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Our Vision – to Improve the Health & Wellbeing of our Communities

Item Number: 6.2

GOVERNING BODY MEETING Meeting Date: 26 November 2014 Report’s Sponsoring Governing Body Member: Carrie Wollerton

Report Author: Prepared by Jennifer Loggie, Quality and Performance Team Facilitator

1. Title of Paper: Commissioning For Quality and Outcomes – Quarter 2 Report 2014/15 2. Strategic Objectives supported by this paper: (check those which apply) ☒ To create a viable & sustainable organisation, whilst facilitating the development of a different, more innovative culture ☒ To commission high quality services which will improve the health & wellbeing of the people in Scarborough & Ryedale ☒ To build strong effective relationships with all stakeholders and deliver through effectively engaging with our partners ☐ To support people within the local community by enabling a system of choice & integrated care ☒ To deliver against all national & local priorities incl QIPP and work within our financial resources 3. Executive Summary: This report provides an overview of our progress and activities in Commissioning for Quality and Outcomes predominantly between 1 July and 30 September 2014. Key areas to bring to the Governing Body attention include:

• Sign up to safety commitment • Update on mortality data • A&E including ambulance handover times • Progress on work to reduce falls • Progress on reducing health care acquired infection • Referral to treatment time targets • Cancer waiting times • Safeguarding

4. Risks relating to proposals in this paper: This paper provides an update to the Governing Body. Risks relating to Quality and Outcomes are managed through the Quality and Performance Committee risk register. 5. Summary of any finance / resource implications: N/A 6. Any statutory / regulatory / legal / NHS Constitution implications: N/A

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Our Vision – to Improve the Health & Wellbeing of our Communities

For further information please contact: Name: Carrie Wollerton Title: Executive Nurse ☎: 01723 343654

7. Equality Impact Assessment: N/A 8. Any related work with stakeholders or communications plan: N/A 9. Recommendations / Action Required The Governing Body is asked to note this report. 10. Assurance The Quality and Performance Committee receives monthly reports relating to the quality and outcomes of patient care.

NHS SCARBOROUGH AND RYEDALE CLINICAL COMMISSIONING GROUP Commissioning for Quality and Outcomes Second Quarter Report 2014/15

18/11/14

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Contents 1. Introduction .................................................................................................................. 3

2. National/Local Developments ..................................................................................... 3

2.1 NHS England Annual Review 2013/14; a year of putting patients first..................... 3

2.2 Outpatients Appointment Survey; May 2014 ........................................................... 3

2.3 National Care of the Dying Audit for Hospitals ........................................................ 4

2.4 Sign Up to Safety; Safety Pledges .......................................................................... 6

2.5 Cardiopulmonary Resuscitation; new guidance ....................................................... 7

2.6 My NHS; comparative website tool ......................................................................... 7

2.7 Quality Assurance Strategy ..................................................................................... 8

3. Quality and Performance - Patient Safety .................................................................. 8

3.1 Mortality .................................................................................................................. 8

3.1.1 Mortality – Monthly Time Series .............................................................................. 9

3.2.1 Mortality - Comorbidities ....................................................................................... 11

3.2 Ambulance Service ............................................................................................... 12

3.2.1 Response Times ................................................................................................... 12

3.2.2. Handover Times ................................................................................................... 13

3.3 Serious Incidents (SIs) and Never Events ............................................................. 16

3.4 Healthcare Associated Infection (HCAI) ................................................................ 18

3.4.1 Methicillin resistant Staphylococcus Aureus (MRSA) bacteraemia ....................... 18

3.4.2 Clostridium difficile (C.diff) .................................................................................... 19

4. Quality and Performance - Clinical Effectiveness .................................................. 20

4.1 Strategic Clinical Network Development (SCN) ..................................................... 20

4.2 Strategic Clinical Network Activity (SCN) .............................................................. 21

5. Quality and Performance - Patient Experience ........................................................ 24

5.1 CCG Patient Relations .......................................................................................... 24

5.2 Provider Complaints/Feedback ............................................................................. 26

5.2.1 YFT Complaints and Feedback ............................................................................ 26

5.2.2 Tees, Esk and Wear Valley (TEWV) Mental Health Provider ................................ 28

5.3 Referral to Treatment Times (RTT) ....................................................................... 29

5.4 Cancer Waiting Times ........................................................................................... 30

5.5 Accident and Emergency Services (A&E) ............................................................. 31

5.6 Friends and Family Test (FFT) .............................................................................. 33

6. Commissioning for Quality and Innovation Framework (CQUIN) ........................... 36

7. Care Quality Commission (CQC) .............................................................................. 36

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7.1 Key CQC Inspection Activity Report ...................................................................... 38

8. Safeguarding Children ............................................................................................... 38

8.1 Child Sexual Exploitation (CSE)............................................................................ 38

8.2 CSE in North Yorkshire and York .......................................................................... 39

8.3 North Yorkshire Referral Process .......................................................................... 40

8.4 Child Protection Conference Reports for Medical Practitioners ............................. 40

8.5 Looked After Children (LAC) Initial Health Assessments Re-audit ........................ 40

8.6 Health Passports for Care Leavers ....................................................................... 41

8.7 Young and Yorkshire ............................................................................................ 41

9.0 Safeguarding Adults .................................................................................................. 41

9.1 Mental Capacity Act (MCA) and Deprivation of Liberty Safeguard (DoLS); Development Project ....................................................................................................... 42

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1. Introduction The purpose of this report is to provide an overview to the Scarborough and Ryedale Clinical Commissioning Group (the CCG) in relation to Commissioning for Quality and Outcomes. This report includes relevant key developments and policy updates that have occurred in this quarter.

This report primarily sets out summaries of the quality and outcomes in respect of main services commissioned, and actions that are currently underway to improve quality and outcomes.

This report is additional to the performance exceptions report that is provided bi-monthly to the Governing Body, and aims to give the Governing Body insight into, and overview of, the proactive and reactive work of the quality and performance team and the measures used to promote patient safety, patient experience and clinical effectiveness.

2. National/Local Developments

2.1 NHS England Annual Review 2013/14; a year of putting patients first NHS England has published its Annual Review 2013–14: A year of putting patients first. The review details some of the successes over the last year and includes case studies showing how the organisation has put patients first. One of the case studies shows how patients in six GP practices in Wakefield, West Yorkshire are benefiting from extended opening hours with longer appointments for people with more complex needs. The Family and Friends Test (FFT) is also highlighted which has gathered more than three million individual pieces of feedback from patients about their care since its launch in April 2013.

The report can be read in full at the link below:

http://www.england.nhs.uk/wp-content/uploads/2014/09/nhse-annual-rev.pdf

2.2 Outpatients Appointment Survey; May 2014 The findings of the Outpatients Appointment Survey have been published. Over 2,700 patients participated in the survey on behalf of NHS England and the health regulator Monitor, which looked at the number of patients being offered choice of provider by their GPs.

51% of patients were aware of their legal right to choose a hospital or clinic for an outpatient appointment, and a similar proportion (53 %) referred for an outpatient appointment first had a discussion with their GP about where to receive treatment.

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Less than two fifths of patients, however, said they were offered a choice of hospital by their GP when being referred for an outpatient appointment.

It is important that, in consultation with their GPs, patients are offered their legal right to choose as set out in the NHS Constitution, particularly given the differences between hospitals on such things as waiting times.

The survey also found that:

• people from black and minority ethnic groups were more likely to have discussed choice with their GP (66% compared with 52% of white patients) although less likely to be aware of their legal right beforehand (42% compared with 51% of white patients)

• people not currently working, including retired people, were more likely to be aware of their right to choose (55% compared with 46% of those who are working)

• people in rural areas were more likely both to be aware of their right and to have been offered a choice of provider for their care and treatment (45% compared with 36% of those in urban areas)

• Most of those who were offered a choice felt that they had enough information to choose (89%), and were able to go to their preferred hospital or clinic (92%).

As previously reported the CCG has commissioned a referral support service which will be fully implemented across our GP practices during the course of November 2014. This service will ensure that our patient population receives choice of provider for their care and treatment needs.

The findings of the report can be read in full here:

http://www.england.nhs.uk/wp-content/uploads/2014/08/populus-surv-res-summ.pdf

2.3 National Care of the Dying Audit for Hospitals The findings from the National Care of the Dying Audit have been published in May 2014. The Royal College of Physicians (RCP) in collaboration with Marie Curie Palliative Care Institute Liverpool (MCPCIL) prepared the aforementioned report, which can be read in full by clicking on the following link.

https://www.rcplondon.ac.uk/sites/default/files/ncdah_national_report.pdf

The desired outcome from the report is the expectation that it will contribute to continual learning and improve the care and experience for dying patients and their loved ones.

