Agenda Item No. 3.1

Manchester Health and Care Commissioning Board Meeting

Agenda Item 3.1 Date 27 March 2019

Report Title Performance and Quality Improvement Report

Report Author The Performance and Quality Improvement Team

This report summarises the quality and performance highlights to be brought to the attention of Manchester Health and Care Commissioning (MHCC). The report covers Summary national, regional and local key performance indicators as set out in the annual planning guidance and those embedded as requirements in provider contracts. Improve the health and wellbeing of people in Manchester Strengthen the social determinants of health and promote Strategic healthy lifestyles Objectives Ensure services are safe, equitable and of a high standard considered in this with less variation report Enable people and communities to be active partners in their health and wellbeing Achieve a sustainable system Risks identified in this report are included in the organisational risk register. 749 Local Care Organisation Risks considered in 750 Single Hospital Service this report 752 Service capacity 753 Care Pathways 757 Provider Service Delivery 758 Strategic Partnerships Agenda Item No. 3.1

Yes - the Performance, Quality and Improvement (PQI) team have undertaken an Equality Impact Analysis (EIA) on their Confirmation that PQI Framework released for 2018/19. Alongside the 9 equality analysis protected characteristics the team has identified sub- has been fully categories that are important to capture to better facilitate our considered in the work, these include: homelessness, carer status, dementia, preparation and learning disabilities, asylum/refugees, looked after children design of the and employment status. Where we undertake a breach reported policy, analysis or deep dive a review of protected characteristics is plan or strategy. undertaken as a matter of course and will be reported accordingly to committees and boards.

Financial N/A Implications

Public Engagement N/A

The Board is recommended to:

Recommendations 1. Support the actions being undertaken to improve the quality and performance of services commissioned for the population of Manchester.

Agenda Item No. 3.1

EXECUTIVE SUMMARY

Urgent Care

Accident and Emergency (A and E) 4hr performance continues to be challenging across all Manchester hospitals with all sites reporting performance short of the agreed monthly and quarterly sustainability and transformation fund (STF) trajectories in January. Following significant underachievement in December, North Manchester Care Organisation (NMCO) reported an improving position, with Manchester Royal Infirmary (MRI) and Wythenshawe reporting a deterioration of performance month on month.

A weekly 4 hour performance improvement trajectory has been agreed with acute providers, with MFT to achieve 85.5%, and NMCO to achieve 81.2%, by the end of March.

Achievement of the 30 minute ambulance handover turnaround target remains a challenge. In January MRI, Wythenshawe and NMCO sites did not meet the required standard. However the North site only narrowly missed the 30min target achieving 30minutes and 56 seconds

MRI site continues to achieve the 3.3% delayed transfers of care (DTOC) target with Wythenshawe and NMGH sites failing to achieve this target

Elective Care

Diagnostic and RTT incomplete performance was below trajectory at all sites in December and performance remains challenged. There has been a slight decrease in the numbers of patients on incomplete pathways between March and December 2018.

At MFT, a significant improvement has been made in the over 52 week waiters with deep inferior epigastric perforators (DIEP) procedures expected to hit the trajectory of reducing breaches by 50% by the end of the year.

PAHT continue to work towards delivering no 52 week waiters by the end of the year, although bed pressures present a risk.

Cancer

All Trusts are engaging with MHCC and have improvement trajectories for underperforming specialities, with recovery of the 62-day standard expected in quarter 4 for both providers. Investigations are completed for breaches and lessons Agenda Item No. 3.1 learnt are shared to improve performance. Risks continue to be monitored and escalated as appropriately.

Quality

Quality exceptions are presented for both MFT and PAHT in relation to complaints, staff training, medicines management and mixed sex accommodation breaches. Service Delivery Improvement Plans (SDIP) for 19/20 will be in place with providers for the following KPIs:

 Medicines at PAHT – this will be led by the MHCC Medicines Management team. The ambition is to align the KPIs and targets to those in the MFT contract so these are aligned prior to North Manchester moving into the single hospital.  Complaints at MFT

PQI will seek assurance from providers regarding the other quality KPI exceptions in quarter 4.

Children and Family Health

An update on maternity KPI exceptions is provided. MHCC will meet with both providers to identify any data quality issues and have a plan in place to resolve these and provide positive assurance in quarter 4.

Mental Heath

The number of people receiving psychological therapy continues to increase. MHCC is confident in delivering the access target of ensuring 4.75% of people with a mental health condition enter treatment in quarter 4 and the 18 week waiting time standard. Achievement of the 6 week waiting time and the recovery standard are forecast to be achieved in quarter 1 of 19/20.

A summary of the quality walkround at Redwood Ward in the Park House Unit, situated in North Manchester General Hospital is included.

Manchester Local Care Organisation

KPI exceptions are presented in relation to RTT, Learning Disabilities, staff training, complaints, looked after children and health visiting. The community paediatrics service has an action plan in place to improve RTT performance. There are also improvement plans in place regarding complaints and staff training. Formal escalation is in place regarding delays in notifications for LAC assessments and there are plans to recruit additional health visitors. Service leads and health and social care commissioners are in the process of mapping out whole scale service re- design in relation to the LD services (both health and social care). The aim is to design an integrated service model based on the new service specification, which will also address the waiting time issues in the longer term.

Agenda Item No. 3.1

Primary Care

Quality and Performance of general practice is highlighted in this section with exception reports for practices requiring intensive support. There have been no changes to CQC inspection ratings since the last report. Building on the success of the past year, the PQI team are now working towards developing a visit toolkit to use with practices to help proactively identify any areas requiring support at an early stage.

Adult Social Care

Quality and Performance of nursing and care homes is highlighted in this section with exception reports for homes requiring intensive support. There have been no changes to CQC inspection ratings since the last report.

Smaller Providers

An update is provided on those providers which remain a cause of concern to the team due to quality and/or performance issues. Those providers are:

• Alliance Medical – Magnetic Resonance Imaging (MR) • Concordia – Dermatology • Mediscan – Non Obstetric Ultrasound (NOUS) and MR • PRIMO – Musculoskeletal service

Issues are being managed via contract review meetings

CCG Improvement and Assessment Framework

The latest iteration of the CCGIAF dashboard was published on the 13th February 2019. This is the 5th dashboard that has been produced on the Manchester footprint. Within the Better Health / Better Care sections there are 43 reported indicators for Manchester. 3 indicators are in the top quartile, these are:  IAPT Access  Estimated diagnosis rate for people with dementia  Choices in maternity services

Contract Planning

A final version of the national contract was published in February. The PQI team have reviewed the national publications and ensured any updates are reflected in the relevant quality schedules and KPIs. The deadline for agreeing contracts is 21 March 2019 and final meetings are being held with providers. The CQUIN guidance has not yet been published; this was expected before the end of January but now looks likely to be published in March at the earliest. It has been indicated in the contract consultation that the value of CQUIN will reduce from 2.5% of the value of the contract to 1.25%.

A service development improvement plan (SDIP) has been agreed with MLCO covering 4 key areas: Agenda Item No. 3.1

 Integrated Neighbourhood Teams – develop a suite of metrics that will demonstrate the benefits of implementing the new models of care. This will build on the theory of change work and the benefits articulated through business cases and service specifications.  Elective access and non-consultant waiting lists – to ensure waiting times for community services are subject to the same scrutiny as secondary care services.  Quality assurance – to work together to enhance the current regime of quality assurance.  Children and Young People’s Transition – to develop small number of metrics that demonstrate the smooth transition from children to adult’s services.

1.0 Introduction

1.1 This report summarises the quality and performance highlights to be brought to the attention of Manchester Health and Care Commissioning (MHCC). The report covers national, regional and local key performance indicators as set out in the annual planning guidance and those embedded as requirements in provider contracts.

1.2 The team has set out a timetable to ensure all sectors are covered periodically throughout the year. This month the sectors included are:

• Urgent care • Elective • Cancer • Quality • Children and Family Health • Mental Health • Manchester Local Care Organisation • Primary Care • Adult Social Care • Small providers • CCG Improvement and Assessment Framework • Contract Planning

1.3 Performance data is published on the second Thursday of the month. The data published is for the month ending approximately 6 weeks prior to the publication date. The data contained in this report is for the month of December 2018 and was published on 14 February 2019. Performance data for January 2019 will be published on 14 March 2019 (i.e. after the deadline for papers to be circulated) and will therefore be included in the next report. The narrative has been updated to the most recent local information.

1.4 The following scorecards are attached:

Appendix A CCG including 5 Year Forward View and Public Health measures Agenda Item No. 3.1

Appendix B Manchester University NHS Foundation Trust (MFT) contract key performance indicators (KPIs) Appendix C Pennine Acute Hospitals NHS Trust (PAHT) KPIs Appendix D Manchester Local Care Organisation (MLCO) contract KPIs

1.5 Also attached:

Appendix E CCG Improvement and Assessment Framework – position statement on bottom quartile indicators (as reported to the quarter 3 GM assurance meeting)

Agenda Item No. 3.1

2. Acute

2.1 Urgent Care

Agenda Item No. 3.1

4 Hour A&E Performance

Summary

In January, Manchester Foundation Trust (MFT) and North Manchester Care Organisation (NMCO) reported accident and emergency 4hr performance short of the agreed monthly sustainability and transformation fund (STF) trajectories.

Following significant underachievement in December, NMCO reported an improving position, with Manchester Royal Infirmary (MRI) and Wythenshawe reporting a deterioration of performance month on month.

Key actions taken / planned

Due to continued underperformance of the A&E 4 hour target at GM level, NHS England Regional Director Richard Barker has written to MHCC and a significant number of GM organisations who will now be subject to statutory intervention.

Agenda Item No. 3.1

In response, an urgent care 4 hour recovery plan has been developed to improve performance through to the end of March with the following actions agreed:

MFT

 St Mary’s and Royal Manchester Children’s Hospital (RMCH) achieve a step change improvement in performance toward 100%  Minors – moderate stream, zero tolerance on non-admitted demand twilight and overnight  Maximise the utilisation of total bed stock across the Wythenshawe and Trafford hospital sites  During the autumn of 2018, the Trust’s transformation team undertook an audit of the urgent care system against best practice. A review of the implementation of the actions commenced 7th February 2019  Weekly Director level conference calls to review all patients with a length of stay over 21 days  A stranded patients’ improvement trajectory reduction of 120 patients by end of March 2019

NMCO

 Increase the number of surgical inpatients who are discharged before noon  Increase the number of surgery triage / assessment beds  Increase the number of patients seen within the ambulatory care unit  Weekend social worker input to the wards  Reduce Bury stranded patients to release acute bed capacity through reopening closed community beds

MHCC/ Manchester Local Care Organisation

 Alternative to transfer see and treat - new pathways for children and extend the 15 minute call back time  Hear and treat – introduce secondary triage in hours  Provide GP input 5 days per week into the MRI frailty service supporting in- reach into A&E  Working with the MRI to increase nurse & therapy support in A&E  Intermediate care - ensure planned expected date of discharge is robustly in place for all patients

A weekly 4 hour performance improvement trajectory has been agreed with acute providers, with MFT to achieve 85.5%, and NMCO to achieve 81.2%, by the end of March. Monitoring of the actions and performance is in place with system partners, and assurance on a weekly basis through MHCC executives meeting.

We continue to monitor the winter deliverables for quarter 4 and the social care winter schemes, highlighting outcomes achieved and associated risk against those yet to be implemented. Assurance on the delivery is sought every month through the Manchester and Trafford operational delivery group (ODG), with escalations to Manchester and Trafford urgent care strategic board (UCSB) as required.

Agenda Item No. 3.1

The monthly review of the improvement plan identified a number of schemes, particularly those associated with Manchester Local Care Organisation (MLCO) winter monies, which are currently off track. Primarily this is due to recruitment issues which has delayed mobilisation.

