including in important clinical areas.

Overall

Rating

2.2.1 Planned Care

2.2.2 Unscheduled Care

2.2.23 Cancer

2.2.4 Mental Health

2.2.4

Learning disability

2.2.5

Maternity 6

Amber

2.3 Executive Summary - Sustainability

This domain looks at how the CCG is remaining in financial balance, and is securing good value for patients and the public from the money it spends

Rating

2.3.1 Year to date surplus variance to plan (%)

2.3.2 Forecast surplus to plan (%variance)

2.3.3 Forecast running costs in comparison to running cost allocation (%)

2.3.4

Forecast savings delivery in comparison to plan (%)

2.3.5

Year to date BPPC performance in comparison to 95% target (%)

2.3.6

Cash drawdown in line with planned profile (%)

2.3.7 Forecast capital spend in comparison to plan (%)

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Green

2.4 Executive Summary – Better Health (1 of 2)

This section looks at how the CCG is contributing towards improving the health and wellbeing of its population, and bending the demand curve.

Current CCG Performance

Period National Glos

CCG

What is good? Trend

Smoking: Maternal smoking at delivery: The

percentage of women who were smokers at the time

of delivery, out of the number of maternities

*New*

Q4

18/19

10.9% 10.1% Low % Down from last

quarter (-)

Child Obesity: Number of children in Year 6 (aged

10-11 years) classified as overweight or obese in the

National Child Measurement Programme (NCMP)

attending participating state maintained schools in

England as a proportion of all children measured.

Next publication January 2020

2017/

2018

34.3% 32.1% Low % Up from last

year (-)

Diabetes: Three (HbA1c, cholesterol and blood

pressure) for adults and one (HbA1c) for children: The

percentage of diabetes patients that have achieved all

3 of the NICE-recommended treatment targets – New

indicators being measured for 2017/18 – update to

follow

2016/

2017 39.7% 36.4% High % No change

Personalisation and choice: Indicators relating

to utilisation of NHS e-referral service to enable

choice at first routine elective referral.

*New*

May

2019 79.7% 71.2% High %

Up from last

month (+)

These indicators show the latest known position from nationally available data

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2.4 Executive Summary – Better Health (2 of 2)

This section looks at how the CCG is contributing towards improving the health and wellbeing of its population, and bending the demand curve.

Current CCG Performance

Period National Glos CCG What is Good? Local Trend

Personal health budgets Per 100k

population Q3

18/19 59.9 144.6

High rate

(National target

100-200 by 2021)

Higher than Q2

2018/19

Percentage of deaths which take place

in hospital Q3

18/19 46.8% 40.4% Low %

Lower than

national average.

1% Higher than

2017/18 (+)

People with a long-term condition

feeling supported to manage their

condition(s). Next publication Nov 2019

2017/

2018 59.6% 64.0% High %

Lower than

2016/17 (-)

Health inequalities: Inequality in avoidable

emergency admissions for chronic ambulatory

care sensitive conditions – indicator not updated

Q3

17/18 1992.07 1889.33

Low rate

Indicator not

updated – to be

retired

Appropriate prescribing: Prescribing of

broad spectrum antibiotics in primary care (co-

amoxiclav, cephalosporins, and quinolones as a

percentage of total antibiotics prescribed)

12

months

to

March

2019

9.8% 8.7% <10% Lower than July

2018

Carers: Quality of life of carers Indicator methodology has been updated – awaiting publication

2018 Tbc 63.5% High %

No data

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These indicators show the latest known position from nationally available data

3.0 Performance Dashboard

78.4%

Performance (all Gloucestershire

patients)

2 Week Waits

2 Week Waits Breast

31 Day 1st Treatment

31 Day Waits Surgery

89.4% 100%

31 Day Waits Drugs

31 Day Waits Radiotherapy

62 Day GP Referral

62 Day Screening

62 Day Upgrade

99.0% 93.5% 100% 96.3% 66.5% 85.2% 70.6%

Planned Care

June 2019

RTT Incomplete <18 weeks RTT 52 week breaches Gloucestershire GHFT Gloucestershire GHFT

Diagnostics >6 weeks (Gloucestershire) (GHFT) .