The audit was comprised in three sections, these were:

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• Organisation – key elements that underpin delivery of care • Case note review – anonymised case note review of the patients who died

within a certain timeframe, excluding sudden unexpected deaths • Local survey views of bereaved relatives or friends – using validated self-

completion questionnaire to understand and assess care delivery in the last days of life.

The report is lengthy and detailed, however some of the key findings are:

• Only 21% of sites had access to face-to-face palliative care services 7 days per week, despite a longstanding national recommendation that this be provided; most (73%) provided face-to-face services on weekdays only.

• Mandatory training in care of the dying was only required for doctors in 19% of trusts and for nurses in 28%, despite national recommendations that this be provided. 82% of trusts had provided some form of training in care of the dying in the previous year; 18% had not provided any.

• Most patients (87%) had documented recognition that they were in the last

hours or days of life, but discussion with patients was only documented in 46% of those thought capable of participating in such discussions. Communication with families and friends was recorded in 93% of cases. These discussions occurred on average 31 hours prior to death.

• In keeping with national guidance, most patients (63-81%) had medication

prescribed ’as required’ for the 5 key symptoms which may develop at the end of life. In the last 24 hours of life, 44% received medication for pain and 17% for dyspnoea. 28% had a continuous subcutaneous infusion of medication via a syringe driver.

• 76% of those completing the questionnaire reported being very or fairly

involved in decisions about care and treatment of their family member; 24% did not feel they were involved in decisions at all.

• Overall, 76% felt adequately supported during the patient’s last 2 days of life;

24% did not. The CCG along with York Foundation Trust (YFT) discussed the findings of this audit during the September Quality and Performance Sub-Group meeting. The Trust have devised an action plan which was shared with commissioners and will be reviewed as and when necessary.

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2.4 Sign Up to Safety; Safety Pledges In our Quarter 1 report we discussed the sign up to safety initiative, which is a national campaign launched on 24 June 2014 with the mission to strengthen patient safety across the NHS and make it the safest healthcare system in the world.

The five Sign up to Safety pledges and the actions we will undertake in response are set out below, and we will publish this on our website for staff, patients and the public to see. The following also show our commitment to turn these actions into a safety improvement plan which will show how we intend to save lives and reduce harm for patients over the next 3 years.

1) Put safety first. Commit to reduce avoidable harm in the NHS by half and make public our goals and plans developed locally. We will: • Ensure the patient focus is central to everything we do • Support the development of a culture that is committed to learning and improvement and that continually strives to reduce avoidable harm • Continue with our focus on reducing HCAI in line with agreed trajectories • Ensure robust arrangements are in place for safeguarding adults and children • Work with our providers on ensuring staffing levels to drive up standards of care and reduce avoidable harm

2) Continually learn. Make our organisation more resilient to risks, by acting on the feedback from patients and by constantly measuring and monitoring how safe our services are. We will: • Actively listen, respond to and involve patients and the public in planning, design, development and delivery of the services we commission. • Seek assurance from healthcare service providers in relation to actions taken in response to complaints and compliments • Monitor staff survey results and ensure that actions are taken to resolve any significant concerns. • Capture real time patient/carer experiences to inform service improvements and future commissioning.

3) Honesty. Be transparent with people about our progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong. We will: • Actively promote the involvement of patients in discussions about their own care and treatment • Ensure our health priorities support and actively enable safer patient care, driven by honesty and candour • Work collaboratively to promote a culture of openness, transparency and inclusiveness to drive the delivery of high quality care, holding healthcare providers to account on their contractual duty of candour

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4) Collaborate. Take a leading role in supporting local collaborative learning, so that improvements are made across all of the local services that patients use. We will: • Promote a culture of reflective learning and improvement • Promote organisational learning from patient safety incidents and complaints • Promote open communication between providers and commissioners to improve service provision and care delivery

5) Support. Help people understand why things go wrong and how to put them right. Give staff time and support to improve and celebrate progress. We will: • Identify, reduce and learn from patient safety incidents identified through incident reporting and soft intelligence • Actively performance manage and publicly disseminate learning from incidents to improve care • Promote activities across the local healthcare system that supports staff learning, demonstrating the celebration of best practice • Work with providers to develop a patient focused complaints process that utilises a consistent approach and is easily accessible.

2.5 Cardiopulmonary Resuscitation; new guidance The British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing have published new guidance on decisions relating to cardiopulmonary resuscitation (CPR), which replaces the 2007 Joint Statement published by the three organisations. The guidance has increased emphasis and additional information on advance care planning, communicating and recording decisions, communicating decisions to other healthcare providers, and reviewing CPR decisions. The guidance also takes into account the Court of Appeal judgement in the recent Tracey vs Cambridge case, which concluded that there should be a presumption in favour of patient involvement and that there needs to be convincing reasons not to involve the patient.

The new guidance can be found on the following link:

https://www.resus.org.uk/pages/DecisionsRelatingToCPR.pdf

2.6 My NHS; comparative website tool A new comparison website tool has been published that allows health and social care organisations to see how their services compare with those of others.

‘MyNHS’ is a transparency web tool that compares on a range of outcomes at both national and regional level.

It has been developed by NHS England, together with the Department of Health, the Health and Social Care Information Service, the Care Quality Commission and Public Health England.

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MyNHS gives commissioners, providers and professionals a central snapshot of published data, to drive improvements in the quality of care.

The information currently covers hospitals, providers of social care and public health, and supports the wider commitment on ensuring more transparent health and care services.

The data is now available on NHS Choices website and will be developed further in the coming months to include more areas and reflect feedback from users.

2.7 Quality Assurance Strategy The CCG has been working on the development of a Quality Assurance Strategy in order to make clear the CCGs approach to monitoring and supporting improvement in our commissioned services, and the actions we take when there are signs of a failing service. This strategy will be further developed through the Quality and Performance Committee and will be published during Quarter 3.

3. Quality and Performance - Patient Safety The CCG Quality and Performance Committee continue to meet monthly and discuss a variety of standing and new items at each meeting. The Committee manages a risk matrix which feeds into the corporate risk register. The safety of our patients is fundamental to the business of the CCG. The monitoring of our commissioned services is through contractual arrangements, via national reporting at Trust level, and through the triangulation of data coming into, and sought by the CCG team.

3.1 Mortality Reducing unexpected mortality is a priority for the CCG and for our main acute provider, YFT. The Summary Hospital-level Mortality Indicator (SHMI) reports on mortality at trust level across the NHS in England.

The latest data has been produced using an interim solution from colleagues in our Business Intelligence Unit, while we await our new reporting process for mortality data.

The following data shows the current situation for Scarborough General Hospital (SGH). It is sourced from the Healthcare Evaluation Data (HED) tool, and uses the same definitions and metrics as the Mortality Packs produced in 2013-14 by Yorkshire and Humber Public Health Observatory (YHPHO), these were our previous providers of our mortality reporting. As SHMI is regularly re-based, the latest part of the time series shows a discontinuity between the time series provided by YHPHO, and the latest 12 month period sourced from HED.

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Hospital Site Apr 11 - Mar 12

Jul 11 - Jun 12

Oct 11 - Sep 12

Jan 12 - Dec 12

Apr 12 - Mar 13

Jul 12 - Jun 13

Oct 12 - Sep 13

July 13 – June 14

York 110 105 105 102 99 96 93 94.9

Scarborough 115 117 112 106 108 108 104 106

Overall 112 108 107 104 102 101 97 * Awaiting confirmed range

* “The latest data was provided through an interim reporting solution where there was a choice of hospital based data or organisational based data. Hospital based data was judged to be the more useful, and thus provided. We are unable to calculate the overall organisational position due to the complexities of the calculations, but we will be able to source this once normal reporting of mortality is resumed.”

3.1.1 Mortality – Monthly Time Series The chart below shows the monthly SHMI time series. There is a discontinuity in the series; this is because of re-basing the SHMI expected death count, and finalising the actual death counts.

The latest data suggests no significant trend up or down in the series, but the monthly variation over the past 12 months is over a third lower than the previous 12 months.

Over the past 12 months the SHMI score has in all bar one month stayed below 100, which means the overall interpretation of current scores is that they fall within the ‘expected range’.

The SHMI for the whole of the latest 12 months was 106 as noted previously within the table above.