A streaming model pilot was implemented at Wythenshawe on the 5th December 2018 on a 12 hour basis 7 days per week. The decision was taken to change the model after a number of weeks to 6 hours per day by doubling up the clinical input provided to improve the activity within the model. Further changes to the model have been made in order to increase the coverage at weekends. A full evaluation will be conducted following the end of the pilot.

The Manchester and Trafford operational pressures escalation levels (OPEL) framework remains in place with system partners in order to respond to surge and escalation pressures at any time. Through regular reporting, actions agreed in escalation and communication routes we ensure a co-ordinated approach is taken throughout the system. Routine daily surge and escalation calls were formally stepped down at the end of January with the ability of system wide calls to be re- established as required.

An Easter planning process has been agreed with system partners, which will be co- ordinated by the urgent care system resilience team. This process will provide assurance that services have plans in place covering staffing, operational hours, and contact details, highlighting any variance from business as usual over the period 19th to 22nd April.

Delayed Transfers of Care (DTOC)

Summary

The MRI site continues to meet the 3.3% DTOC target in January, with the Wythenshawe and North Manchester sites failing to meet the target. The average number of Manchester residents delayed as a DTOC has reduced at North Manchester month on month, with increases at MRI and Wythenshawe.

Key actions taken / planned

The urgent care system continues to focus on stranded (length of stay > 7 days) and super-stranded patients (length of stay > 21 days) recognising that improvements to these metrics will help to achieve longer-term sustainability in the DTOC position and patient flow.

As part of this focus, MFT stranded patient reduction targets were assigned to the Manchester Local Care Organisation (MLCO), along with Trafford Local Care Authority (TLCA) and Stockport CCG, to achieve a collective reduction of 120 patients by March 2019.

MLCO continue to offer on-site support through MRI priority discharge meetings between system partners, ward level reviews of discharge processes focussed on AM1, AM2 and Manchester Ward, and attending site board rounds and bed meetings. Agenda Item No. 3.1

Regular monthly multi-agency discharge events (MADE) are in place at all sites with system partners involved in order to resolve barriers to discharge and respond to common reasons for delays.

In order to identify further areas of improvement the emergency care intensive support team (ECIST) team supported MFT in early February on stranded patients and delays in discharge.

The Manchester urgent care control room continues to operate as a single point of contact for escalation by offering support to help enable discharges to community, discharge to assess and care homes.

An internal escalation protocol has been developed for the integrated discharge teams (IDT) aligned to the OPEL escalations. It looks at the total number of DTOC and medically optimised awaiting transfer (MOAT) patients and informs teams of the appropriate routes of escalation in order to resolve delays. All internal system partners within North and South Manchester, and neighbouring boroughs, are utilising the protocol on an operational basis.

During escalation it is expected that stepped communication and/or on-site presence of the control room team will support the movement of patients out of hospital to a more appropriate care setting as quickly and safely as possible.

Ambulance Handovers

Summary

Achievement of the 30 minute ambulance handover turnaround target remains a challenge. In January MRI, Wythenshawe and NMCO sites did not meet the required standard. However the North site only narrowly missed the 30min target achieving 30minutes and 56 seconds

Key actions taken / planned

Focussed work through the North West Ambulance Service (NWAS) task and finish group has seen a reduction of 1 hour and 2 hour handover breaches at North site for January compared with previous month, whereas MRI and Wythenshawe sites have reported an increase.

Key areas of work are aligned to the GM ambulance handover standards and led through the task and finish groups. Priorities are:

NMCO

 An agreed escalation area for implementing reverse queuing policy  Recruitment nearly complete to provide a corridor nurse and a clinical navigator role

Agenda Item No. 3.1

MRI

 Pathway development to support suitable ambulance admissions directly to gynaecology department. This is still early in development with implementation dates to be agreed

Wythenshawe

 An agreed escalation area for implementing reverse queuing policy  Joint pilot commenced on 28th January between NWAS and Trust to provide the clinical navigator role. Early indications are that this is having a positive impact improving turnaround and handover performance  Currently reviewing staffing models to provide corridor nurse

In addition, each locality is to complete a self-assessment against the recommended actions of NHS Improvement guidance ‘Addressing hospital handover delays’. Compliance and assurance will then be sought by the Manchester and Trafford ODG, and circulated to our system partners.

The system resilience team will continue to lead monthly meetings and offer support to NWAS, MFT and NMCO in order to realise improvements against the ambulance handover standard.

Risks

The key risks to the delivery of the performance standards are as follows:

 Staffing – there is a high risk to staffing across the health and social care system. The acute sites have had difficulties with consultant and nurse shortages and are heavily reliant on agency staffing. Care homes struggle to recruit nurses in order to open nursing beds  Demand – increased year on year demand for acute hospital services, resulting in higher numbers of attendances and admissions  Maintaining patient flow - high bed occupancy which results in pressures in the emergency department and compromises patient safety

Agenda Item No. 3.1

2.2 Elective Care

Agenda Item No. 3.1

Agenda Item No. 3.1

Diagnostics

Summary

Both MFT and MHCC failed to achieve the 1% standard in December 2018. Ongoing demand pressures coupled with workforce challenges in Clinical and Scientific Support (CSS) and adult endoscopy remain, and are a risk to delivery into quarter 4.

Pennine Acute Hospital Trust (PAHT) did not achieve the standard; Manchester patients at PAHT are waiting in excess of the target. This represents 56 patients out of 1,951 waiting over 6 weeks. This is primarily due to underperformance in audiology, echocardiography, and MRI. The trust reported the overrun of MRI service work and capacity issues, however the Trust expect the validated January position to show an improvement, with delivery expected in March 2019.

Key actions taken / planned

 Additional waiting lists have been provided by the independent sector, following clinical triage of referrals. The additional capacity has been built into scheduling and trajectories Agenda Item No. 3.1

 Transformation teams completed an internal review of endoscopy services at Manchester Royal Infirmary, Trafford and Wythenshawe hospitals. Findings and recommendations have now been shared with executives for each hospital  Workforce pressures and increasing demand for MRI scan in paediatrics continues to place some risk to recovery trajectories in quarter 4  Additional anaesthetists were secured for paediatrics in the summer however the increase in demand has continued out with the capacity secured with extra consultants  PAHT audiology is on track to deliver the diagnostic target at month end; an external review of audiology services is ongoing  Sleep is a vulnerable service to performance with small staffing numbers and relatively high demand. Recent recruitment attempts have failed to appoint additional technicians; exploring if recruitment via Salford or MFT will assist  Demand for echocardiography has increased from 475 in November 2018 to 779 at the end of December 2018. This surge in demand impacted PAHT ability to meet the 1% target, review of the growth to plan extra capacity is taking place

Referral to Treatment (RTT) – 18 and 52 week waits

Summary

18 Weeks

MFT failed to meet the Referral to Treatment (RTT) incomplete national standard (92%) in December at 87.7%. The number of RTT incomplete pathways has grown by 8.7% at MFT and 14% for MHCC patients between March and December 2018. The national focus for 18/19 is to maintain the waiting list size at March 2018 levels.

Given the demand and capacity pressures, MFT are reporting that they may not now meet the RTT standard and waiting list ceiling target by March 2019. A taskforce and PMO remains in place at MFT to manage the programme of work related to RTT and waiting times.

PAHT failed to meet the Referral to Treatment (RTT) incomplete national standard (92%) in December at 85.1%. The Trust is unlikely to deliver the national standard by the end of the year.

Key actions taken / planned

Performance improvement continues across PAHT:

 Total incomplete pathways have reduced through extensive validation of the waiting lists  Review of duplicate referrals between colorectal and gastroenterology underway  Establishing a process for early warning of potential 52 week breaches due to late onward referrals Agenda Item No. 3.1

 Plastics have requested support from MFT to help to improve short notice cover arrangements to enable planning  The Breast service will be at 92% for the end of March  Digestive diseases continues to be challenged and has seen significant growth in demand compared to last year. Insourcing work for general and colorectal surgery at the weekends and to increase the amount of insourced work for gastroenterology  2 new fixed term middle grades have commenced in post in urology, however a gap of 3 consultants remains.

52 Week Waiters

At MFT, a significant improvement has been made in the over 52 week waiters with deep inferior epigastric perforators (DIEP) procedures expected to hit the trajectory of reducing breaches by 50% by the end of the year. The December figure of 22 patients is slightly decreased from 26 patients in November.

At PAHT long waiting patients have continued to be booked during the winter period; however, they remain the most vulnerable in terms of priority for beds versus cancer surgery and other clinically urgent patients. In December there were 39 patients waiting more than 52 weeks at PAHT. There was 1 Manchester patient waiting over 52 weeks this was in gastroenterology and the RCA has been completed. The patient was delayed due to capacity delays in colorectal before being referred to gastroenterology at week 40, treatment started 7/1/19. PAHT are working to deliver no 52 week waiters by the end of the year, although bed pressures remain a risk.

Key actions taken / planned

At MFT:

 RTT task force continues to meet weekly  Clinical review and root cause analysis continue to be undertaken for all breaches of the 52 week standard  A review of referral variation by practice is underway  A review the effectiveness of the Manchester gateway triage system is underway  The RTT waiting list at MFT is being validated  Manchester CCG is funding additional independent sector outpatient attendances and elective procedures in February and March 19 up to the financial value of £1.2m  MFT to outsource where possible with existing contracts are in place with a number of providers including BMI, Spire, HCA and MSS  Support is to be provided from NHSI IST at MFT

At PAHT: .  Exec level monthly assurance meetings with MHCC are taking place  A North East sector CCG action plan is in place to support the recovery of RTT  The RTT waiting list validation continues to have a positive impact Agenda Item No. 3.1

 OMFS at NMGH is experiencing challenges in terms of growth in demand, predominantly from out of area. 52 week breaches are reducing due to micromanagement to ensure there are no patients waiting over 52 weeks by the end of March

Cancelled Operations

Summary

There were 7 cancelled elective operations not rebooked within 28 days at PAHT for MHCC patients. PAHT reported issues with bed availability at Oldham. Orthopaedics and ENT also had capacity issues resulting in cancellations, which reduced the ability to rebook within 28 days. December presented seasonal challenges for rebooking patients due to reduced capacity, bank holidays and patient choice.

Actions

 Capacity and planning for services with cancelled operations taking place.  Specialities have been asked to flag patients who have been cancelled to prioritise patients  Patient choice remains a challenge; the offer of other consultants when appropriate is taking place

Utilisation of the NHS e-referrals service

Utilisation of the e-referral service was reported as 93.8% against a target of 100% for December. MFT have been asked via the monthly performance meeting to investigate and provide a response.

Children waiting more than 18 weeks for a wheelchair

The target for this indicator has not been met for quarter 1 (90.4% against a target of 94.8%) and again in quarter 2 (92.9% against a target of 97.9%). PQI team will discuss this service and its challenges at the next monthly performance meeting with the provider.

Agenda Item No. 3.1

2.3 Cancer

Agenda Item No. 3.1

Summary

Manchester CCG delivered of 4 out of 9 cancer standards in quarter 3. The failing standards were:

 cancer 2 week waits  breast symptoms 2 week waits  31 day wait subsequent treatments (drugs)  cancer 62 day wait following urgent GP referral  cancer 62 day wait consultant upgrade.

The 2 week wait performance has improved steadily over the course of quarter 3 to deliver 90.3%. Although overall performance for quarter 3 was below the standard, it was delivered in December 2018, reflecting the actions taken to recover performance at local providers.

Agenda Item No. 3.1

The performance of cancer two week wait for breast symptoms did not meet the national standard and was impacted by patient choice particularly during holiday periods and capacity. 133 of 166 patients met the standard in December (83.7% against a 93% target).

Whilst 62 day performance recovered slightly from quarter 2 the performance did not meet the national target. This reflects the difficulty local Trusts have had in 2018 and mirrors the national trend. The patients who have breached the 62 day standard were seen across various specialities and Trusts, with 206 out of 267 cancers being treated within 62 days in quarter 3. The majority of breaches impacting 62 day performance this quarter were within Urology. While capacity was an issue, there were also patient choice and did not attend reasons. The other specialities with breaches were lung, breast, gynaecology, skin lower GI and upper GI.