Diagnostics >6 weeks (YTD) (Gloucestershire) (GHFT)

1.6% (all)

1.4% (all)

Unscheduled

Care

4 Hour A&E July (System)

4 Hour A&E July (GHFT)

Category 1 Ambulance July 19

(Gloucestershire)

Category 1 Ambulance YEAR TO DATE

(Gloucestershire)

92.2% 88.5% 7.3 mins 6.8 mins

Delayed Transfers of

Care (DToC)

June 19 (GHFT)

2.29%

IAPT

(YEAR TO

DATE)

June 2019

Access (target 1.42%)

Recovery (target 50%)

1.43% 50%

GHFT

Performance

Cancer

Dashboard (June 2019)

1.1% (GHFT)

0.8% (GHFT)

Dementia

Diagnosis

July 2019

Estimated Diagnosis Rate (Target 66.7%)

68.0%

Amber

82.0% 81.2% 85 86

89.4% 98.9% 93.8% 88.2% 100% 68.0% 78.6% 50% 85.2%

Key: Arrow direction = performance

RAG rating: Green = target achieved

Amber = within 10% of target Red = Target not achieved

3.1 System Overview Unscheduled Care

111 Call Volume 111 Disposition

Ambulance – Category 1

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System A&E 4 hr Performance

3.1 System Overview Unscheduled Care

GHFT average Length of Stay GCS average Length of Stay

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Gloucestershire whole system

performance was 92.2% in July 2019,

reflecting performance of 88.5% against

the 4 hour target at GHFT and 98.8%

across all MIIU sites. YTD whole

system performance is 91.4% against

the 4 hour target, with GHFT YTD

performance at 87.4%. Performance

remains volatile day-to-day however in

July the 95% national 4 hour standard

has been met across both Type 1 acute

sites several times.

National 4 Hour performance remains

challenging across the country, however

GHFT has managed to remain in the top

third of acute trusts (GHFT performing

19/119 acute trusts for Type 1 activity –

July 2019).

On an STP level, Gloucestershire

system ranks 1st out of 42 STPs for 4

hour performance (Type 1) in July 2019

at 88.6% and 2nd out of all STPs for all

4 hour performance across the STP

footprint at 92.2%.

3.1 Unscheduled Care – 4 hour A&E

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Top Line Messages:

Green

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3.1 Type 1 A&E performance to 4 hour target by site

Updates/Actions:

Focus for unscheduled care remains the 3 outcomes of the Urgent Care summit:

Theme 1: To identify opportunities to enhance positive “decision” making across Urgent

and Emergency Care.

Theme 2: Develop the “Home First” philosophy and pathways, reducing reliance on bed

based pathways.

Theme 3: Enhance streaming and signposting at Emergency Department “Front door”

While volume of activity for admissions has not significantly increased, spend on admissions

is significantly up, and a review of coding will be necessary to understand the reasons for

these increases.

Out of Hours (OOH):

• Summer months are challenging for shift fill, with higher numbers of vacancies. There has

been improved performance in KPIs – particularly timeliness of face to face contacts.

• Care UK are working well with test and learn in Cheltenham for colocation of Emergency

Department minors and OOH; further work on streaming of patients to the most

appropriate setting will be progressed from these pilots.

• CQC inspection of the service has been announced and will take place within the next few

weeks.

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3.1 Unscheduled Care

NHS111 – Performance for calls to NHS111 service

• Call abandonment rates remain volatile, but with particularly poor performance over

weekends (and some Mondays).

• Performance against the 60 second call answering standard has been challenging, with the

target missed on a number of days recently. Care UK have launched a “Back to Basics”

action plan to improve performance across all key metrics.

• Cat 3 and 4 call validation continues to ensure patients are treated in the appropriate setting;

Cat 2 checking is being stepped down as this has shown little impact. A national review of

which pathways would be benefit most from clinical validation is still outstanding and will

need to inform how call validation is taken forward.

• An increase in activity in NHS111 that has been seen in recent months is likely a result of

how calls are assigned regionally to a geographical area – BNSSG have seen an equivalent

drop in activity for the same period so the Gloucestershire increase is likely due to some calls

being assigned incorrectly from the North Bristol area.