Chart 1: Monthly SHMI for SGH

The following two sub-charts show the changes in each of these series that influence the overall SHMI score:

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Monthly SHMI for Scarborough General Hospital, April 2010 to June 2014

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Chart 2 depicts the actual deaths data and chart 3 depicts expected deaths data that is used to construct the SHMI score. There was a small adjustment to the actual number of deaths in the latest series, mostly in the last month, but a greater change in the expected number of deaths which results from re-basing of the SHMI. Re-basing occurs when Health and Social Care Information Centre (HSCIC) recalculate the regression coefficient (Regression Coefficient is the term used when interpreting statistical data which represents the relation between the dependent and independent variables) each risk variable, such as age, gender, primary diagnosis, admission method, comorbidity and year of admission, using a later set of all England admissions. This results in a different expectation of death for each admission, when compared to the expectation of death calculation from the earlier set of all England admissions.

Chart 2: Actual Mortality for SGH

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Monthly Number of Actual Mortalities for Scarborough General HospitalApril 2010 to June 2014

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Chart 3: Expected Mortality for SGH

3.2.1 Mortality - Comorbidities Comorbidities are important in determining the expected number of deaths for a hospital, for example a richer case mix could result in a higher number of expected deaths. Chart 4, below shows the comorbidity score for the discharged spells each month.

Chart 4: Average comorbidity score

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This could be as a result of a change in the morbidity of patients, or a change in coding practices at the hospital, on review it does not appear to impact on the SHMI scores given the number of actual deaths is not affected, and the relationship between the crude mortality rate and SHMI remained fairly constant over the year, this is depicted on chart 5.

Chart 5: Crude Mortality and SHMI Comparison

3.2 Ambulance Service

3.2.1 Response Times As previously reported, ambulance response times remain a challenge across the wider geographical patch. The improvements made during Q1 have remained stable throughout Q2, however category A 19 minutes (transportation time) continues to remain under the 95% target.

Indicator (SR CCG) Target Q1 2014/15

July August Sept Q2 14/15

YTD 14/15

Red 1 8 minutes 75% 75.6% 72.0% 77.8% 72.9% 74.1% 74.9%

Red 2 8 minutes 75% 80.0% 79.3% 77.0% 81.3% 79.1% 79.6%

Cat A 19 minutes (transportation time)

95% 93.7% 93.3% 90.9% 93.3% 92.5% 93.1%

At the end of Quarter 1, YAS identified an action plan for improvement at regional level during Quarter 2 & 3, the following are actions currently being implemented:-

• Increasing triage capacity to enable increased clinical assessment at incidents • Introduction of Clinical Floor Walkers in 111 to review ambulance dispositions • Increasing Health Care Practitioner (HCP) resource, part of this will include:

o Formalise the Patient Transport Services crew resource as part of this mixed HCP resource to provide weekend support

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o Establish a HCP crew dispatch facility in the Emergency Operations Centre (EOC)

• Optimise use of existing resource, which will include: o Emergency Care Assistants (ECA) used as transport following

assessment by clinical hub o ECA respond as ‘First Responder’ to confirmed Red 1 calls

• Review Operational changes to include: o Review of shift patterns and meal break times and flexible working

arrangements o Review relief policy

• Recruitments to funded establishments (Paramedics and Emergency Care Assistants ECA’s)

• Development of forecasting tool to aid resource planning • Staff movement and flexible working • Implement a 24/7 procedure for road side standby with new standby points

We continue to work closely with YAS to understand reasons where we experience poor performance and support them to put in place improvement measures. The action plan will be monitored and updated as part of the monthly contract monitoring arrangements between commissioners in Yorkshire and Humber and YAS.

We continue to report the underperformance as part of the exceptions report.

3.2.2. Handover Times In line with the NHS Contract, YAS are reporting handover times to the Accident and Emergency Department (A&E) staff, with the aim of completing the process within 15 minutes.

Graph 1 below show the percentage of calls categorised as Red 1 & Red 2 per month that the ambulance crew ‘handed over’ within the target of 15 minutes. The chart also shows the number of calls split by those who were within the target and those outside of it.

Graph 2 shows the percentage of calls categorised as Red 1 & Red 2 per month that the ambulance crew turned around, therefore ‘handed over the patient to A&E, cleaned the ambulance and were ready to take the next call’, within the target of 25 minutes. It also shows the number of calls split by those who were within the target and those who fell outside of the target.

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Graph1: Handover within 15 minutes Graph2: Turnaround within 25 minutes

Delays to handovers of longer than 30 minutes and 60 minutes incur financial penalties. We had started to see improvements in breaches beyond 30 and 60 minutes in quarter 4 2013/14 with improvements over the year. In the first quarter of 2014/15 the Trust appeared to broadly sustain their position, despite a small increase during the course of May and June, when A&E attendances increased, which can be seen on the graph below.

Graph3: Percentage of Ambulance Handover within 15 minutes, by hospital, April – September 2014

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Moving into the second quarter of the year, attendances to the department continued to grow. During the course of July, August and September A&E attendances increased. During Q2 a total of 12,253 attendances were reported, in comparison to Q1 where a total of 10,968 attendances were reported, and this appears to have a knock on effect to handover times. A weekly summary including proxy number of breaches beyond 30 and 60 minutes is shown below since April 2014 to present.

Scarborough General Hospital - Performance by Week Week ending % within

15mins % 15 to 30

mins % 30 to 60

mins % 60 to

120 mins % > 120

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06/04/2014 73.8% 18.5% 6.8% 0.9% 0.0% 13/04/2014 74.5% 19.1% 4.3% 2.1% 0.0% 20/04/2014 73.5% 22.4% 3.5% 0.6% 0.0% 27/04/2014 68.5% 23.1% 5.2% 2.5% 0.6% 04/05/2014 73.4% 18.1% 7.2% 1.3% 0.0% 11/05/2014 57.7% 20.6% 12.5% 8.9% 0.3% 18/05/2014 71.1% 19.8% 6.2% 2.8% 0.0% 25/05/2014 79.6% 17.5% 2.7% 0.3% 0.0% 01/06/2014 67.8% 23.9% 7.8% 0.6% 0.0% 08/06/2014 69.0% 22.3% 8.5% 0.3% 0.0% 15/06/2014 60.6% 22.2% 12.5% 4.7% 0.0% 22/06/2014 64.9% 22.7% 8.3% 4.0% 0.0% 29/06/2014 71.5% 16.6% 9.5% 2.4% 0.0%

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rter

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06/07/2014 55.3% 24.8% 14.4% 4.1% 1.4% 13/07/2014 62.3% 24.6% 10.8% 2.3% 0.0% 20/07/2014 64.2% 21.0% 8.2% 6.3% 0.3% 27/07/2014 58.6% 20.3% 11.7% 8.6% 0.8% 03/08/2014 71.6% 22.1% 5.7% 0.6% 0.0% 10/08/2014 48.2% 23.5% 16.0% 10.1% 2.3% 17/08/2014 62.1% 26.3% 9.8% 1.7% 0.0% 24/08/2014 69.5% 17.5% 8.3% 4.6% 0.0% 31/08/2014 65.1% 24.2% 7.3% 3.4% 0.0% 07/09/2014 54.8% 28.3% 11.4% 5.4% 0.0% 14/09/2014 54.6% 23.0% 17.5% 4.6% 0.3% 21/09/2014 59.4% 21.9% 12.8% 4.3% 1.7% 28/09/2014 57.0% 24.8% 12.1% 4.5% 1.5%

Qua

rter

3 05/10/2014 70.4% 22.8% 5.7% 1.2% 0.0%

12/10/2014 51.4% 26.0% 13.3% 5.6% 3.7% 19/10/2014 51.2% 22.1% 15.6% 7.1% 4.1% 26/10/2014 59.3% 23.8% 11.9% 4.4% 0.6% 02/11/2014 73.3% 19.3% 7.4% 0.0% 0.0%

YTD Total 64.0% 22.1% 9.7% 3.6% 0.6%

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Delays to assessment and treatment have the potential for harm and a poor patient experience. The performance has slipped significantly into quarter 2 and it is clear more work needs to be undertaken to look at how a sustainable improvement can be achieved.

Current actions that CCG are undertaking to work alongside the provider to address and support improvements to the performance issues include:

• Operational resilience planning based around implementation from Perfect Week; closer CCG involvement in plans and roll out.

• Discussion at our monthly Contract Management Board (CMB) which includes representatives from both the CCG and York NHS Foundation Trust (YFT), to focus on improving patient flow through the hospital; the work around ‘operation fresh start’ will support this.