The 31 day wait subsequent drug treatment did not meet the standard. MFT reported delays due to patient having a comorbidity or conflicting drug issue. 29 of 30 patients met the standard in December (96.7% against a 98% target).

Performance against some standards in December was impacted by low numbers which impacted the percentage performance reported. For example 62 day wait – screening, with 5 out of 6 patients being treated within 62 days (83.3% against a 90% target).

Development of the MHCC cancer strategy for 19/20 will help ensure we have future vision and the correct focus for the population of Manchester.

Key actions taken / planned

The PQI team continues to attend all Trust cancer boards. This allows discussion about performance and the reasons for each breach is discussed.

MFT has care organisation level action plans in place for all failing specialities. Actions taken include:

 Urology Improvement Board to monitor progress of improvement actions o Review the prostate pathway to identify opportunities within the diagnostic pathway and referral process to the Christie o Review of capacity and demand for the cryoablation service is underway o Cancer nurse specialist has planned 7 day cover for urology from January o A template biopsy business case is being written to support a MFT wide offer  Colorectal service is working to review the diagnostic pathway to identify opportunities to streamline processes and increase straight to test endoscopy  A new locum consultant has been appointed for general surgery, this will support capacity  Work to ensure consistency across MFT locations will continue in quarter 4 for better patient outcomes

Agenda Item No. 3.1

PAHT has seen the benefits of actions taken in October and November to recover the 2 week wait performance to 91.2% in December from 73% in November. This is expected to drop in January due to capacity issues and patient choice over the festive period.

Actions to improve 62 day performance:

 NMGH has 2 extra locums in place until the end of March/April within breast services  Endocare is providing out-patient treatment and scopes  Cancer improvement boards in place at NMGH  Pathway improvements for prostate cancer patients and concentrating on expedited diagnosis  There has been a reduction in the overall PTL size for all tumour groups in December, this focus will continue  Targeted work to improve the timely and effective communication between the booking and scheduling department and the relevant directorate will help recovery

Risks

The risks to delivery of cancer standards are similar for all Trusts. The highest risks are diagnostic capacity and staffing for specialities and trackers. There is an issue in obtaining PET scans due to a shortage of radio-nucleotide; this is a nationwide supply chain issue.

Cancer pathways within Manchester can start and end with different providers, due to complex diagnostics there can be delays in patients being transferred and this presents a risk to delivery of the 62 day standard for Trusts.

The risks will continue to be monitored by the PQI team and escalation processes are in place.

Timescales for delivery

Both MFT and PAHT have improvement plans in place and a forecast recovery of the 62 day performance to be delivered in quarter 4 18/19.

Cancer pathways longer than 104 days

Summary

The number of 104 day cancer breaches for quarter 3 is:

 17.5 at MFT (all CCGs)  24 at PAHT (all CCGs)

After investigation, there were no reported harms due to delays.

Agenda Item No. 3.1

Key actions taken / planned

104 day reviews at both providers follow a defined process:

 Coordinator completes full pathway map for each patient which is reviewed by the cancer manager  All pathways are then reviewed by lead cancer clinician and executive lead for cancer with case notes for harm or errors  If harm is identified a serious incident process is started  Any questions or learning points they identify from the review are then sent to the consultant responsible for the patient care and/or the directorate management teams for comment and clarification  Responses are reviewed again and any actions or learning monitored by the cancer manager  Final summary is shared with Trust cancer committee and CCG

Risks

The risks to the services with capacity constraints like Lung, Urology, LGI, UGI, Cancer of Unknown Primary (CUP), Breast and Plastic remain. Every effort is made to avoid breaches.

The themes for delays include and will remain a risk in the future:

 Patient choice, or did not attend, or not well enough for treatment  Complex cancers requiring multiple MDT’s and diagnostic tests  Transfers between hospitals with specialist cancer treatments  Delays to clinical trial eligibility  Capacity to treat patients

Timescales for delivery

There is no national performance target. Trusts are expected to reduce 104 day breaches as often as possible. PQI will continue to monitor the performance and escalate any concerns.

Agenda Item No. 3.1

2.4 Quality Exceptions

2.4.1 Effectiveness

Agenda Item No. 3.1

Agenda Item No. 3.1

Training KPIs

There are challenges in relation to performance against the training KPIs. MFT is underperforming against the following indicators:

 Safeguarding Children Level 2  Safeguarding Children Level 3  Safeguarding Adults Level 2  Dementia awareness training  Infection Control – Clinical staff  Percentage of staff who have had a performance development review (PDR)

PAHT is underperforming against the following indicators:

 Safeguarding Children Level 2  Safeguarding Children Level 3  Safeguarding Adults Level 1  Safeguarding Adults Level 2  Infection Control Training for clinical and non-clinical staff  Infection Control training for clinical staff  Percentage of staff who have had a performance development review (PDR)

Key actions taken / planned

At MFT alignment of clinical mandatory training has been a very complex task as there are so many different training requirements dependent upon the role an employee has. Traditionally this training has been very different at the two legacy sites as has the way that compliance has been reported. The alignment process has required input from all the relevant professional leads and a task and finish group was established in August 2018 to enable this to happen. A paper outlining the new approach has been presented at the Professional Education Forum and the Workforce Education Committee on 13th February prior to introducing the new aligned programme from 1st April 2019. This new programme should ensure better performance against these indicators.

PAHT are not fully meeting the safeguarding training KPIs. There are also concerns as to how this training translates into practice especially in relation to deprivation of liberties and mental capacity act assessments. The MHCC Safeguarding Team and the PQI team have a meeting set up to fully discuss this and a further update will be provided in due course.

High sickness rates and vacancy levels at the NMCO have impacted on mandatory training and the number of PDRs completed. An improvement plan is in place and this KPI will continue to be monitored closely.

Risks

Training KPIs and number of staff receiving a PDR were introduced to ensure MHCC has oversight of key areas that impact widely on safety. MHCC uses these as a leading indicator for harm, i.e. if staff are not trained appropriately this could lead to Agenda Item No. 3.1 harm (such as a patient not being referred to safeguarding, a DoLS assessment not being undertaken or an infection occurring). MHCC needs to continue to closely monitor these and fully understand the rationale for underperformance and the plans to address these.

Timescales for delivery

It is expected that by the end of quarter 1 19/20 MFT will be meeting all training KPIs. This timescale is less certain for PAHT especially in respect to safeguarding training and a detailed update on safeguarding and training will be provided in the next report following the meeting between the Safeguarding and PQI team.

Macular patients

Performance against the targets of macular patients having their first injection within 14 days and then their follow up injection within 7 days has deteriorated. Performance is 76.5% (first injection at 14days) and 81% (follow up at 7 days) against a target of 90% for both indicators. A small cohort of patients (4) exercised patient choice to delay treatment which has affected performance.

The percentage of EMAC patients clinically assessed against the standard of three days was 76.5% against a target of 90%. This was a cohort of 9 patients, 2 opted to delay their assessment exercising patient choice. With the remaining 7 patients there was difficulty in contacting them based on the information from the referrer.

There was 1 incidence of endophthalmitis infection against a target of 0. The patient remained stable and did not require any further surgical intervention. It should be highlighted that this rate is 0.015%, which is below the 0.025% national benchmark from the Royal College of Ophthalmologists.

2.4.2 Experience

Agenda Item No. 3.1

Complaints

Both MFT and PAHT continue to underperform in relation to responding to complaints within the timeframes as agreed with the complainant.

Key actions taken / planned

MFT has added this indicator in their Board Assurance Report which is published in the public domain every two months. Improvement is a priority across all hospital sites. MFT has set two targets in respect to complaints with 25 days as the target for the less complex complaints and 40 days for more complex complaints; this is what they report and manage against internally and to MHCC. MFT agrees the timeframe for response with the complainant, updates the complainant on progress of the investigation and agrees extensions to this with the complainant if they are needed - this is not captured in reporting to MHCC. Given the underperformance of this KPI it has been agreed that a service development and improvement plan (SDIP) will be instigated in 19/20 and progress against this will be reported quarterly. Agenda Item No. 3.1

PAHT has invested a large resource into the patient experience and complaints team, increasing the Patient Advice and Liaison (PAL) teams across the sites and introducing more robust governance and oversight into the management of complaints. This work is now showing results with the number of complaints resolved within the timescale as agreed with the complainant improving month on month. MHCC will continue to monitor positive progress in relation to this indicator.

Risks

It is important to ensure that our providers have robust processes in place to ensure that they respond to complaints in a timely manner and in line with national legislation.

Timescales for delivery

A SDIP will be put in place with MFT in respect to complaints for 19/20. Compliance with the KPI target for complaints for PAHT should be delivered by the end of quarter 1 19/20.

Mixed sex accommodation breaches

From 1 December 2010, the collection of monthly mixed sex accommodation (MSA) breaches was introduced. NHS organisations submit data on the number of occurrences of unjustified mixing in relation to sleeping accommodation.

Both MFT and PAHT continue to have MSA breaches in December.

Key actions taken / planned

Since the integration of all the adult critical care units within Clinical & Scientific Services (CSS) and the formation of CSS as a Managed Clinical Service across MFT there has been a focus on standardising the reporting of same MSA breaches in line with Department of Health guidance and NHS Operating Frameworks. The standard followed is contained in the Operating Policy for the Critical Care Units which incorporates the standards agreed across the Greater Manchester Critical Care Network. Given the recent integration of all the adult units aligning this standard into all unit policy documentation is yet to be completed and is one of the work streams for the Critical Care Quality & Safety Committee.

The reporting has identified inconsistencies in the reporting of MSA and Group adherence to the Network guidance. The issue is specifically related to step down capacity from critical care areas and not cohorting of single sex if there are capacity issues for transfer of patients no longer requiring level 2 care. The delivery of the action plans and the purchase of additional mobile monitors at Wythenshawe on 3rd December 2018 will further mitigate the risk of a MSA breach. Concerted attention and focus on the step down of critical care patients will be put in place to mitigate MSA breaches at across all hospital sites.

MHCC met with PAHT earlier this year and we had received assurance that the new processes that they were putting in place in relation to advance planning and Agenda Item No. 3.1 escalation should ensure that breaches would be reduced by August - this has not materialised. A quality visit was also undertaken to the critical care unit to review patient safety and experience; there were no concerns noted at this time.

PAHT are in the process of developing a standard operating procedure (SOP) for the management of MSA breaches. MHCC will review this once completed and monitor its implementation.

Risks

MSA is a nationally reported indicator and whilst there are no immediate risks to patient safety when a patient is stepped down, a breach of MSA impacts negatively on patient experience and there needs to be a clear plan in place to manage this.

Timescales for delivery

MHCC will undertake a quality visit to MFT and will have resolved queries about internal reporting versus externally reporting before the end of quarter 4.

A meeting is to be held early in quarter 4 with PAHT to progress this longstanding issue and to ascertain what positive assurance can be provided.

2.4.3 Safety

Agenda Item No. 3.1

Agenda Item No. 3.1

Medicines Management

PAHT is underperforming against the following KPIs:

 Medicines reconciliation  Allergy status

PAHT is currently not reporting against:

 Medicines omissions  Medicines omission critical drugs

Key actions taken / planned

PAHT has been underperforming against these KPIs now for some time now. To bring a focus to this area a SDIP has been agreed for 19/20 which will be led by the MHCC Medicines Management Team with PQI. The ambition is to align the KPIs and targets to those in the MFT contract so these are aligned prior to North Manchester moving into the single hospital.

Risks

Preventing harm from medications remains a top patient safety priority not only in hospitals but also across the continuum of care for patients. MHCC needs to continue to closely monitor these and fully understand the rationale for underperformance and the plans to address these.