• GP in SPCA pilot has been launched for 2 months from 18th July to support 111 calls

(immediate triage of GP dispositions from 111 outcomes). This GP will also provide in-hours

HCP advice for residential care homes in the county to try to reduce the use of SWAST in

particular by these care homes.

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3.1 Unscheduled Care - NHS 111

3.2 Unscheduled Care – Ambulance Category 1

Gloucestershire performance in Category 1 for July 2019 has risen slightly to 7.3 minutes on average, but remains within a

10% threshold of the 7 minute average response time target of 7 minutes. YTD performance across Gloucestershire is 6.8

minutes on average. SWAST Performance across all geographical areas (South West) was 7.2 minutes in July.

A national review of handover delays by NHSE has led to a country-wide focus on achieving a 50% reduction in 15 and 60

minute handover delays. Full details of the target and the plan for Gloucestershire will be presented at the A&E Delivery

Board. In the South West, additional resource is expected to be focussed on 8 acute trusts with poor performance around

handover delays. Gloucestershire is not in this cohort, so will be expected to implement the reduction in delays as

business as usual, taking on board any learning from other sites.

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Amber

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3.2 Unscheduled Care – Ambulance Category 2

Category 2 performance again remains above the target of an average response time of 18 minutes in July 2019. This

target has been missed consistently across the SWAST patch since the introduction of the ARP standards and remains a

focus for improvement for South West commissioners in 2019/20.

Increased demand on SWAST, particularly in Gloucestershire, has led to current over-performance against contract activity

throughout the YTD, but July has seen a reduction in this with above contract activity dropping to 3% (down from 8% at the

highest point in April 2019).

A working group has been set up to assess demand management for SWAST incidents and define actions to reduce

incidents requiring an ambulance response focussing on:

• 111 demand (validation of Category 3 and 4 calls)

• High Intensity Users

• Care home activity

Amber

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3.2 Ambulance Category 1 response performance by district

(April 2018 to date)

3.21 Unscheduled Care – Delayed Transfers of Care

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The DToC rate at GHFT has been above the 3.5% national target for the last 2 months, however for June has dropped

back to below the target threshold at 2.29%.

A plan to support the Urgent Care summit aim (Develop the “Home First” philosophy) has been developed, which will also

ensure delays in transfers of care are minimised. Key actions include:

• Review of the Community Hospital Bed model to enable rehabilitation and maximise patients potential;

• Early discharge planning & MDT communication from admission;

• Improving communication with patients, especially around funding for care;

• Development of the positive risk taking programme at GHFT;

• Care Home support project.

Amber

Top Line Messages:

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3.21 Long Stay (>21 day LoS)

A long stay patient is defined as a patient who has been in an acute hospital for a period of 21 days or more.

To meet the national ambition in reducing Long Stays in acute hospitals, GHFT have been set a target of reducing patients

with stays of longer than 21 days in the hospital to no more than 114 (average number of long stay patients in the hospital

during that week).

As of the 5th August 2019, the weekly average long stay patient figure was 108, equating to an 81 patient reduction and

meeting the ambition in full.

Green

3.3 System Overview - Planned Care:

Referral Trends Diagnostics

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Amber

RTT >18 weeks 52 week waits (RTT)

3.4 Planned Care – Diagnostics >6 weeks

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CCG Performance in June was 1.6% against the 6 week wait target, a slight decline on performance in May (which was

1.2%). There were 163 breaches of the 6 week target for GCCG patients in June across all tests.

GHFT performance declined to just miss the 1% target, with 1.1% in June (90 breaches).

Imaging performance has deteriorated in June, particularly in MRI. In particular, GHFT reported 24 breaches in MRI –

primarily due to issues with estates at the hospital.

Non-obstetric ultrasound remains an area of concern, with both GHFT and GP Care reporting 17 breaches of the 6 week

target. While GP Care have increased non-obstetric capacity and overall breach numbers are stable compared to May, the

service has flagged their continuing financial pressure around the provision of non-obstetric ultrasound, in particular soft

tissue ultrasound - for which they are the only current provider for direct GP access.

Cytoscopy and Urodynamics remain the tests with the lowest performance, however due to activity volume in these tests

this reflects a small percentage of the total breaches reported (Cytoscopy – 7 breaches, Urodynamics – 2 breaches).