• Monitoring of performance through monthly dashboard meetings • Exploring with our GP community and with YAS about how we can reduce

A&E attendances including working towards direct GP admissions to wards and reducing number of calls to YAS that result in conveyance to hospital.

3.3 Serious Incidents (SIs) and Never Events Serious incidents are reported through our colleagues in the Commissioning Support Unit (CSU). The team have been collating the number of serious incidents reported by each NHS provider who deliver a service for our patients, plus those patients from surrounding CCGs. The CSU provide a comprehensive report which is presented each month at our Quality and Performance Committee Meeting, the purpose of the monthly report is to allow the North Yorkshire and York CCGs (NY&Y CCGs) to identify emerging themes or trend between providers. The Quality Leads from each of the North Yorkshire CCGs meet together every 6 weeks to discuss each SI in detail, agree challenges to be put back to the provider where further clarification is needed, share learning and best practice, monitor action plans and close off SIs.

Listed below is each provider who reported an SI concerning an SRCCG patient, for the period ending 30th September 2014:

NHS Provider: July August Sept YTD York Hospital site 0 0 0 3

Scarborough Hospital (including Bridlington Hospital) 4 6 2 27

Tees Esk and Wear Valley 0 0 1 1

Leeds Teaching Hospital Foundation Trust 0 0 1 1

Yorkshire Ambulance Service 0 1 0 4

TOTAL 4 7 4 36

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As Scarborough and Bridlington Hospitals are the main providers for our CCG, the number of SIs for Scarborough and Ryedale CCG at these sites, is summarised in the graph below by type of SI (please note, the graph reports 17 SIs for Q2, however 2 of the listed incidents relate to other CCG patients):

York Foundation Trust (YFT) began reporting Grade 3 & 4 pressure damage as Serious Incidents (SI’s) and Falls where the patient experiences harm, across all its hospitals and community settings as SI’s since the 1st April 2014. This is in line with national guidance and has resulted in an increase in the number of SI’s reported by the Trust to Scarborough & Ryedale CCG. The number we had received in Quarter 1 exceeded the total number of SI’s in the previous year and this continues to escalate.

There is a backlog of SI reports and action plans being completed by YFT; there are 20 Pressure Ulcer SI’s open at the end of Quarter 2. Due to the number and quality of SI reports that are being submitted by the Trust, Yorkshire and Humber Commissioning Support (YHCS), who manages the SI service on our behalf, have held three meetings with York Trust to discuss the process and have agreed that combined Pressure Ulcer review reports will be completed with key themes identified and action plans included. The Trust have established twice monthly Pressure Ulcer Review Panels to discuss Pressure Ulcer SI’s and agree actions. We are awaiting receipt of the newly agreed format of the Trust Pressure Ulcer review report.

There is a backlog in the incident reports related to Falls being completed by YFT. At the end of Quarter 2 there are 9 open SI’s.

YFT has approved a new Falls Policy and revised the assessment tool currently being piloted in community hospitals in paper format. An electronic tool is in process of development, to use on both acute hospital sites. Until this is available the current

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assessment tools continue to be used. This has been identified as an organisational priority.

At every opportunity principles of care identified in the new policy, and learning from SIs are reinforced with staff. Additional training has been delivered for Root Cause Analysis (RCA) investigations.

The Trust recognises from analysis of incident reports relating to patients falling in hospital, that there are some contributory factors which regularly feature. With this information the revised RCA tool will indicate several recognised contributory factors, which should be considered in all patient falls incident investigations, these will include:

• Nursing staff numbers and grade at the time of the incident • Delirium / confusion • Patients in side rooms • The use of bed rails • Postural hypotension • Polypharmacy

3.4 Healthcare Associated Infection (HCAI) As Commissioners, we assure ourselves that the services which we commission are compliant with legislation and have plans in place to monitor and review all health care associated infections within their population. The CCG commission Infection Control operational services from the Community Infection Prevention & Control Team hosted by Harrogate Foundation Trust and a strategic service from Yorkshire and Humber Commissioning Support (YHCS).

3.4.1 Methicillin resistant Staphylococcus Aureus (MRSA) bacteraemia NHS Commissioning Board’s NHS planning guidance for 2014/15, Everyone counts: Planning for patients 2014/15, sets a zero tolerance approach to MRSA bloodstream infections, there have been zero MRSA bacteraemia assigned to SRCCG from April 2014 to date. The table below provides a comparison of output against previous years attributed cases.

NHS S&R CCG community attributed cases from 2012 – 2014/15

MRSA Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Total

2012/13 0 0 0 0 0 0 0 0 1 0 0 0 1

2013/14 1 1 0 0 1 0 0 0 1* 0 0 0 4*(3)

2014/15 0 0 0 0 0 0 0

* April 2013 case appealed and removed for CCG cases

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3.4.2 Clostridium difficile (C.diff) NHS England set annual reducing Clostridium difficile infection (CDI) objectives for all NHS organisations. SR CCG objective for 2014/15 has been set at 34 cases and a rate of 30.8 per 100 000 head of population. This objective has decreased by 13 cases from the 2013/14 objective and is based on an 8% reduction on actual output for 12 months ending October 2013.

The national HCAI mandatory reporting database records that 14 cases of CDI have been assigned to SRCCG to the end of September 2014, which is 2 cases (11%) below the monthly plan to be achieve the CCG annual objective and 4 cases less than 2013/14 year Quarter 2 position. This is demonstrated below in Figure 1 and Figure 2.

Figure 1: NHS S&R CCG CDI cases Vs Objective 2014/15

Figure 2: NHS S&R CCG CDI cases 2014/15 Vs CDI cases 2013/14

A review of the cases listed on the national healthcare associated database demonstrates that a peak of 7 cases occurred in September 2014. Further review

05

10152025303540

Cumulative SRCCG assigned cases 2014/15 vs objective

Objective

Actual cases

05

101520253035404550

Cumultive SRCCG assigned cases 2013/14 vs 2014/15

2013/14

2014/15

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demonstrates that of the 14 cases allocated to S&R CCG: 5 are GP samples, 3 are samples taken within 72 hours of admission to hospital and therefore fit the definition of community attributed cases and 6 cases are identified as a Trust attributed cases

The North Yorkshire Community Infection Prevention Team produce RCA summaries for Community attributed cases. Figure 6 provides key findings from community C.diff RCA’s undertaken in Quarter 2 2014. The community team also provide a C. diff card and advice leaflet to each patient following a toxin positive result and provide telephone follow-up support and advice within 7 days for those patients over 65 years.

Key themes from the Community attributed cases include the number of patients on a proton-pump inhibitor (PPI) that would benefit from review by the GP which has been fed back via GP communications and the majority of cases have received antibiotics within the previous 12 weeks from either primary or secondary care. The cases are sporadic and un-linked. The RCA Outcomes from York Foundation Trust have been requested.

4. Quality and Performance - Clinical Effectiveness The clinical effectiveness dimension of quality, means understanding success rates from different treatment for different conditions. Assessing this includes clinical measures such as mortality or survival rates, complication rates and measures of clinical improvement.

4.1 Strategic Clinical Network Development (SCN) A planned NHS England review will include the function of networks, NHS Improving Quality (NHS IQ), Academic Health Sciences Network (AHSN) and Clinical Senates and how they work together. This aims to create a better support system for CCGs; a decision on the future structure is expected in December.

The latest guidance from NHS England is “commissioners need to be satisfied that networks are being used for the following”:

• Addressing unwarranted clinical variation • Securing adoption of the most efficient clinical practices in services to free up

resources for patient care.

North Yorkshire and Humber Collaborative groups for Cancer and Cardiovascular Disease are now in place but no collaborative programmes have yet been agreed. Dates are also in diaries for Yorkshire and Humber oversight groups and discussions are underway to ensure representatives provide presence.

Specialist Services; arrangements for co-commissioning are being developed and have been broadened to cover more out of hospital care. Guidance is expected late

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autumn and will include: overview of models, opportunities and parameters of each, advice on conflict of interest management, financial flows and delegation process

4.2 Strategic Clinical Network Activity (SCN) Domain Key Points:

Cancer The national focus continues to be on 62 day pathways. Capacity within diagnostics and an increase in referrals continue to be key factors. Developing regular breach analysis meetings will help provide clarity on issues and corrective action required.

The CCG needs to work with the trust to review symptomatic breast service provision on the SGH site and ensure that timescales are realistic.