Timescales for delivery

A SDIP will be put in place with PAHT in respect to medicines KPIs for 19/20

Agenda Item No. 3.1

3. Children and Family Health

There are two KPIs underperforming at present at both MFT and PAHT, these are:

 Breastfeeding rates - initiation  Skin to skin contact in the first hour post delivery

Historically both St Mary’s Hospital and the maternity unit at Wythenshawe have performed well in these areas. MHCC have also visited both areas and do not feel that the reporting is reflective of the care on the ground. In light of this a meeting is being set up to better understand how these KPIs are being recorded and reported and what alternative positive assurance can be given if there is a data quality issue.

To better understand what PAHT is doing to address the underperformance of these indicators and if there are data quality issues MHCC will be meeting with the NMCO maternity team. The aim of this meeting will be to better understand how these KPIs are being recorded and reported and what alternative positive assurance can be given if there is a data quality issue.

Risks

It is important that all new mothers are supported appropriately when they choose to breastfeed; the health gains associated with breastfeeding are well known. Skin to Agenda Item No. 3.1 skin contact in the first hour of delivery helps to regulate the baby’s breathing, heartbeat and temperature and supports bonding and feeding. Oversight of these areas is important to promote the best start in life.

Timescales for delivery

MHCC will meet with both providers to identify any data quality issues and have a plan in place to resolve these and provide positive assurance in quarter 4.

Agenda Item No. 3.1

4. Mental Health

Improving Access to Psychological Therapies (IAPT)

Summary

The number of people receiving psychological therapy for their mental health condition continues to increase and more people are being seen within 18 weeks of referral. However, increasing the number of people seen within six weeks and increasing the recovery rates following treatment continue to be a challenge.

In December, 63% of people of people waited less than six weeks (target 75%) for psychological therapy. The recovery rate for those completing therapy in December was at 42% (target 50%). Performance against both measures have been particularly challenging for Greater Manchester Mental Health Trust (GMMH) who provide treatment to people with complex conditions.

Local performance data has been used, due to a data submission error reported by GMMH in August, impacting on published performance data up to January 2019.

Agenda Item No. 3.1

Key actions taken / planned

GMMH focussed their resources on ensuring people are seen within 18 weeks, as well as reducing the historical waiting list that existed prior to the acquisition of adult mental health services by GMMH. This explains why there has been little improvement to the six week waiting time target. Given that the majority of historical waiters have now been discharged and new people referred to GMMH are being seen within 18 weeks, the focus has now moved to the six week target. The recruitment of an additional 22 staff at GMMH will also lead to a positive step change in both the six week and the recovery standard.

The increase in recovery rate is also being driven by a change in culture and by addressing underperformance in the south Manchester GMMH IAPT division. There is a focus on providing high quality clinical supervision to staff, additional operational management support, and strong clinical leadership. There is now an effective triage process in place so that only patients who are likely to benefit from therapy are accepted, as well as a more proactive discharge procedure. GMMH are also undertaking targeting work to increase access for the over 65s who have better recovery rates.

Risks

Failure to appoint and retain staff will impact on the delivery of the IAPT standards.

Timescales for Delivery

MHCC is confident in delivering the access target of ensuring 4.75% of people with a mental health condition enter treatment in quarter 4 and the 18 week waiting time standard. However achievement of the 6 week waiting time and the recovery standard are forecast to be achieved in quarter 1 of 19/20.

A and E 4 hour standard for patients presenting with mental health conditions

Summary

The Mental Health Liaison Teams in North, South and Central Manchester moved onto a new IT system in August 2018. Following the move, the teams have been gaining familiarity with the new system and the new inputting procedures. The previous patient record had been in place for over a decade, so it was expected that teams would require an embedding period. As anticipated, there have been some challenges with fully embedding the new IT system.

Recording issues have impacted the three A&E sites in September, October and November. An interim solution was introduced at Wythenshawe Hospital in December, and this has improved accuracy, with 90% of people attending A and E due to a mental health condition either admitted or discharged within four hours. This system has been rolled out in North and Central, and will ensure the accuracy of recording pending the full embedding of the new system.

Agenda Item No. 3.1

Key actions taken / planned

The A and E Mental Health Liaison Service at MRI are expanding the workforce. However, the recruitment and retention of mental health nurses continues to be an ongoing challenge. This is being addressed by a GM wide work-stream and in partnership with other GM providers, supported by the Greater Manchester Combined Authority.

At the A and E site based at MRI, GMMH have implemented an ambulatory care model as an alternative clinical area for mental health care. Around 15% of people attending A and E due to mental health are being redirected to the new unit.

An all age Mental Health Liaison Service will go live in each of the A and E sites from April 2019. This will mean children and young people in crisis will have timely access to a 24/7 service in the same way that adults do.

Risks

Failure to recruit the additional nursing staff will impact on 4 hour performance.

Timescales for Delivery

Data recording issues are expected to be resolved during quarter 4 as team members become more competent in using the new system.

Subject to successful recruitment, an additional 16 mental health nurses at the MRI site are planned to start in April 2019.

Children and Young People’s (CYP) Mental Health

Summary

Between April and November, a total of 4,500 CYP accessed treatment, equating to 36% of CYP estimated to have mental health condition. Manchester is planned to achieve a 45% access rate - above the national 32% target and higher than any other GM locality.

There is no national measure on the length of time CYP wait from treatment. However local waiting time data from the main specialist Child and Adolescent Mental Health Service (CAMHS) shows performance against the 18 week referral to treatment for October was at 95%, below the 98% target. More recent data has shown improvements with performance at 98% for the month of December.

Key actions taken / planned

The service continues to work on improving the management of people waiting for treatment. This includes interventions for parents waiting for group sessions as it can take several months before a group session is offered, therefore impacting on waiting times.

Agenda Item No. 3.1

The specialist CAMHS is reporting high caseload and increases in referrals, including emergency referrals. To address this, the service is reviewing its pathways, particularly for children with autism and attention deficit hyperactive disorder. It is also working closer with wider mental health services to support children in a more integrated way.

MHCC is working closer with CCGs across GM in its approach to improving the reporting of outcomes measures by the four specialist CAMHS service across GM.

Risks

Increase in caseloads and referrals could impact on waiting times going forward.

Mental Health Walk Around

A walk around of an adult mental health acute inpatient ward, called the Redwood Ward took place on the 7th December 2018. This ward is based at GMMH’s Park House Unit, situated in North Manchester General Hospital. It is a single sex male ward with 20 beds in total. All beds were occupied on the day of the visit.

Overall feedback from the walk around was positive. Patients were happy with the quality of care provided and felt safe in the ward. There were adequate staffing levels to ensure patients were well looked after. The staffing team worked well together, and were kind, respectful and caring towards patients. The ward was managing safety incidents well and there was regular monitoring of patients’ physical health.

Areas for further improvement were noted in terms of the physical environment of the ward. Also patients reported that they were not involved in developing their care plans. Patients further reported limited activities available and that food choice was limited. Safeguarding training levels could be further improved. Also the development of a ward risk register which is shared and regularly discussed with staff would further help improve patient and staff safety. A full copy of the report and the action plan are available on request.

5. Manchester Local Care Organisation

Agenda Item No. 3.1

Agenda Item No. 3.1

Referral to Treatment Times (RTT) consultant led services – 18 and 52 week waits

Summary

MLCO has three consultant led services - community paediatrics, tier 2 gynaecology and community audiology.

Agenda Item No. 3.1

There are no patients waiting in excess of 52 weeks in any of the three services. Audiology and tier 2 gynaecology report no breaches of the 18 week standard.

MLCO is taking action to reduce waits in community paediatrics. The longest wait for this service is 42 weeks.

Key actions taken / planned

Community paediatrics report the following actions to reduce waiting times:

 From April 2019, a replacement consultant will be in post  Locum doctors are undertaking additional waiting list sessions  Multiagency pilot for the autism pathway is in place  Capacity and demand review across the service

MLCO is undertaking significant manual validation in order to report waiting times. The informatics team, working with services, are leading on implementing a data quality improvement programme. This will result in more accurate and automated management information as well as more robust reporting against contractual key performance indicators.

Staff Appraisal

Summary

MLCO has only recently started to receive medical appraisal data which is showing under performance. The non-medical appraisal rate, which is currently lower than the mandated threshold is adversely impacted by recording and reporting difficulties in the North locality, where services do not currently have the ability to locally record appraisals onto an MFT electronic system.

Key actions taken / planned

 The Chief Medical Officer has written to all doctors whose appraisal has expired to arrange appraisal dates.  Further work is being undertaken to address the issue of recording non- medical appraisal to enable teams in the North to report in line with other MLCO localities.

Training KPIs

Summary

MLCO is underperforming against a number of indicators in relation to mandatory training. This is largely a recording issue. MLCO recognise that legacy systems and North data has not been aligned into the electronic reporting system.

MLCO performance for a number of safeguarding indicators is below the expected thresholds. Intercollegiate guidance published in August 2018 necessitated a review of safeguarding training. This resulted in changes in the categories of staff eligible to Agenda Item No. 3.1 attend each level of training. The underperformance against this indicator is partly due to these changes.

Key actions taken / planned

 Manual processes for recording mandatory training in infection control are currently in place whilst an electronic solution is being explored.  Dementia awareness training was not previously mapped for legacy CMFT staff and has now been set as a requirement for all staff during 19/20. We have asked MLCO to report actual numbers and will set a target for delivery in 19/20.  Teams are identifying areas of non-compliance to do targeted work to increase rates  MLCO is working to align reporting from all sites and teams  Requirements for the safeguarding indicators are now mapped for MFT, based on the intercollegiate document with single competences rather than the legacy ones from the former Trusts. An improvement plan within directorates is in place. This is being led by the safeguarding team, and includes additional training sessions.

Looked After Children (LAC)

Summary

MLCO performance against a range of indicators falls below the mandated threshold. Achievement of the mandated target is reliant on the MLCO receiving timely notifications from partner organisations.

Key actions taken / planned

 Where delays in receiving the Initial Health Assessment (IHA) paperwork is over 8 days, a formal escalation process is in place which includes the MLCO Chief Nurse.  System wide work is now underway to resolve the challenges presented by a failure to notify within the required timescales.

Complaints

Summary

Three complaints were received by the MLCO and all were responded to within timescale. However, the three complaints received were not acknowledged within 3 working days.

Key actions taken / planned

Systems have now been improved to minimise the risk of breaches of the complaints indicators. This includes:

 Improved oversight at directorate level Agenda Item No. 3.1

 Audits of staff awareness of the complaints processes have been carried out and actions taken in response to the findings  Training for investigating officers to enhance complaints management is being delivered during March 2019

Health Visiting (HV)

Summary

There are a number of indicators aimed at monitoring the performance of health visiting services. These are aimed at ensuring children receive new birth visits and assessments in a timely manner. MLCO is compliant against the 6 – 8 week assessment and the 9 to 12 month assessment standard (within 15 months). The service is breaching in 4 other areas.

Key actions taken / planned

 Business case has been approved by commissioners which, subject to a successful recruitment process, will see capacity increase significantly.  Capacity within the service is adversely impacted by a higher than would be expected vacancy rate. The service is working to mitigate the issues that arise from capacity challenges locally.  Saturday appointments for new birth visits  HV teams are informed of new-born babies on a daily basis via the child health system and parents are sent an appointment through the external post for a visit between 10-14 days.  HV will liaise with the ward and family to offer support and advice to initiate the new birth visits which is then completed on discharge.

Other Service Challenges

Community Learning Disabilities Team (CDLT)

Specific issues to the CDLT relating to clinical capacity and links with other services have been raised with the MLCO.

Key actions taken / planned

 Service leads and health and social care commissioners are in the process of mapping out whole scale service re-design in relation to the LD services (both health and social care). The aim is to design an integrated service model based on the new service specification, which will also address the waiting time issues in the longer term.  The MLCO’s Chief Operating Officer has committed to actively pursuing a reduction in waiting times and setting appropriate targets and stretch targets for the service to address this issue.  The service challenges in psychiatrist capacity will start to resolve from February 2019. Targets and trajectories to address the waiting time issue will be agreed as a matter of priority.