Amber

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3.4 RTT

June 2019 data shows that GCCG

incomplete pathways (>18 weeks) stands

at 82% - an improvement in the locally

agreed planning target (for June the

trajectory was to achieve 78%. GHFT

performance for May was 81.1%. While

significantly below the national target of

92%, GHFT performance against this

standard benchmarks similarly to other

providers across the South West reflecting

the continuing pressure of demand for

consultant led treatment.

Reviewing the PTL (Patient Tracking List)

by week shows that there is a long tail of

patients waiting beyond 18 weeks, and a

significant number with “long waits” of

more than 35 weeks.

There were 86 fifty-two week incomplete

waiters: 85 of these were at

Gloucestershire Hospitals NHSFT across

a number of specialties, with the highest

number of breaches recorded in Upper

and Lower GI surgery and ENT.

Top Line Messages:

3.5 System Overview Cancer: June 2019

2WW (GP Ref’d) 2WW (Breast)

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Amber

76.0%78.0%80.0%82.0%84.0%86.0%88.0%90.0%92.0%94.0%96.0%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2018/19 2019/20 Target

CCG 2ww - 2018/19 to 2019/20

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2018/19 2019/20 Target

CCG 2ww Breast - 2018/19 to 2019/20

76.0%78.0%80.0%82.0%84.0%86.0%88.0%90.0%92.0%94.0%96.0%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2018/19 2019/20 Target

CCG 2ww - 2018/19 to 2019/20

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2018/19 2019/20 Target

CCG 2ww Breast - 2018/19 to 2019/20

76.0%78.0%80.0%82.0%84.0%86.0%88.0%90.0%92.0%94.0%96.0%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2018/19 2019/20 Target

CCG 2ww - 2018/19 to 2019/20

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2018/19 2019/20 Target

CCG 2ww Breast - 2018/19 to 2019/20

3.5 System Overview Cancer: June 2019

31 day 31 day subsequent treatm’t: Surgery

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31 day subsequent treatm’t: Drugs 31 day subsequent treatm’t: Radiotherapy

Green

3.5 System Overview Cancer: June 2019

62 day: Consultant Upgrade

62 day: GP referral 62 day: Screening

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Red

3.6 Cancer – 2 week waits (2ww)

In June 2019, 2 week wait performance was 89.4% for both GCCG and GHFT. For GCCG there were 215 breaches of the

2ww target –occurring in Lower GI (170 breaches – 55.3%) and Upper GI (17 breaches – 88.4%) specialties. All other

specialties met the 93% target in June showing excellent recovery, particularly in Dermatology, where there were only 7

breaches out of 466 patients seen (down from 83 breaches in May 2019).

The Trust have indicated that 2ww performance will remain below target in July in part as a result of Dermatology 2ww

referrals having increased by over 100 in July. A business case is proceeding within the Trust for additional Dermatology

resource while meetings progress with the CCG on demand management initiatives.

There has also been a notable reduction in the number of patients using the lower GI Straight-to-test pathway as a result of

an increase in FIT testing (Bowel screening). An endoscopy task and finish group has been formed to focus on improving

capacity across all sub-types of referral for Lower GI.

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Amber

3.7 Cancer – 62 days

62 day treatment performance has remained stable since 2016, with 2018/19 end of year performance averaging 74.5%.

The ability of GHFT in particular to meet the 85% target has constrained by long term problems in capacity of their Urology

specialty, surgical waits and complex pathways in general (across several specialties in addition Urology e.g. Upper and

Lower GI) have also contributed to pressure on this target. GHFT have highlighted the number of new treatments for

cancers have risen – increasing by 19.7% as a whole in 2018/19 when compared to 2017/18. This is a significantly higher

rise than the referral volume, with conversion % of referrals also increasing at the trust from 2017/18 to 2018/19.

June performance was 68.0% for GCCG, and was 66.5% at GHFT.

There were 55 breaches (6 in Gynaecology (45.5%), 4 in Haematology (42.9%), 5 in Head and Neck (28.6%), 10 in Lower

GI (56.5%), 7 in Lung (56.3%), 1 in Upper GI (93.3%), 22 in Urology (42.1%)).