The priority pathways for Yorkshire & Humber are pancreatic, sarcoma and head and neck.

SCN have sent out a survey across North Yorkshire and Humber regarding issues within diagnostics and the appetite for bringing together a time limited group to explore this in more detail. Links to this group will be essential in ensuring regional work helps with local issues and minimises financial risk.

End of Life (EoL)

Leadership Alliance for the Care of Dying People (National Group) – It is anticipated this group will be disbanded with no national replacement planned. This could result in a lack of national leadership for EoL and no review of national strategy as had been planned, however locally SRCCG and VoY CCG continue to lead and support a local End of Life and Palliative Care Partnership Board that is currently working on a strategic approach. Palliative Care Funding Review – NHS England is planning workshops to update on the project and explain the next steps.

Cardiovascular Disease (CVD)

Prevention is high on the agenda with priorities seen as management of high blood pressure and detection and management of Atrial Fibrillation. There is an ambition to develop a Yorkshire and Humber wide CVD Prevention Strategy.

Stroke The regional stroke work is progressing. Key standards and performance indicators for hyper acute care are being agreed. A data pack for each provider will be produced showing their strengths and weaknesses against these standards. These will then be sense checked locally before regional discussion.

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Organisational Sentinel Stroke National Audit Programme (SSNAP) has been completed and results are being analysed for discussion at the December stroke meeting. The SCN has mapped out current provision of Early Supported Discharge (ESD) working with providers. The next stage needs to be working with commissioners to determine a service specification and discuss different funding mechanisms. This may not be in time to support current ESD plans.

Cardiac Specialist services are taking forward a review of Primary Percutaneous Coronary Intervention (PPCI) and complex device implantation services. The outcome may have an impact on patient flow within non-specialised services and this will be monitored. There is potential for regional resilience work on cardiology services, which would include agreeing standards for different levels of service and exploring developing a network of care across the region. This would be in line with the five years forward plan. A meeting has been planned to discuss and review in further detail.

Renal The SCN are developing a Cardiovascular Disease (CVD) Network Group which will incorporate Renal, therefore, the Local Implementation Groups have not been meeting. Acute Kidney Injury continues to be an issue. The use of e-alerts is already being rolled out in acute trusts and the aim is to do the same in primary care in 2016. CCGs need to consider how this will be done in their locality.

Diabetes The Diabetes Strategic Clinical Network Foot-Care group have developed a baseline assessment for local diabetic foot pathways and are working with all localities in Yorkshire and the Humber to undertake the assessment. The tool has been developed through a commissioner / provider working group. Work continues with providers on diabetes related amputation rates in the locality.

Critical Care North Yorkshire & Humberside Operational Delivery Adult Critical Care Network has reminded providers that they should be having ‘Trust Critical Care Delivery Group’ meetings on a regular basis and to re-establish them where necessary. Commissioner representation has been requested. Trusts are working on their feedback for the Specification for Critical Care Units and Standards for in Intensive Care Units and

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formulation of Network response to the draft consultation. If significant changes in resources are indicated then this has potential to result in an increased local tariff in the future.

Major Trauma Major Trauma Centres (MTC) and local trauma units are preparing for peer review in early 2015. Both centres and units are seeking improved consistency and standardisation in the approach to peer review. This is a process in its infancy and similar services are receiving variable outcomes on some measures. Local trauma units will need to ensure they are reporting and recording trauma data on the Trauma and Accident Research Network (National Database). Yorkshire and Humber CSU will work with local CCGs and NHS England in the coming months to support 'coupled' service specifications for MTCs and trauma units.

Children and Maternity

Close links are being forged with the North of England on the National Stillbirth Programme. Criteria for admission to neonatal units are being reviewed to address variation. A work programme for Child and Adolescent Mental Health Services (CAMHS) is being developed. Special Educational Needs and Disability (SEND) database also developed.

Mental Health and Dementia

Dementia - diagnosis rates in the North Yorkshire and Humber area are an issue, the Area Team have asked to meet with the SCN to discuss. The Mental Health Crisis Concordat is a national agreement between services and agencies involved in the care and support of people in crisis. It sets out how organisations will work together better to make sure that people get the help they need when they are having a mental health crisis, plans are in to sign off the Mental Health Crisis Concordat (MHCC) before the deadline of 31/12/14.

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5. Quality and Performance - Patient Experience

5.1 CCG Patient Relations The following tables detail numerically the type of contact made to the CSU, and the type of complaints made to the CCG and through the Partnership Commissioning Unit during the course of April – October 2014.

The rolling year to date (YTD) total is shown alongside the final total for the previous year 2013/14 to allow us to compare rates over each quarter. Colleagues in the Yorkshire and Humber Commissioning Support (CSU) look for themes and trends and provide analysis on each complaint made; this is fedback to our Associate Director of Corporate Affairs who liaises with the team and follows up any anomalies within the data.

Total Number of Complaints received during 2014

Summary of contact type

Total 13/14

YTD 14/15

April May June July August Sept Oct

Complaints 19 13 0 2 3 2 1 1 4

PALS 100 82

9 10 7 30 10 9 7

Compliments 0 2 1 0 0 0 1 0 0

Parliamentary and Health Service Ombudsman

0 1 1 0 0 0 0 0 0

NHS England 16 11 4 1 1 3 2 0 0

Total 135 109 15 13 11 35 14 10 11

During the most recent reporting period, 4 complaints were received for SRCCG: Total Number of Complaints received during 2014

Complaints

Total 13/14

YTD 14/15

April May June July Aug Sept Oct

CCG Commissioning 3 2 0 1 0 0 0 0 1

CCG Funding 2 0 0 0 0 0 0 0 0

CCG Joint with other organisations

2 3 0 0 0 0 0 0 3

CCG Total (excluding SRCCG PCU cases)

7 4 0 1 0 0 0 0 3

CCG total including SRCCG PCU cases)

19 13 0 2 2 2 2 1 4

SRCCG PCU Mental Health commissioning

1 1 0 0 0 0

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SRCCG PCU Children’s Services commissioning

0 0 0 0 0 0

SRCCG PCU CHC current assessment

8 4 0 0 1 1 2 0 0

SRCCG PCU CHC retrospective review

4 5 0 1 1 1 0 1 1

Of the complaints which were closed during October 2014 the main themes identified were:

• Delays – response delays to all the concerns raised by the complainant. • Miscommunication - complainant provided with misleading and inaccurate

information. Further explanations needed, which then resulted in further contact for clarity.

• Administration errors - mistakes and inaccuracies noted within responses to the complainant. Documents were not sent out as promised and evidence of legal authority had not been provided in initial stages, causing further delays.

Lessons learned: Our patient relations team has identified that more robust monitoring systems are required, to ensure that regular updates are received as to how individual cases are progressing which in turn, will enable complainants to remain fully informed and receive accurate updates. The Patient Relations Manager is now ensuring that every response addresses all issues raised and written in a personalised, yet appropriate and professional tone. In the most recent reporting period, 7 PALS contacts were received. Numbers continue to reduce and themes from October 2014 were as below:

The table below shows the number of contacts PALS received since April to October 2014. Of the 83 contacts received, 67 of these were in relation to general advice or a request for further information. A further 3 were in relation to complaints and the

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complaints procedure; the remaining 13 were signposted to GP practices, NHS England or another NHS organisation.

PALS

Total 13/14

YTD 14/15

April May June July August Sept Oct

CCG 28 63 5 7 5 30 8 6 2

Independent contractors

28 10 3 1 2 0 1 2 1

NHS Trusts 37 6 2 2 0 0 0 0 2

Other PALS calls 7 4 0 0 0 0 1 1 2

Total 100 83 10 10 7 30 10 9 7

5.2 Provider Complaints/Feedback Reports on complaints are provided regularly to the CCG both directly and via the Quality and Performance Sub Groups with top themes, trends and lesson learned identified.

5.2.1 YFT Complaints and Feedback Information in this section is extracted from YFT Board report shared quarterly with CCG.

Our main acute provider has a systematic approach to the collection and utilisation of patient experience data including regular monitoring and reporting on:

- Complaints - PALS activity - NHS Choices Feedback - Friends and Family Test - National Patient Surveys The Trust review all complaints and consider themes or emerging trends, over each quarter, the table below reports the total number of complaints received throughout July, August and September 2014, by site. During this quarter Medicine & Acute Medicine, Emergency Medicine and Obstetrics & Gynaecology are the specialities that received the highest number of complaints.