Agenda Item No. 3.1

Quality walk rounds

MHCC will be undertaking two service walk rounds during quarter 4. The first will take place at the neuro-rehab service in north Manchester where they have recently been nominated for an Excellence Award and consideration is being given as to whether to expand the service to a city-wide footprint.

The second walk round will take place in March to look at the autism pathway within the community paediatrics team where they have challenges around waiting times. The resulting reports will be shared with members in due course.

Contract update 19/20 - Service Development and Improvement Plan (SDIP)

The 19/20 MLCO contract will include a service development improvement plan (SDIP). This is commitment by MHCC and the MLCO to work together on a number of areas. This is set out in the contract update part of this report.

Care Quality Commission (CQC) Inspection Report – March 2019

MFT (including MLCO) was inspected by CQC in October/November 2018 and the report published on 19th March 2019. Community health services have been rated ‘good’ in all 5 domains, with some areas of outstanding practice highlighted. The full CQC report is available here: https://www.cqc.org.uk/sites/default/files/new_reports/AAAH7336.pdf

6. Primary Care

Summary

This section of the report details the work being led by MHCC’s PQI team in relation to practices where their current Care Quality Commission (CQC) rating is ‘requires improvement’ or ‘inadequate’.

The table below provides a summary breakdown of CQC ratings as of 27 February 2019.

CQC Rating Number of GP % practices

Outstanding 5 5.7%

Good 74 85% Requires Improvement 1 1.2%

Inadequate 1 1.2% Not Rated (due to change of provider/registered 6 6.9% manager)

87* 100% Total

Agenda Item No. 3.1

The above table has been generated from Greater Manchester (GM) data source which gives a comprehensive breakdown of GP practice CQC ratings for Manchester.

*There are currently 89 GP practices in Manchester. Artane Medical Centre does not show in GM supplied CQC data table due to being incorrectly registered with CQC. (An update for this practice is included in the main body of this report.) Queens Medical Centre also does not feature in the GM data table as they are included in the inspection of Cheetham Hill Medical Centre.

Registration requests submitted to CQC for an additional service or site location, e.g. a 7 day access hub sites are also displayed in the GM data as ‘not rated’. These are as follows:

Not rated (due to Cheetham Hill, Conran, Dickenson Rd, Five Oaks, additional location 8 North Manchester OP, Jolly MC, West Gorton, request to CQC) Whitley Rd

MHCC – GP practice CQC rating by neighbourhood – updated 27 February 2019 North Central South Ancoats, Clayton and Ardwick and Longsight Didsbury Burnage and Bradford Chorlton Five Oaks Family Practice  Drs Ngan & Chan  Kingsway Medical Practice  Urban Village MP  Ailsa Craig Medical Practice  Barlow Medical Centre  Lime Square MC  Surrey Lodge Group Practice Merseybank Surgery  Drs Hanif and Bannuru   David Medical Centre  Cornerstone Family Practice  Dickenson Road Medical Didsbury Medical Centre  Florence House Medical Centre  Burnage Healthcare Practice Practice  Dr Cunningham & Partners   Eastlands Medical Practice  Drs Chiu, Koh & Gan  New Islington Medical Centre  Parkside Medical Centre  Mazhari & Partner  Longsight Medical Practice  New Bank Health Centre  Crumpsall and Cheetham Chorlton, Whalley Range Withington and Fallowfield and Fallowfield Artane Medical Centre Ashville Surgery  Borchardt Medical Centre  The Neville Family Practice  The Range Medical Centre  Ladybarn Group Practice  Collegiate Medical Centre  Princess Road Surgery  Mauldeth Medical Centre  Cheetham Hill Medical Centre  Chorlton Family Practice  Bodey Medical Centre  Wellfield Medical Centre  The Wilbraham Surgery  Fallowfield Medical Centre  Queens Medical Centre  The Alexandra Practice  Al-Shifa Medical Centre  Park View Medical Centre  Corkland Road M P  Jolly Medical Centre  Higher Blackley, Harpurhey Gorton and Levenshulme Wythenshawe and Charlestown Valentine Medical Centre  Levenshulme Medical Centre R K Medical Practice  Beacon Medical Centre   Peel Hall Medical Practice Conran Medical Practice  West Point Medical Centre  Maples Medical Centre  The Avenue Medical Centre  Gorton Medical Centre  Bowland Medical Practice  Singh Practice  Mount Road Surgery  Benchill Medical Practice  Agenda Item No. 3.1

Fernclough Surgery  West Gorton Medical Centre  Cornishway Group Practice  Willowbank Surgery  Ashcroft Surgery  Tregenna Group Practice  Dam Head Medical Centre  Hawthorn Medical Centre  Charlestown Surgery  Miles Platting, Newton Heath, Hulme, Moss Side and Wythenshawe and City Centre and Moston Rusholme Northenden Brookdale Surgery  The Robert Darbishire Practice Northenden Group Practice  Droylsden Rd Family Practice   The Park Medical Centre  St Georges Medical Centre  Manchester Medical  Brooklands Medical Practice  Whitley Road Medical Centre  Wilmslow Road MC  Northern Moor Medical Hazeldene Medical Centre  The Arch Medical Practice  Practice  Newton Heath Health Centre  The Whitswood Practice  Woodlands Medical Practice  Victoria Mill Medical Practice  Cornbrook Medical Practice  Simpson Medical Practice  The Docs  City Health Centre 

Practice updates This section of the report provides an update on those practices MHCC are actively working with due to a current or previous rating of inadequate or requires improvement by CQC.

Practice: Brookdale Surgery Neighbourhood: Miles Platting, Newton Heath, City Centre & Moston List size: 2,339

Previous CQC inspection report published: 5 July 2018 http://www.cqc.org.uk/sites/default/files/new_reports/AAAG8940.pdf

CQC rating: Inadequate Safe  Effective  Caring  Responsive  Well led  Primary Care Quality Assurance and Improvement Framework category: Intensive

Current CQC inspection report published for Brookdale Surgery: 9 January 2019 https://www.cqc.org.uk/sites/default/files/new_reports/AAAJ0263

Current CQC rating: Good (previously inadequate in all areas) Safe  Effective  Caring  Responsive  Well led  Primary Care Quality Assurance and Improvement Framework category: Intensive

Overview

The CQC undertook an announced re-inspection of Brookdale Surgery on 3 May 2018 following a series of inspections that resulted in an ‘inadequate’ CQC rating on three separate occasions. Subsequently, the CQC advised MHCC they would be moving to an urgent cancellation of Brookdale Surgery’s CQC registration under their enforcement procedures.

To ensure continued provision of primary care medical services, an alternative primary care provider was appointed by MHCC to manage the practice contract for a fixed period, with an option to extend should this become necessary. The new Agenda Item No. 3.1 provider undertook an immediate diagnostic assessment of the practice and produced a comprehensive action plan which was shared with MHCC.

MHCC initiated a series of visits to work with the new provider and ensure areas within the action plan were supported. The practice was re-inspected by CQC on 10 December 2018 and is now rated ‘good’ in all domains.

MHCC continues to work collaboratively with the new provider to offer support and seek ongoing quality assurance in relation to any outstanding issues that were identified during the transition from the previous to the current provider.

Practice: Merseybank Surgery Neighbourhood: Didsbury, Burnage & Chorlton List size: 2,727

CQC rating: Not rated (previously inadequate in all areas) Safe  Effective  Caring  Responsive  Well led  Primary Care Quality Assurance and Improvement Framework category: Moderate

CQC inspection report published for Merseybank Surgery: 4 May 2017 https://www.cqc.org.uk/location/1-534642144

Overview

Following three consecutive unsatisfactory inspections, the CQC made the decision to cancel the registration of Merseybank Surgery. From July 2017 the contract was varied onto a neighbouring practice’s contract (David Medical Centre) by mutual agreement in anticipation of a formal practice merger. Preparatory work is taking place at both practices in advance of the full merger of practice lists.

The lead practice is working to an action plan and is meeting regularly with MHCC to provide assurance that high quality, safe and effective care is being maintained for patients registered at both practices. Further patient and stakeholder engagement has now commenced ahead of the formal merger.

Practice: Cornerstone Family Practice Neighbourhood: Ancoats, Clayton and Bradford List size: 7,130

CQC rating: Inadequate Safe  Effective  Caring  Responsive  Well led  Primary Care Quality Assurance and Improvement Framework category: Intensive

CQC inspection report published: 26 September 2018 https://www.cqc.org.uk/sites/default/files/new_reports/AAAH6705.pdf

Overview

Cornerstone Family Practice was initially inspected by CQC on 14 November 2017 and the report published on 11 January 2018 determined the practice overall rating as ‘requires improvement’. A further inspection took place on 31 July 2018 and the Agenda Item No. 3.1 resulting report was published on 26 September 2018. The practice was rated overall as ‘inadequate’ and placed in special measures by CQC. This means that the practice will be under review and another inspection will be carried out within a six month period.

MHCC has initiated a programme of support and is meeting with the practice on a regular basis to help drive quality improvement and achieve compliance. This includes external support, via the GM Excellence Programme and the Royal College of GPs (RCGP), to aid delivery of a tailored action plan and identify next steps that are aligned to CQC and MHCC action plans.

Practice: Artane Medical Centre Neighbourhood: Crumpsall & Cheetham List size: 1,501

CQC rating: Requires Improvement Safe  Effective  Caring  Responsive  Well led  Primary Care Quality Assurance and Improvement Framework category: Intensive

CQC inspection report published: 18 February 2016 (archived by CQC)

Overview

MHCC board and committee members have received previous briefings in relation to the ongoing significant quality concerns at Artane Medical Centre. The quality concerns were subject to both CQC enforcement and MHCC contractual action which resulted in a contract termination notice being served to the practice on 11 December 2017.

Members will recall intensive work with this practice following a series of CQC inspections throughout 2017 and the continued failure of the provider to achieve contractual compliance. In December 2017 it became necessary, in the best interests of patients, to secure primary care provision with an alternative provider. A neighbouring practice took responsibility to care-take the patient list for those patients registered with Artane Medical Centre.

MHCC is pleased to report that the care taking practice has since met all areas of their action plan and patient feedback is positive. The future of the patient list is to be determined and engagement with patients and key stakeholders, including councillors has now commenced.

Practice: Woodlands Medical Practice Neighbourhood: Wythenshawe and Northenden List size: 3,227

CQC rating: Requires Improvement Safe  Effective  Caring  Responsive  Well led  Primary Care Quality Assurance and Improvement Framework category: Moderate

CQC inspection report published: 15 June 2018 Agenda Item No. 3.1 https://www.cqc.org.uk/location/1-4250667606

Overview

This practice is currently rated ‘requires improvement’ following a CQC inspection report in June 2018.

Regular meetings with the practice to support CQC, contractual, and quality improvement planning, in line with the Primary Care Quality Assurance and Improvement Framework, are in place.

During the last four months visits have taken place with the practice to review the practice’s action plan and offer support and signposting. A new practice manager has been appointed and the practice has made a number of changes to support improvement.

A further CQC inspection is likely to take place in early 2019; in the meantime MHCC will continue to support the practice.

Primary Care Quality Assurance and Improvement Framework – next steps

The Performance Quality and Improvement (PQI) team has held a series of internal workshops to review the visit process to date. The team is now working towards developing a visit toolkit to use with practices to help proactively identify any areas requiring support at an early stage.

Agenda Item No. 3.1

7. Adult Social Care

Summary

This update highlights the current Care Quality Commission (CQC) and MHCC quality compliance status of the nursing and residential care homes across Manchester and the progress of the quality improvement programme.

The tables below show the overall CQC ratings for the care homes in Manchester as at 4 March 2019.

Nursing homes Residential homes

CQC rating No of care % CQC rating No of care % homes homes Outstanding 0 0% Outstanding 2 5% Good 17 53% Good 20 49% Requires 13 41% Requires 15 37% Improvement Improvement Inadequate 0 0% Inadequate 1 2% Not yet rated 2 6% Not yet rated 6 7% Total 32 100% Total 41 100%

The current MHCC compliance ratings of the nursing and residential homes are shown below. A series of priority visits are underway and will be completed by the end of March 2019. The ratings are based on current CQC ratings including intelligence from previous team visits during 17/18.