In June 2019 there were 19 104 day breaches for first treatment for GCCG patients, of which 18 were first seen GHFT,

and 1 at North Bristol Trust. This comprised: 13 Urology (including the patient first seen at NBT), 2 Gynaecology, 2

Haematology, 1 Lung and 1 Lower GI.

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Red

Actions to improve performance:

GHFT is looking to reliably improve performance across several specialties to mitigate the continuing impact of

Urology performance – this impacts both the 2ww standard and 62 day performance and includes:

Trust actions:

• Demand and Capacity modelling across all specialties led by Deputy Cancer services manager;

• Pathway analysis to be conducted in conjunction with NHSI in July for Prostate, Lower GI, Gynaecology and

Head and Neck;

• Daily Cancer huddles to be piloted in Gynaecology, Head and Neck and Urology from July onwards;

• Introduction of best practice timed pathways (Cancer Alliance has supported the latest bid for this work);

• Direct Access for GPs for Ultrasound (Post-Menstrual Bleeding pathway) – pilot due for July;

• Continuation of GLANSO lists for endoscopy (in July);

• 0-7 day booking to start in August onwards;

• Band 5 Pathway Coordinator and Pathway Tracker for Urology due to go out for interview in July.

GCCG/GHFT Combined actions:

• Continued review of primary care referrals by the referral improvement project team to identify patterns and

reduce variation.

• Dermatology currently scoping out the use of a Referral Assessment Service (RAS) in order to triage

referrals and divert to most suitable pathway for patients.

• Roll out of Cinapsis A&G platform (September go-live) for dermatology in conjunction with dermatoscope

equipment and training in primary care.

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3.7 Cancer – Actions and updates

3.8 System Overview: Mental Health - IAPT

Access Recovery

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Green

In-Stage Waits

3.8 Mental Health - IAPT

Top Line Messages:

Recovery performance has been

excellent throughout 2018/19, with the

50% target being met in each month, and

this has continued into the new financial

year with June 2019 performance at 50%.

June access was 1.43% and the YTD

cumulative access is 4.29% (against a

target of 4.25%). The access rate target

will be held at the equivalent (if based on

12 months) of 17% for Q2, to ensure in-

stage waits can be managed (see below).

2G have been working to resolve the

ongoing issue regarding “in-stage” waits

for a second treatment appointment.

These waits particularly affect patients

waiting for Step 3 therapy. The numbers

of patients on the backlog waiting lists

have stabilised and it is anticipated that in

Q2, the number of people waiting will

reduce further, supported by:

• Use of IESO (digital based therapy);

• Enhanced supervisory oversight at the

Step 2 / Step 3 interface;

• Group therapy for Step 3 treatment.

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Green

3.9 Continuing Health Care – Referrals

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Referral volume has been steadily increasing in recent months, with positive checklists received rising in the first 4

months of 2019/20 to 73 per month on average (compared with the 2018/19 average (61/month)).

Fastrack activity has also remained high – and Gloucestershire is an outlier in the rate for Fastrack funding provided.

This is being reviewed by the CHC team and a project is being established to consider the best way forward. Reviews

of patients remaining on Fastrack longer than 12 weeks have been prioritised by the team. Referral quality continues

to be an area of concern, with growing numbers of negative checklists received as well as an increase in both positive

checklist (CHC) and Fastrack referrals that are discounted.

Green

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3.9 Continuing Health Care Assessments completed in 28 days

Red

Top Line Messages:

Performance remains significantly below the 80% target for assessments to be carried out within 28 days of referral,

however July 2019 performance has improved on the position year to date to reach 50%. The average time waited for

assessments completed in July 2019 was 21 days for standard CHC (reducing the wait by more than 50% from the position

at the start of the year) and 108 days for LD cases.

Actions to support performance include:

• Monthly audits now being completed by Business Manager to review the administration and recording of completed

cases for full assessments, negative checklists & Fast Tracks.

• LA assessor and agency staff in place to support backlog reduction.

• Improved communication and contact between Brokerage and care homes.

• LD agency staffing and focus on long waits for assessment and review.

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3.10 Regional Comparison – June 2019

If you require more information than the data provided in the Monthly

Performance Report or Accompanying Scorecard please contact:

Performance Department - GLCCG.GCCGperformance@nhs.net

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