Complaints Received York Foundation t York Hospital

Scarborough Hospital

Total

New complaints Q2 (July to September 2014)

94 56 150

Figures for Q2 2013 (as a comparator) (July to September 2013)

75 81 156

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The Trust has to respond to complaints within 30 days to ensure compliance with the NHS Complaints regulations; over quarter 2 the Trust reported 19 responses were late. The top themes raised over quarter 2 have been reported as:

• All aspects of clinical care and treatment • Attitude of Staff • Communication and Information

Complaints by Directorate in Quarter 2 Directorate Child Health 2 Clinical Support Services 1 Elderly Medicine 9 Emergency Medicine 26 Facilities 1 Medicine (General & Acute) 27 Specialist Medicine 8 General Surgery & Urology 16 Head and Neck & Ophthalmology 16 Obstetrics & Gynaecology 19 Orthopaedics and Trauma 8 Anaesthetics, Theatres & Critical care 4 Community Services (District Nursing) 4 Sexual Health 2 Radiology 3 Corporate 1 Pharmacy 1 Physiotherapy 4 There were 3 new Ombudsman’s cases in Quarter 2. The Health Service Ombudsman delivered its decision on 1 complaint, which was not upheld.

Positive feedback is collected by the Trust in every quarter. A total of 1955 letters, cards and emails were recorded by the Patient Experience Team in the most recently reported quarter. As expected, given these are the things that matter most to patients, the themes from compliments mirror those issues raised in complaints, i.e. clinical care and treatment, communication and staff attitude. The feedback is also used as part of the customer care training within YFT.

The Trust handled 1589 PALS contacts in Quarter 2. Of these 325 were handled on the Scarborough site and 1264 were handled on the York site. PALS themes in this period include:

• Concerns relating to the pain clinic at Scarborough • Concerns relating to the audiology clinic at Scarborough • Callers concerned that telephones are not answered

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• Poor seating in Intensive Care Unit (ICU) for relatives

5.2.2 Tees, Esk and Wear Valley (TEWV) Mental Health Provider Our main mental health services provider Tees, Esk and Wear Valley (TEWV) deliver monthly performance reports in preparation for the monthly Contract Management Board (CMB) meeting. Our Partnership Commissioning Unit (PCU) has taken over the running of this contract on behalf of the relevant North Yorkshire CCGs. TEWV have reported 9 complaints across North Yorkshire CCGs; all of which came from the Adults Mental Health department, these are not all specific to SRCCG patients. Nevertheless of the 9 complaints, 2 were reported as attitude, 6 relate to aspects of clinical care and 1 relating to the environment.

The chart below shows the complaints by type for the full year June 2013 – June 2014. The CCG works alongside the PCU to gain further insight into the reporting of complaints and their outcomes. We continue to work with our partnership commissioning unit to develop our approach to monitoring complaints and PALs issues.

Complaints by Type: TEWV

Over the course of June, 18 PALS enquiries were dealt with by TEWV, the themes emerging across this month are:

• Clinical Care o Medication o Transfer o Deteriorating Mental Health

• General Advice o Benefits and Welfare o General Information

• Staff Compliments

As before, the following chart highlights the PALs enquiries by type covering the period June 2013 – June 2014.

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PALS by Type: TEWV

5.3 Referral to Treatment Times (RTT) The CCGs position against the 18 week referral to treatment time targets is reviewed monthly and reported through our dashboard and performance exception report on a bi-monthly basis. Performance issues are discussed at the Quality and Performance Committee and at each Governing Body meeting.

The main providers who are struggling to deliver the RTT target across all specialties are YFT and HEY.

Performance over the last four quarters for the CCG is shown in the table below:-

Referral to Treatment Waiting Times for non-urgent consultant led treatment

Indicator Target Q3 Q4

Year end

position 13/14 Q1 Q2

Referral to Treatment Pathways: Admitted

90% 89.2% 83.2% 87.6% 86.4% 80.3%

Referral to Treatment Pathways: Non Admitted

94.9% 95.5% 95.2% 95.1% 95.8% 95.7%

Referral to Treatment Pathways: Incomplete 91.9% 91.1% 92.7% 92.7% 92.5% 92.5%

Action Plans for recovery As part of a nationwide initiative to reduce long wait patients, the CCG is working closely with main providers to develop action plans to address the long wait patient backlog. The CCG has been working to address the challenges in delivery of the 18 week targets and detailed actions plans by specialty have been developed and are now in place.

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Plans are also now in place to utilise the additional 18 week resilience monies at both HEY and YFT and extra capacity is scheduled over the next 8 weeks.

Evening and weekend sessions have been put in place at YFT to treat long wait patients and maximise capacity, and capacity has also been secured at Independent sector providers in York. The Trust is working with another local NHS provider in order to offer choice of alternative location for a number of specialties over the next month.

Ophthalmology capacity on the Scarborough site remains problematic and discussions are ongoing internally at the Trust regarding additional capacity and also with private sector providers, with a view to utilising theatre capacity going forward.

Impact on performance As providers focus a higher proportion of capacity on long wait patients, this will have a short term negative impact on 18 week performance, mainly for admitted patients. However, this planned failure of the targets has been agreed with CCGs, Department of Health and Monitor will support sustainable delivery of the targets during the remainder of 2014/15 and beyond. Monitoring The Planned Care Group, which is a subgroup of the System Resilience Group, will oversee implementation of the Intensive Support Team recommendations, following their systemwide review in March 2014, which we have previously reported on. The Group will also monitor progress in terms of the 18 week back log clearance. RTT progress meetings are taking place on a weekly basis for YFT, where updates on additional capacity and delivered activity are provided. The impact on waiting lists is also monitored on a weekly basis to ensure a continued reduction in the number of patients waiting for treatment as a result of the additional work. The group is chaired by our Governing Body GP lead for quality.

5.4 Cancer Waiting Times Breast Symptomatic Following the decision to temporarily suspend the service on the Scarborough site and move this to York, performance for Breast symptomatic waiting times has improved significantly over the last few months.

Although a much improved postion, the Trust did not meet the overall target for Quarter 2, but based on the improved performance since July we would expect the target to be met from Quarter 3. Both the CCG and Trust are committed to reinstate this local service as soon as possible and the Trust is reviewing capacity and staff recruitment plans to support this.

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Cancer 2 week wait Increased numbers of referrrals are still putting pressure on site specific cancer performance, in particular in Skin and Urological suspected cancers, which we think is partly linked to recent national adversting campaigns around rasing cancer awarerness. CCG growth in ‘2 week wait’ referrals in the first and second quarters do reflect the national level of growth but these are putting extreme pressure on 2 week wait performance. There maybe lessons to be learned here about planning for the impact of national campaigns in the future.

Actual cancer diagnosis rates remain consistent with previous years despite the increase in referrals. The CCG is working closely with GPs in primary care, and has reissued the Cancer 2 week wait guidance to ensure continued adherence to the threshold criteria for referral. The CCG is also working with other CCGs to look at other model options to improve the referral pathways for these patients.

Performance over the last four quarters for the CCG is shown in the table below:-

Referral to Treatment Waiting Times for non-urgent consultant led treatment

Indicator Target Q3 Q4

Year end

position 13/14 Q1 Q2

Cancer 2 week wait 93% 93.5% 95.4% 95.9% 86.8% 87.5%

Cancer 2 week breast symptomatic 93% 71.0% 67.0% 80.0% 31.2% 63.7%

Improvement in the performance is expected during Quarter 3. The CCG alongside the Trust continue to monitor this target and report monthly on the situation to the Quality and Performance Committee.

5.5 Accident and Emergency Services (A&E) Accident and Emergency (also known as Emergency Department) has been challenged for several months, the A&E waiting time indicator, has regularly failed to meet the 95% target for patients waiting under 4 hours. During the period July to September, you can see within the table below that the department has narrowly missed the 95% target over the course of this period.

Indicator (SRCCG) Target July August Sept Q2 2014/15

YTD 2014/15

A&E waiting time: total time in the A&E department

95% 92.8% 92.4% 92.5% 92.6% 93.3%

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70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

Rate comparison with linear trend

HEY SGH STees Linear (SGH)

The CCG is actively looking at why the department is struggling to meet the 95% target, the graphs below identify variations between York Foundation Trust (YFT), Scarborough site in comparison to our neighboring Trusts; these being Hull and East Yorkshire Hospitals NHS Trust (HEY) and South Tees Hospitals NHS Foundation Trust (STH). These Trusts were chosen for comparison due to the similar variation in rates they have experienced over the course of this year, which will allow a fair comparison.