Nursing homes Residential homes

MHCC rating No of care % MHCC rating No of care % homes homes CQC action 2 6% CQC action 4 10% taken/high risk taken/high risk

Visit Priority 1 9 28% Visit Priority 1 9 22% Visit Priority 2 6 19% Visit Priority 2 10 24% Visit Priority 3 15 47% Visit Priority 3 18 44% Total 32 100% Total 41 100%

Timeline of MHCC monitoring Rating Action/Timeframe 0 All homes visited monthly (if not weekly) to support improvement plans 1 Rolling out of new audit tool, currently 90% complete with action plans in place, will be 100% complete by end of December 2018. 2 Priority for Q4 with the aim to audit all homes and develop action plans by end of March 2019. 3 Rolling out of quality self-assessment with the aim to complete with care homes by end of Dec 2018 whilst introducing to homecare, extra care and supported accommodation. Final completion by end of March 19 as per Agenda Item No. 3.1

section 4 timeline of framework 2018/19.

The table below shows the 73 individual care homes that have been inspected by locality and indicates the CQC rating and order of MHCC priority to undertake a visit/support in improving or maintaining quality. 8 homes remain to be inspected within year.

CQC ratings of the 73 care homes inspected, by locality  Inadequate  Requires Improvement  Good  Outstanding 0 High risk 1 High Risk 2 Medium Risk 3 Low Risk North (N1&2) Central (C1&C2) South (S1&S2) Blackley City Centre, Ardwick, Old Moat and Withington Gorton North and Gorton South Byron Lodge 1 Gorton Parks 1 Downing House  1 Allendale Residential 2 The Dell 1 Brocklehurst  2 Eachstep Blackley 2 Beyer Lodge  3 Polefield Nursing Home 2 Blackley Premier Care 3 St Euphrasia’s 3 Charlestown, Crumpsall and Hulme, Moss Side, Chorlton Park, Didsbury Harpurhey Whalley Range, and Burnage Holmeleigh 1 Abbotsford 2 Ashley House 1 Chataway Nursing Home 3 Polonia Care Home 1 Laurel Court 1 Chestnut House  1 Alness Lodge Ltd 2 Rowsley House 1 Israel Sieff Court 3 Mariana House 2 Russley House 1 Oakbank Care Home 3 Dom Polski 3 Chorlton Place 2 Wellfield House 3 Belong Nursing Home 3 Fairleigh House 3 Holmefield Care 3 Yorklea Nursing Home1 Moston, Cheetham, Miles Rusholme, Longsight Northenden, Sharston Platting and Newton Heath and Levenshulme and Woodhouse Park Moston Grange  1 Oakland House 2 Yew Tree Manor 0 Averill House 1 Victoria Nursing Hm 2 Cornish Close 1 Doves Nest 1 Grange Avenue 3 Ringway Mews 1 Lightbowne Hall 0 Park Crescent 3 The Peele 1 Beechill Nursing Home 1 Richmond Care 3 Mainwaring Terrace 2 Brookdale View 0 St James House 2 Marion Lauder House 3 St Mary’s Nursing Home 2 St Joseph’s Mcr 3 Bradgate Cl 3 Lindenwood Residential 0 St Bonaventures 3 Acacia Lodge 3 The White House 3 Next Steps Moston 3 Norlands Nursing Home 3 NWCS 11 Bacup St 3 NWCS 20 Swallow St 3 Silverdene Residential 3 The Royal Elms3 Wellington Lodge 3 47 Averill Street 3 Ancoats, Clayton and Chorlton and Fallowfield Brooklands and Baguley Bradford Agenda Item No. 3.1

Brownlow House 0 Alexandra Lodge 2 Maybank House 1 Seymour Care Home 2 EAM Lodge CIC 3 Parkview Care Home3 Mary & Joseph House 3

Recent inspection resulting in revised CQC rating

There have been no revisions in the month of February to CQC inspection outcomes, however we have early intelligence that Laurel Courts CQC outcome will take the home from requires improvement to good.

Care Homes currently inspected as Inadequate:

Lindenwood Locality: Moston, Cheetham Hill, Miles Platting and Newton Heath Number of Beds: 16

Safe  Effective  Caring  Responsive  Well led 

 CQC inspection carried out in December 2018 and report published in January 2019  New manager appointed and improvement action plan developed  PQI working closely with owner on a sustainable service for the future  Ongoing recruitment of carers, especially night time carers

Care homes requiring improvement

There are currently 28 care homes across Manchester that have been rated as ‘requires improvement’.

The PQI team have completed a service audit of all 28 care homes. This is a comprehensive audit that takes two staff a minimum of 1 full day and seeks assurance through measuring key lines of enquiry (KLOEs) and contract requirements. It is anticipated that once complete all homes that require improvement will have a full action plan for improvements to enable them to move to good at their next CQC inspection.

As part of the work programme for 19/20 the PQI team will reviewing key themes from these audits in order to inform delivery of focused improvement projects with providers in the coming year.

To offer further assurance at this time, visits to care homes are prioritised in terms of risk and the RAG rating given is captured on the PQI team risk log. All of these homes are being monitored on a regular basis by the team.

Agenda Item No. 3.1

8. Small Providers

This section provides an overview of small providers where quality and/or performance challenges have been identified. Those providers are as follows:

• Alliance Medical – Magnetic Resonance Imaging (MRI) • Concordia – Dermatology • Mediscan – Non Obstetric Ultrasound (NOUS) and MRI • PRIMO Musculoskeletal (MSK)

Alliance Medical – Registered with the Care Quality Commission (CQC) but not yet inspected:

Previous reports have reflected that the service was failing on 9 of their 16 key performance indicators (KPIs) including:

 Rejected referrals  Referrals triaged within 1 day  Initial patient contact within 5 days  Appointments cancelled by the provider  Waiting time in clinic

In December 2018 the provider presented an action plan and trajectories supporting achievement of the underperforming KPIs by March 2019. December performance reports and discussions with the provider in February 2019 support the improvement of KPIs and the provider remains on trajectory for achievement of KPIs by the end of March.

PQI monitoring will continue until the targets have been met and sustained.

Concordia – CQC rated: Good

The Contract Performance Notice (CPN) and associated Remedial Action Plan (RAP) remain in place. The CPN was issued due to:

 Increase in number of patient complaints about the service  Prescribing issues  Data flow issues  Recurrent themes arising whereby improvement and change is not being sustained

In January 2019 the PQI team met with a clinical lead and lead commissioner to discuss the Concordia dermatology service. A number of new actions to support both the performance and quality of the service have been agreed with the provider. The provider will report against the agreed action in March 2019.

PQI will update the CCG with progress against the actions in future reports.

Agenda Item No. 3.1

Mediscan – Registered with the Care Quality Commission (CQC) but not yet inspected:

A number of concerns were initially identified about this provider. Those were:

 Safeguarding issues  Registration of sonographers  Poor quality scans

Safeguarding and registration issues were actioned and resolved. To assure the quality of the scans Mersey Internal Audit Agency (MIAA) are undertaking a 2 part audit. The draft result from part 1of the audit has been received. A meeting is being arranged with PQI and the MHCC clinical lead to discuss the audit results and concerns raised by GPs regarding the quality of the scan reports to determine next steps.

The PQI team will provide an update in the next report.

PRIMO MSK – CQC rating as per MFT - awaiting rating following inspection in October 2018:

This service has been commissioned by MHCC since November 2016 and the contract ends at the end of October this year.

Issues around KPI performance were identified in April 2018 and pertained to high DNA rates and patients not being seen within 4 weeks and treated within 6 weeks of referral. The provider has put several action plans into place to support achievement of the targets.

A number of audits are being undertaken by the provider and MHCC. The results of the audits which will be discussed at the contract review meeting in March 2019. Following this a decision will be made by MHCC whether to escalate the issues to the main Performance and Quality meeting between MHCC and MFT.

Walkround

The CCG undertook a walkround at a Spire Hospital Manchester. The walkround teams consisted of a clinical lead, nurse, senior pharmacist safeguarding lead and patient representation. The walkround report is in draft and an update will be provided when complete. Overall feedback from the participants was positive.

9. CCG Improvement and Assessment Framework (IAF)

Introduction

The CCGIAF is intended as a focal point for joint work, support and dialogue between NHS England, NHS Improvement, CCGs, providers and STPs/ ICSs. Data is updated regularly, with the most recent data for each metric published each quarter, enabling everyone to see, in-year, what is working well and what is off-track. Agenda Item No. 3.1

NHS England’s national and regional teams are working together to ensure that the breadth of the framework is discussed with the leaders of CCGs during the year, through a targeted programme of local conversations, drawing on expertise and insight from the national programme teams.

The latest iteration of the CCGIAF dashboard was published on the 13th February 2019. This is the 5th dashboard that has been produced on the Manchester footprint.

The ongoing monitoring sheet has been updated and is available on request.

March 2019 update

The summary points from the March 2019 update are:

Within the Better Health / Better Care sections there are 43 reported indicators for Manchester, which has:

 3 indicators in the top quartile  21 indicators in the ‘Inter’ quartiles  16 indicators in the bottom quartile  3 do not yet have quartile ranking

For each indicator, the ranking for Manchester nationally and against its closest peers is provided.

Indicators in the top quartile

 IAPT Access (10 / 195)  Estimated diagnosis rate for people with Dementia (18 / 195)  Choices in maternity services (40 / 195)

Indicators in the bottom quartile

 Primary care workforce (192 / 195)  Population use of hospital beds following emergency admission (191 / 195 )  Emergency admissions for urgent care sensitive conditions (188 / 195 )  Inequality in unplanned hospitalisation for chronic ambulatory care sensitive conditions and urgent care sensitive conditions (185 / 195)  High quality care – adult social care (184 / 195)  Quality of life of carers (183 / 195)  Percentage of children aged 10-11 classified as overweight or obese (180 / 195 )  IAPT recovery rate (177 / 195 )  Out of area placements for acute mental health inpatient care (176 / 195)  One-year survival from all cancers (166 / 195)  Proportion of people with a learning disability on the GP register receiving an annual health check (166 / 195)  Neonatal mortality and stillbirths (157 / 195)  Injuries from falls in people aged 65 and over (156 / 195 ) Agenda Item No. 3.1

 Dementia care planning and post diagnostic support (153 / 195)  People with urgent GP referral having first definitive treatment for cancer within 62 days of referral (151 / 195)  People with diabetes who attend a structured education course (149 / 195)

The bottom quartile indicators are a key focus of the quarterly assurance meetings with the GM partnership, with the locality asked to comment on how it is working to improve performance in these areas.

Appendix E gives an updated position statement in relation to those bottom quartile indicators as reported to the quarter 3 GM assurance meeting.

Since the November publication, 25 indicators were updated, with:

 13 improving their score  10 have deteriorating score  2 have stayed the same

Indicators with improved scores

 People with diabetes who attend a structured education course (2.9% - 3.5%)  Personal health budgets (23.5 - 24)  % NHS CHC assessments taking place in acute hospital setting (9.5% - 13.3%)  Anti-microbial resistance: Appropriate prescribing of antibiotics in primary care (1.104 – 1.095)  IAPT recovery rate (43.5% - 45.3%)  IAPT Access (4.2% - 5.8%)  People with first episode of psychosis starting treatment with a NICE- recommended package of care treated within 2 weeks of referral (65% - 69%)  Out of area placements for acute mental health inpatient care (812.6 - 302)  Proportion of people with a learning disability on the GP register receiving an annual health check (38.5% - 41.3%)  Completeness of the GP Learning Disability register (0.46% - 0.48%)  Delayed Transfers of Care (17.5 – 11.7)  People waiting 18 weeks from referral to hospital treatment (90.3% - 91.2%)  Diagnostics – 6 weeks (1.9% - 1.7%)

Indicators with deteriorating scores

 Diabetes patients achieving NICE recommended treatment targets (40.1% - 39.8%)  Utilisation of the NHS e-referral service to enable choice at first routine elective referral (91% - 85.4%)  Inequality in unplanned hospitalisation for chronic ambulatory care sensitive conditions and urgent care sensitive conditions (3,782 – 3,787)  People with urgent GP referral having first definitive treatment for cancer within 62 days of referral (77.5% - 74.6%) Agenda Item No. 3.1

 Reliance on specialist inpatient care for people with learning disability or autism (51% - 52%)  Maternal smoking at delivery (9% - 9.86%)  Estimated diagnosis rate for people with Dementia (79.9% - 79.7%).  Emergency admissions for urgent care sensitive conditions (3,415 – 3,545 )  Percentage of patients admitted, discharged or transferred from A+E within 4 hours (83.9% - 83.1%)  Population use of hospital beds following emergency admission (617.4 - 628)

7 indicators changed their quartile ranking:

4 improved

 IAPT Access (Inter to Top quartile)  People with first episode of psychosis starting treatment with a NICE- recommended package of care treated within 2 weeks of referral (Bottom to Inter quartile)  Percentage of patients admitted, discharged or transferred from A+E within 4 hours (Bottom to Inter quartile)  Delayed Transfers of Care (Bottom to Inter quartile)

3 deteriorated

 People with diabetes who attend a structured education course (Inter to Bottom quartile)  Utilisation of the NHS e-referral service to enable choice at first routine elective referral (Inter to Bottom quartile)  People with urgent GP referral having first definitive treatment for cancer within 62 days of referral (Inter to Bottom quartile)

10. Contract Planning

In preparation for contract updates the PQI team have met with key leads and commissioners across MHCC. Following this key quality schedules and local KPIs were revised.

Initial meetings with MFT, PAHT and GMMH were held in November/December 2018 to review the current national, GM and local requirements and talk through any new performance and quality requirements for 19/20 that were identified locally. A meeting was held with the MLCO in January in the same format.

National publications

A draft 19/20 contract was published for consultation in December 2018. There have been a small number of changes to Schedule 4: B National Quality Requirements as follows:

 Providers’ sanction for an over 52 week breach is £2,500 reduced from £5,000 Agenda Item No. 3.1

 The 12 hour ‘trolley’ waits in A&E has been changed to – ‘Waits’ in A&E not longer than 12 hours  Removed 4 indicators relating to the submission of data on SUS and mental health minimum data set  Added 3 additional indicators: (1) proportion of service users attending A&E who undergo sepsis screening and who, where screening is positive, receive IV antibiotic treatment within an hour (90% target, no financial penalty) (2) proportion of service user inpatients who undergo sepsis screening and who, where screening is positive, receive IV antibiotic treatment within an hour (90% target, no financial penalty) (3) Maternity services: proportion of relevant service users who are booked onto a Continuity of Care Pathway (35% target by March 2020, no financial penalty)

A final version of the contract was published in February. The deadline for agreeing contracts is 21 March 2019.

The CQUIN guidance has not yet been published; this was expected before the end of January but now looks likely to be published in March at the earliest. It has been indicated in the contract consultation that the value of CQUIN will reduce from 2.5% of the value of the contract to 1.25%.

The PQI team have reviewed the national publications and ensured any updates are reflected in the relevant quality schedules and KPIs.

Acute and mental health sector update

Following on from the meeting the refreshed KPI spreadsheet and outstanding queries in relation to quality schedules and standards have been sent through to the providers and a further meeting will be held following the release of the finalised national contract in February to finalise all performance and quality schedules, standards and KPIs.

Manchester Local Care Organisation

Key Performance Indicators

The health indicators have been discussed at several meetings and the teams are working to agree by the contract deadline. The Adult Social Care (ASC) Improvement Programme will inform the KPIs for 19/20.

Quality Standards

The standards proposed for the MLCO are aligned to those of MFT. These standards are with the Trust for internal review before final sign off.

CQUIN

The national guidance is not yet released and will be discussed following publication. Agenda Item No. 3.1

Service Development Improvement Plans

The 19/20 MLCO contract will include a service development improvement plan (SDIP). This is a commitment by MHCC and the MLCO to work together on a number of areas. These include

 Integrated Neighbourhood Teams – develop a suite of metrics that will demonstrate the benefits of implementing the new models of care. This will build on the theory of change work and the benefits articulated through business cases and service specifications.  Elective access and non-consultant waiting lists – to ensure waiting times for community services are subject to the same scrutiny as secondary care services.  Quality assurance – to work together to enhance the current regime of quality assurance.  Children and young people’s transition – to develop small number of metrics that demonstrate a smooth transition when children move to adult services.  Adult care services (ASC) – to produce a comprehensive assurance framework for these services.

Work in each of these areas has already started. Progress will be reported monthly to the Performance and Quality contract meeting.

Independent Providers

Key Performance Indicators

KPIs are complete for the vast majority of providers; the remainder will be signed off in line with the contract deadline.

Quality Standards

The team is in the final stages of drafting the social value and inclusion aspects of the contract schedule. All other schedules are complete. The quality risk profile tool is being amended.

CQUIN

CQUINs will only be applicable to those providers where the value exceeds £20,000. The national guidance is not yet available.

11. Recommendations

MHCC Board is asked to support the actions being undertaken to improve the quality and performance of commissioned services for the population of Manchester. APPENDIX A

APPENDIX A

APPENDIX A APPENDIX B

APPENDIX B

APPENDIX B

APPENDIX B

APPENDIX C

APPENDIX C

APPENDIX D

APPENDIX D

APPENDIX D

APPENDIX D

APPENDIX D

APPENDIX E CCGIAF – MHCC indicators in the bottom quartile (Mar 19 Assurance) Below is a list of the key actions relating to the areas identified as in the bottom quartile of the CCGIAF. Area Indicator(s) Lead National Rank Actions

Child Health  102a Percentage of children Sarah Doran / 180 / 195 (2014/15 Childhood obesity and aged 10-11 classified as Darren Parsonage – 2016/17) Maternity overweight or obese Manchester received our 2017/18 NCMP (National Child Measuring Programme) in October 2018. 40.8% of Year 6 Pupils were at an excess  125a Neonatal mortality and weight, an increase on the previous year overall figure for overweight (Tier 2 - stillbirths 158 / 194 (2016) 91st centile) and obese (Tier 3 - 96th Centile) children. N.B. the centile is a BMI score to measure child weight.

For children presenting as overweight, we have actually achieved an annual decrease in the number of children becoming overweight;  2015/16 - 13.5%  2016/17 -13.1%  2017/18 - 12.8%

This would demonstrate consistency with effectiveness of our Tier 2 Children's Weight Management Service and the work of Healthy Schools Team in implementing Daily Mile, Healthy lunchboxes etc.

Our Obesity figures however are increasing; these are children who have exceeded the threshold for the Tier 2 weight management programme and have no current children's Tier 3 service. This is commonly families with poor engagement.  2015/16 - 11.4%  2016/17 - 11.7%  2017/18 - 12.0%

We are intending to commission a revised weight management service in October 2019 as a Tier 2 & Tier 3 Children and Family Weight Management service. A stakeholder workshop took place in November 2018 to begin scoping a new service. A service specification is currently being developed for tender.

A multi-agency obesity safeguarding group was established in 2018, to manage a pathway for children presenting at 96th centile and above to acknowledge parental neglect and none-engagement as a safeguarding concern. Training has then been undertaken with professionals.

APPENDIX E

In terms of GM support, the ten regional authorities were recently placed in competition with one another for the LGA Obesity Trailblazer fund, a national fund. Manchester was unsuccessful despite having an obesity rate higher than the 12 successful authorities nationally (some of which were below the national average). Only one GM authority was successful in going through to the next phase. The funding has not appeared to be allocated equitable to need.

Maternity

Manchester is working as part of the Greater Manchester local maternity system to introduce the Saving Babies’ Lives care bundle. This will aim to deliver improvements in four key areas, one of these being smoking during pregnancy, an area where Manchester benchmarks poorly.

To reduce smoking in pregnancy, Manchester has rolled out the BabyClear programme from December 2018. To support the roll-out Manchester has funded additional midwifery and healthcare assistant support.

Manchester is aiming to improve the experience of women working through the Maternity Voices partnership, jointly commissioned by Manchester and Trafford. Urgent Care  104a Injuries from falls in Stef Cain 162 / 189 (17/18 Urgent Care System interventions people aged 65 and over Q3) There has been a number of recent winter planning meetings to look at what additionality system partners can offer to ensure winter surges can be  106a Inequality in unplanned 188 / 195 (18/19 managed effectively. This will in turn impact on the performance trajectories hospitalisation for chronic Q1) over the winter. The additional schemes will be complimentary to existing ambulatory care sensitive plans. and urgent care sensitive conditions Interventions of note include (within the Manchester and Trafford Urgent Care Improvement Plan): 188 / 195 (18/19  127b Emergency admissions Q1) Local Urgent Care Response– Direct referral crisis response (GM for Urgent Care Sensitive priority Home First) conditions 191 / 195 (18/19 The Local Urgent Care Response is an expansion of alternative to transfer Q1) (ATT) services in Central and South through a multi-disciplinary team (MDT)  127f Population use of community response. The NWAS amber pathway is part of this delivery.

APPENDIX E hospital beds following Service is already live in North Manchester. emergency admission Crisis Response is part of wider developing suite of services called Manchester Community Response (MCR)

There three main aims of MCR are to:

 Help people avoid going into hospital unnecessarily.  Help people be as independent as possible on discharge from hospital.  Prevent people from having to move into a residential home until they really need to.

The services that sit within the MCR model are Crisis Response, Intermediate Care and Reablement, Discharge 2 Assess and Community IV.

Primary care support into care homes (GM priority Stay Well)

In delivery of a standard Manchester model, a 12 month pilot service commenced in one neighbourhood in North Manchester where there was the biggest gap, covering 14 care homes, delivered by GTD healthcare. Currently different models have been in place Central and South Manchester.

Development of neighbourhood teams (GM priority Stay Well) Community services MDT to deliver services within 12 neighbourhoods.

Extensivist model – High Impact Primary Care (GM priority Stay Well) Pilot live in three Neighbourhoods targeting the top 2% of Manchester residents registered with a GP to reduce their usage of unplanned health & care services.

Additional interventions from the Urgent Care Recovery Plan include:

Alternative to transfer New see and treat pathways for children and extension the 15 minute call back time. Hear and treat Additional secondary triage introduced in hours.

MRI frailty service

APPENDIX E Provide GP input 5 days per week into the MRI frailty service supporting in- reach into ED. Frailty Steering Group meeting weekly and monitor activity and performance. Mental  123a Improving Access to Miladur Rahman / 177 / 195 (18/19 Recovery and six week RTT Health Psychological Therapies – Jane Thorpe Q2) recovery As reported at the last assurance meeting, Manchester is confident it will deliver the Q4 access target and the 18 week RTT. However performance  123f Out of area placements 176 / 195 (18/19 against the recovery and 6 week RTT has been challenging, with for acute mental health Q2) achievement forecast by the end of Q1 of 19/20. inpatient care – transformation Work is underway with all commissioned IAPT providers to work together in developing an integrated model that will lead to meeting the entire IAPT standard and will form the basis of a business case to achieve 25% access.

Six week RTT: Performance against the standard has remained stagnant for most part of this financial year. At step 2 (provided by SHS), the 6 week RTT is being consistently achieved averaging at around 80%. However performance at step 3 (provided by GMMH) is averaging at around 50%, therefore pulling overall performance below the standard

At step 3, the focus for most part of this financial year has been on delivery of the 18 week standard, and reducing the number of people on the historical waiting list that existed prior to the acquisition of adult mental health services by GMMH. This explains why there has been little impact upon RTT compliance at 6 weeks at step 3. However given that the majority of historical waiters have now been discharged from the service, together with the increase in staff recruitment at GMMH, Manchester will begin to see improvements against the 6 week standard going forward.