The chart below shows the 4 hour percentage rate for SGH, as well as HEY trusts and South Tees trust per week since April. The red trend line for SGH shows how the rate has deteriorated and could continue to deteriorate into quarter 3. Chart 1: Rate comparison with a linear trend:

The chart below shows how the 4 hour percentage rate has declined based on the day of the week with Friday, Saturday and Sunday experiencing poor results as these have traditionally been the busiest days, however recently it is Tuesday and Thursday which have seen deteriorating performance over the last 7 months.

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70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

Apr May Jun Jul Aug Sep Oct

Rate Comparison by Day - April - October 2014

Mon Tue Wed Thu Fri Sat Sun

Chart 2: Rate comparison by day:

The CCG acknowledge that attendances to the department are fluctuating; the table below shows the total number of attendances across the first two quarters of 14/15, and the comparison of Quarter 2 2013/14 against Quarter 2 of this year:

Indicator (SRCCG)

April May June July August Sept Q2 2013/14

Q2 2014/15

Total A&E attendances 3537 4609 3789 4897 3750 3606 12064 12253

A&E performance continues to be challenging. The hospital overall has been extremely busy during Quarter 2; when the hospital beds are full, flow through A&E is compromised. Therefore, the CCG together with the Trust are working to use the evaluation from the ‘Perfect Week’ improvement event to implement improvements as well as considering further options to support the Trust.

5.6 Friends and Family Test (FFT) The Friends and Family Test (FFT) is a simple test whereby patients are asked the question ‘How likely are you to recommend our ward/A&E department to friends and family if they needed similar care or treatment?’ Answering the question “Would you recommend this service to your friends and family?” will be extended to all NHS services in England, including mental health services, community nursing, primary care and outpatient appointments by the end of March 2015.

The Friends and Family test continues to be implemented across the Trust. The CQUIN framework for 2014/15 has a number of schemes relating to the Friends and

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Family Test (FFT) including roll out to community services, outpatients and day case patients, as well as a separate scheme which will see the Trust implement the FFT to staff on an ongoing quarterly basis from 1st April 2014.

As previously reported, the Trust has established an FFT project steering group and they continue to oversee the delivery of the FFT, monitor performance and future development of FFT. The Trust reports that, the development of the ‘knowing how we are doing boards’ is currently underway which will see feedback from FFT and other sources on their wards being displayed for staff, patients and relatives to see what patients are saying about their experience. The Knowing how we are doing’ boards will also provide information on a quarterly basis about what improvements have been made as a result of feedback – ‘You Said We Did’. Project work-streams for community services and outpatients meet regularly to implement FFT across the whole trust. During September, the FFT was rolled out further and is now being delivered across:

• Community Services (partial roll-out): o District Nursing o Fast Response Team o Intermediate Care Team o Health Visiting o Specialist Nursing

• Outpatients (partial roll-out): o York Main Outpatients o Specialist Medicine including Rheumatology, Dermatology,

Haematology, Chemotherapy o Radiology including VIU, Breast Screening, MIR, X-ray, o Selby/Bridlington Outpatients o Scarborough Outpatients o Head & Neck – all sites o Ophthalmology – all sites o Malton MIU

The table below shows the response rate and FFT score (Net Promoter Score) across Inpatients and A&E, the data has been broken down by each site, and as a comparator we have provided North Yorkshire and Humber area team position and the England position.

Inpatient June

2014 July 2014

August 2014

Response Rate (Whole Trust) 34.2% 41.6% 40.2% FFT Score (Whole Trust) 73 76 76 Response Rate (Scarborough Hospital) 27.4% 40.1% 44.4%

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FFT Score (Scarborough Hospital) 74 77 75 Response Rate (Bridlington Hospital) 60.8% 85.9% 71.1% FFT Score (Bridlington Hospital) 82 88 81 Response Rate (York Hospital) 34.7% 38.9% 36.0% FFT Score (York Hospital) 72 73 76 North Yorkshire and Humber Area Team Score 39.7% 39.8% 42.5% North Yorkshire and Humber Area Team Response Rate 75 76 76 England FFT Score 37.7% 38.0% 36.3% England Response Rate 73 73 73

A&E June

2014 July 2014

August 2014

Response Rate (Whole Trust) 33.9% 22.8% 20.0% FFT Score (Whole Trust) 47 55 44 Response Rate (Scarborough Hospital) 45.2% 35.9% 36.8% FFT Score (Scarborough Hospital) 63 59 67 Response Rate (York Hospital) 27.1% 14.5% 9.4% FFT Score (York Hospital) 31 49 34 North Yorkshire and Humber Area Team Response Rate 21.3% 16.9% 15.3% North Yorkshire and Humber Area Team Score 52 57 51 England FFT Score 20.8% 20.2% 20.0% England Response Rate 53 53 57 The Inpatient chart below, taken from YFT Patient Experience Board Report, shows the net promoter score for the whole trust, has remained stable at around 76. The red line indicates the response rate; this must remain above the 40% level to ensure the Trust achieves the CQUIN at Q4 2014/15.

The following ED chart, shows the whole trust A&E (also reported as Emergency Department – ED) FFT performance figures, again taken from the YFT Patient Experience Board Report. This depicts the current inconsistency of both the net

Trust IP Performance 2014/15

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promoter score and response rate. Currently the response rate falls short of meeting the national CQUIN, however the Trust is working hard to address this issue.

As previously reported, the A&E departments use a token system to gather feedback; NHS England has now provided new guidance around FFT, stating that the token system must not be used beyond 1st April 2015. At the beginning of October 2014, YFT will begin to use a text message service at the York A&E site, whereby patients receive a message to their mobile. Scarborough A&E site will continue to use the token and card system until the Trust has confidence in this new system, however the token system will be removed ahead of the 1st April 2015 deadline.

6. Commissioning for Quality and Innovation Framework (CQUIN) The monitoring of the CQUIN framework takes place through Contract Management Boards and the Sub Contract Management Board, Quality and Performance Groups on a monthly basis, with the majority of schemes reporting actual performance on a quarterly basis. Data is due for submission towards the end of the month following the end of each quarter, i.e. 31st October 2014 for quarter two.

We are currently assessing quarter 2 data and a full summary will be provided in the next report.

7. Care Quality Commission (CQC) The CQC replaced the Health Care Commission and since April 2010, all Providers of health care have been required by law to be registered with the CQC. Registration is subject to compliance with a regulatory framework based upon a series of regulations known as the “essential standards of quality and safety”.

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A new vision and direction for the Care Quality Commission has been published in their Strategy for 2013-2016, Raising standards and putting people first’ and in the recent consultation A new start, which proposed radical changes to the way they regulate health and social care services. The changes were developed with extensive engagement with the public, staff, providers and key organisations. There is strong support for the introduction of Chief Inspectors; expert inspection teams; ratings to help people choose care; a focus on highlighting good practice; and a commitment to listen better to the views and experiences of people who use services. The new framework, principles and operating model that will be used to monitor and regulate providers, will include the five key questions:

• Are they safe? • Are they effective? • Are they caring? • Are they responsive? • Are they well-led?

Figure 1: Overview of CQC Operating Model:

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7.1 Key CQC Inspection Activity Report The CCG is working with our PCU and Local Authority staff in regard to a care home in Filey that has had a poor outcome from their CQC inspection. The care home provides nursing for 43 older people with a physical or sensory impairment. The CQC inspected the home on 19th August 2014, and reported that the overall rating of this home to be inadequate. The CCG has ensured that all patients in receipt of continuing health care and funded nursing care have been reassessed, and heightened surveillance measures have been put in such as, in regard to tissue viability and infection control. We will continue to work with partners to support patient care and follow the CQC process in respect of reviewing action plans and any further actions by CQC.

The CQC is also inspecting the majority of our GP surgeries before December 2014. These are routine inspections and will be in line with new CQC operating framework.

8. Safeguarding Children The Designated professional for Safeguarding Children produces and presents a bi-monthly update of activity and information to the CCG via the Quality and Performance Committee including an update on any Serious Case Reviews and also includes information on Looked after Children.

8.1 Child Sexual Exploitation (CSE) On 21 August 2014, Alexis Jay OBE published the findings of her independent enquiry into Child Sexual Exploitation in Rotherham. This inquiry was commissioned by Rotherham Metropolitan Borough Council in October 2013 with a remit to cover the periods 1997-2009, and 2009-2013.

The report has received wide media attention and scrutiny, and services in Rochdale, particularly Police and Social Care, have been widely criticised for failing to protect the safety and wellbeing of children and young people in their area.