Recovery: Performance against the standard has remained stagnant for most part of this financial year. Recovery at step 2 is above the national standard averaging at 60%. However step 3 recovery rates at GMMH are averaging at around 33% therefore pulling overall performance below the standard.

As mentioned above, with the majority of historical waiters discharged, recruitment of additional 22 staff, majority of whom start in January 19, and with more people being seen quicker, GMMH envisage a positive step change in the recovery rates.

The increase in recovery rate is also being driven by a change in culture

APPENDIX E within GMMH and in addressing underperformance in the south GMMH IAPT division. There is a focus on providing high quality clinical supervision of staff, additional operational management support, and strong clinical leadership. There is now an effective triage process in place so that only patients who benefit from therapy are accepted onto the caseload, as well as a more proactive discharge procedure. GMMH are also undertaking targeting work to increase access to IAPT for the over 65’s who have better recovery rates.

Out of Area Placements

From April, only those patients that are placed in an inpatient bed outside of GM, due to no bed availability within GM, will be reported nationally as an OAP. There has been a significant drop in the number of inappropriate bed nights used outside of GM, reducing from 1,299 in April to zero OAPs in November. Key actions include:

 The opening in August of a new 13-bed male acute inpatient facility and an 8-bedded step down service aimed at improving patient flow by supporting service users’ transition between hospital and home.  GMMH have employed a Strategic Lead for Patient Flow to lead on all aspects of Patient Flow, reducing the use of OAP, identifying barriers to discharge to support flow through the Trust Inpatient services.  GMMH Bed Bureau has been implemented, maximising the use of beds across the system.  GMMH is working with other providers across GM on developing a consistent approach to the recording and reporting of delayed transfers of care (DTOC) across the GM footprint. The new approach will enable accurate data to be collected, identification of blockages and a system of escalation.  The implementation of the Enhanced Community Model in Q4 of 2018/19 will provide a real alternative to inpatient admission. Learning  124b Proportion of people Caroline Bradley 166 / 195 (2017 / With regards to MHCC plans, one element of the Primary Care Standards, Disabilities with a learning disability on 18) which are funded for a 21 month period running from 1st July 2018 – 31st the GP register receiving an March 2020, is specifically aimed at improving the health outcomes for annual health check patients with a Learning Disability (LD). All 89 GP practices have signed up to deliver the Standards and will aim to improve the health outcomes of patients with an LD through the following:

 Improving the accuracy of Learning Disability Registers  Improving the uptake and quality of the Learning Disability Annual Health

APPENDIX E Check  Improving the detection of unmet health needs in people with a learning disability  Reducing the variation in the quality of care and delivery across Manchester and provide accessible healthcare that meets the needs of people with learning disability

The delivery of this will be achieved through:

 Update and review QOF Learning Disability register to ensure accuracy  Each practice will offer annual health checks with a nurse and/or doctor via scheduled appointments lasting 30-40mins. Practices will use easy read invitations and provide easy read ‘what is an annual health check’ leaflet.  Each practice will continue to nominate an LD champion from their clinical staff who has an interest in healthcare for people with learning disabilities, in the same way as the 2017-2018 standard.  A medication review will be conducted with each annual health check, with a particular focus on stopping/reducing unnecessary medications and appropriate monitoring of medications.  Improve the access to screening for eligible patients by offering reasonable adjustments  Identify & record any ‘reasonable adjustments’ required for patients with LD[1] (Equality Act 2010).  Practices will use Health Action Plans for patients with learning disability to act as a prompt/reminder of the consultation  Practices will use easy read materials for people with learning disabilities to better understand their bodies and a range of conditions.

The spreadsheet embedded below outlines improvement in the reported number of people with a learning disability on the GP register receiving an annual health check up to December 2018.

Copy of Learning Disability Health Check - Rolling 12 months position (1).xlsx

Adult Social  121c Provision of high Paul Bickerton 184 / 195 (18/19 ASC has over the last 12 months developed a new support plan for all

[1] There is a section for this to be documented on the EMIS LD Annual Health Check template.

APPENDIX E Care quality care: adult social care Q1) providers in the City. Focus on the PQI teams activity has been dedicated time and effort for those that have a current CQC rating of requires improvement or inadequate. These providers have been party to a new audit toolkit which focuses on all of the elements of a CQC visit and the KLOE, the audit is intensive by nature and requires two PQI officers to complete it, with a dedicated action plan as a result. Providers that are rated as good or outstanding have completed a self-assessment based on contract expectation and CQC KLOE’s to offer assurance on their current provision and practice.

Work on the audit with providers is having a positive effect on the CQC revisits, with the original 6 inadequate care homes in the city, reducing to only 1 by the end of November. Cancer  122b People with urgent GP Alistair Rutherford 151 / 195 (18/19 MHCC strive to deliver all constitutional standards and the achievement of referral having first definitive Q2) cancer standards. MHCC has been assured by MFT and PAHT that recovery treatment from cancer within of the cancer 62 day standard will be delivered by the end of March 2019. 62 days of referral PQI are working with the commissioning team to ensure that we can improve  122c One-year survival from 166 / 195 (2015) and sustain performance. The 2019/20 MHCC commissioning response to all cancers the cancer requirements within the NHS long term plan will describe actions to address the achievement of cancer standards. The plan includes the latest NHS planning guidance, implementation of FIT testing and lung health checks.

One-year survival from all cancers remains a focus for MHCC, this will improve by the timely detection of cancer;  Focus on early diagnosis services e.g. FIT  Focus on improved screening uptake,  Roll out of lung health check.  GP education to recognition signs and symptoms of cancer via Gateway C,  Improved referral process with updated EMIS cancer referral form to include mandatory questions.

Timely diagnosis and treatment will be completed by the implementation of best practice timed pathways at local trusts (supporting the GM transformation work). Diabetes  103b People with diabetes Sara Fletcher 149 / 195 (2017 / MHCC has a programme of work to deliver improvements in treatment targets diagnosed less than a year 18) and increase attendance at Structured education programmes. who attend a structured

APPENDIX E education course The 8 processes of care remain part of the Primary Care standards requirements and have seen an increased uptake of 13% this year. It is predicted that this increase will continue in 19/10.

A review of the Manchester community offer is being undertaken, including a benchmarking exercise of the recommendations of the GM Diabetes Clinical network recommendations. The current community pilot in Central Manchester has seen improvements in clinical outcomes for people with Diabetes, this pilot will be reviewed in 19/20 with a likely recommendation to roll out further.

A stock take and review of current Diabetes structured education programmes has been undertaken and a proposal to have a consistent Manchester offer and service has been recommended which will see increased uptake and improved READ coding. This is on target to ‘go live’ in 19/20. Primary  128d Primary Care Sharmila Kar 192 / 195 (March Our vision for primary care workforce by 2027 is a sustainable workforce Care workforce 2018) system, growing our own workforce, and supporting the development of the existing workforce. Our workforce will continue to work with local communities to enable people and communities to be more active partners in health and wellbeing, continue to provide and promote excellent and higher quality care, and enable a consistent ‘Our Manchester’ approach and linkage between primary care and population health. Further our vision includes developing the resilience to primary care and GP practices to sustain the Manchester Local Care Organisation approach and support the movement of hospital services into the community in a safe and sustainable way; this is crucial to the success of our locality plans.

Specifically, our vision for primary care workforce includes:

 Every practice has a full complement of clinical and non-clinical staff to provide a minimum of 75 appointments per 1000 population with a prescribing clinician  Every neighbourhood will have a full complement of Multi-Disciplinary Staff to support practices, particularly around the care of higher risk patients (top 15 % of population). This could include pharmacists, physiotherapists, ANPs, specialist community nurses, physicians’ assistants, enhanced care workers and others.  An HR and Organisational Development (OD) support function for primary care in partnership with Manchester Local Care Organisation

APPENDIX E (MLCO), providing an employment model to facilitate joint and integrated working across neighbourhoods, professional groups, and all aspects of primary care provision.  A close working relationship with universities and training establishments will be in place, supporting the training and development ‘pipeline’ for the primary care workforce  Increased diversity of job roles such as community navigators and link workers will ensure linkage between public health, primary care and the LCO as “one team”  Local people will be recruited and trained and paid a minimum living wage to enhance social inclusion and resilience in the city

The publication of the NHS Plan and the associated guidance and the associated newly published 5 year framework for GP contract reform to implement the Plan, published 31st January 2019, significantly alters the route to implementation, and creates further challenges in determining the source and mount of investment to be made into primary care workforce and education. More detailed guidance is anticipated before 31st March 2019. What is evident from the NHS Plan is the requirement to accelerate implementation of role diversity in primary care, to increase capacity. Further, the increased profile of neighbourhood working, with the formation of Primary Care Networks and the associated Direct Enhanced Service requires significant time to revise the current workforce planning functions.

Population growth means that all GP practices can expect an increase in the number of patients, and therefore an increase in demand and need for capacity. For some practices within the city centre area, the population growth is predicted to be significant: forecasts based on Manchester City Council’s in-house forecasting model suggest that the total registered population of GPs in Manchester could increase from the current figure of around 635,690 to over 743,000 by 2026 / 27. Population growth will compound existing workforce shortages.

Population changes – reflecting the priorities in each of the 12 neighbourhoods, for example, greater numbers of students and young working professionals may require increased use of technology to provide same day access, requiring different skill sets.

Manchester Primary Care Standards – focus on chronic conditions which require routine as well as specialist input, specifically including diabetes and

APPENDIX E respiratory illness

MHCC is currently in the process of developing the next phase of our workforce strategy and business case, in which the national priorities will be reflected, along with the local priorities developed from the 12 Neighbourhood Workforce Plans.

MHCC has jointly funded a Clinical Fellow scheme aimed at recruiting newly qualified (within 2 years of post-CCT) GPs;

GPFYFV provides a national trajectory of an additional 5000 doctors and 5000 other healthcare professionals: based on emerging data collected locally, Manchester will be in deficit of over 26 wte GPs in the next five years. The current investment plan being developed will aim to attract, recruit and retain GPs within each different career stage: increased number of undergraduate medical trainees and Post-graduate trainees. The above will require increased capacity for training placements with additional funding and plans to fund supervisory capacity and rooms to facilitate increased education.

Increased number of GPs recruited post-CCT by establishing a bi-annual Clinical fellowship scheme.

Improved workload and working conditions for existing GPs (through education, reduction in admin workload through workflow optimisation, increased access to employment support, increased funding to practices).

Scheme to work with GPs approaching retirement to retain skills in new/flexible or part-time roles

The outputs and outcomes from the Workforce Development Team funded through MHCC were designed to inform the next stage of workforce planning. Whilst there has been considerable progress made, production and engagement across all 12 neighbourhoods is still in progress, and final Neighbourhood Workforce Plans (NWP’s) will not be available until mid- March 2019. The evaluation of the WDT is currently being considered to inform the next stage of workforce planning.

APPENDIX E Carers  108a The proportion of Debbie Walker 183 / 195 (2018) An independent review was undertaken by the Gaddum Centre. A Single carers with a long term Point of Contact (SPOC) is being proposed based on the GM Exemplar condition who feel supported Model and what carers have said they want. This will require investment of to manage their condition 1.2m of which Our Manchester Fund has granted 600k and a GMTF Business Case will be presented to Investment Panel on 4th April 2019 to secure 600k match funding. The investment will enable the VCS sector to develop the SPOC and will assist carers who require information, advice, training or support to sustain their role. The model will be based on the three conversations asset based approach to problem solving and assessment. Within the model the expectations of the GM Carers Charter will be adopted:  To be identified as a carer as early as possible, be informed, be respected and included by health and care professionals  To have choice and control about your caring role, get the personalised support you need as a carer to meet you and your family's needs  To be able to stay healthy and well yourself, and for your own needs and wishes as an individual to be recognised and supported  To be socially connected and not isolated  To be supported to full educational and employment potential, and where possible in maintaining employment