The report is lengthy and detailed however the key findings include:

• An estimated 1400 children and young people were sexually exploited over the period of the inquiry;

• In just over a third of these cases, the children were previously known to services because of child abuse and neglect;

• Almost 50% of children involved had misused alcohol or other substances;

• One third of children involved had mental health problems (often as a consequence of abuse) and two thirds had emotional health difficulties;

• Barriers to accessing specialist counselling and/or mental health services for children and young people were a recurrent theme;

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• There were issues of parental addiction in 20% of cases and parental mental health issues in over a third of cases;

The report concludes that many improvements have been made over the last four years by both the Council and the Police. It notes that the Local Safeguarding Children Board (LSCB) already has a detailed Action Plan for tackling CSE but does make some additional recommendations to strengthen this approach across 15 priority areas. Of note the following recommendations are directed to agencies including health:

“Recommendation 8: Wider children’s social care, the CSE team and integrated youth and support services should work better together to ensure that children affected by CSE are well supported and offered an appropriate range of preventive services.

Recommendation 9: All services should recognise that once a child is affected by CSE, he or she is likely to require support and therapeutic intervention for an extended period of time. Children should not be offered short-term intervention only, and cases should not be closed prematurely.

Recommendation 10: The Safeguarding Board, through the CSE Sub-group, should work with local agencies, including health, to secure the delivery of post-abuse support services

Recommendation 11: All agencies should continue to resource, and strengthen, the quality assurance work currently underway under the auspices of the Safeguarding Board.”

8.2 CSE in North Yorkshire and York A Joint Strategic CSE Group was established in its current format by North Yorkshire Police in 2012 to work across the Safeguarding Children Boards of both North Yorkshire and York. The Group has continued to meet on a regular basis to both develop and monitor progress against a broad inter-agency action plan to tackle CSE. The group reports regularly to the full Boards. The CSE Action Plan follows the key elements of the ACPO (Association of Chief Police Officers) Plan – “Prepare, Prevent, Protect and Pursue” together with a further element in relation to the challenge and scrutiny role of the LSCBs.

To date, the work undertaken by the LSCBs and partner agencies includes: • Appointment of a strategic lead for CSE in North Yorkshire;

• Commissioning of a scoping and gap analysis – data collection is in progress;

• Completion of a CSE benchmarking exercise by North Yorkshire LSCB;

• Practitioner surveys and interviews with groups of young people;

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• Development of a proposed data set;

• Development and delivery of training programmes in relation to CSE by both LSCBs;

• The revision of CSE practitioner guidance (including a risk and vulnerability tool) is now at final stage;

• Planned audit of future practice by the North Yorkshire LSCB Quality and Performance Group;

• Development of revised information sharing pathways;

• The “Missing from Home and Care” operational panel now includes consideration of cases of actual/suspected CSE and return interviews for children and young people who have been missing include a specific question in relation to CSE;

• Young people have been involved in designing awareness raising resources for young people, schools and communities;

• Development of additional resources and tools for use within educational establishments;

• A very successful multi-agency CSE conference was held in February 2014.

8.3 North Yorkshire Referral Process A new Contact Centre for the receipt, screening and management of referrals is now in place in North Yorkshire. The Centre will manage referrals for child protection and child in need cases as well as referrals to the Disabled Children’s Team. To support this process, a new standard referral form has been developed which is available via the LSCB website www.safeguardingchildren.co.uk Supporting procedures for referrals have also now been uploaded onto the website.

8.4 Child Protection Conference Reports for Medical Practitioners Following a recommendation that the child protection conference report format should be shortened and amended to reflect the nature of information likely to be shared by medical practitioners has now been completed. A two-sided report pro-forma will shortly become available. And it is hoped that this more relevant and succinct version will support more timely sharing of key information to enhance decision-making at Child Protection Conferences.

8.5 Looked After Children (LAC) Initial Health Assessments Re-audit The second audit of Initial Health Assessments has now been completed by Dr Lyth, Designated Doctor for Safeguarding Children, in conjunction with the Specialist Looked After Children Nursing Team from Harrogate and District NHS Foundation

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Trust (HDFT). The audit demonstrates a considerable improvement in performance subsequent to an agreed multi-agency action plan.

8.6 Health Passports for Care Leavers A pilot has been set up in the Scarborough area whereby Care Leavers will be presented with their “Health Passport” (a summary of their personal health history) at the final Review Health Assessment prior to their 18th birthday. This pilot will be reviewed after 3 months with a view to extending the scheme across the whole of North Yorkshire. The implementation of health passports was a key recommendation from the recent Ofsted inspection of arrangements in North Yorkshire, which we previously reported on. Following a recommendation from the Quality and Performance Committee, a short briefing paper has been produced to inform local GPs of this new arrangement.

8.7 Young and Yorkshire The Children and Young People’s Plan, “Young and Yorkshire” has now been published by North Yorkshire Children’s Trust. The plan has a strong focus on the views of children and young people:

“We, the children of North Yorkshire would like you to make sure that we are: healthy, sporty, happy, clean, eco-friendly, awesome friends, inspired, clever, too cool for school, respectful, given our say, to be hear, to be supported, to have our place in the crowd and to be loved.”

The Plan sets out three key priorities for the next three years:

• Ensuring that education is our greatest liberator;

• Helping all children enjoy a happy family life;

• Ensuring a healthy start to life.

9.0 Safeguarding Adults The Adult Safeguarding lead produces and presents a bi-monthly update of activity and information to the CCG via the Quality and Performance Committee including an update on any Serious Case Reviews and open safeguarding cases.

For this quarter there have been no Serious Case Reviews undertaken or published for the CCG area, for the commissioned providers in the CCG area there have been four care home safeguarding alerts made. At the time of writing this report all but two of these alerts have now been closed. The two that remain open, one was reported in August and the other late October, and is still under investigation by both the Local Authority and Health.

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The Partnership Commissioning Unit (PCU) on behalf of SRCCG continues to work in partnership with the North Yorkshire County council in the investigation of the alerts into allegations of abuse.

The PCU Safeguarding Adults team now meets monthly with a number of different agencies to consider ‘soft intelligence’ about the providers of health care in the CCGs area, all concerns are risk assessed and a lead agency is identified to manage any concerns that have been escalated.

9.1 Mental Capacity Act (MCA) and Deprivation of Liberty Safeguard (DoLS); Development Project The CCGs were invited to apply to NHS England for an allocation of funds to be used to drive up the quality and delivery of services for patients to whom the Mental Capacity Act can apply and those to whom the deprivation of liberty safeguards may apply.

The allocation is in response to the House of Lords inquiry into the implementation of the Mental Capacity Act 2005. Subsequently, in response to the House of Lords Select Committee Report, the Government has published “Valuing every Voice, respecting every right: making the case for the Mental Capacity Act.”

It is in the light of these reports that the four CCGs in North Yorkshire and the City of York have engaged with providers across the health economy, and consulted with the local authorities to inform the strategy.

Desired outcomes from the development project are:

• That the principals of the Act are embedded in clinical team culture and;

• that the provisions of the Act are appropriately and competently applied at every decision point in care and treatment pathways;

• board level commitment and ownership of the objectives;

• senior clinical leadership and corporate ownership;

• an empowering ethos in which parity of esteem exists for all adult patients across the demographic profile;

• empowering staff and supporting the development of MCA Leads in Provider Services;

• engage with those affected, their families and carers and provide resource to increase awareness with the objective of increasing patient awareness and dignity.

An MCA DoLS network group has been established from amongst the MCA DoLS leads within the acute hospitals and wider health economy. An important aim of this

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project is about the network of local expertise that can share ideas and resources between themselves and their local authority counterparts. An intended consequence of bringing the leads together to collaborate in their development strategy is the raising of their profile within their respective organisations.

The project is now at an advanced stage in relation to the deliverables identified in the ‘Valuing every Voice and Respecting every Right’ submission to NHS England Area Team. A network support group of lead professionals has been established with clear terms of reference relating to improved practice at decision points within care pathways; this group has the responsibility of sustaining and developing the project’s achievements.

Targeted professional development conferences led by Barristers expert in the field and with Supreme Court Experience have been organised for senior clinicians and operational managers with the objective pump priming MCA DoLS development. The first of these events was in Scarborough on the 11 September and three similar events are organised for locations in North Yorkshire during the autumn months. The PCU on behalf of the CCG has successfully bid for further funding to continue with the project for another year, to further embed the knowledge in the organisations concerned.