Performance Report

Paper 16

Ayrshire and Arran NHS Board

Monday 19 August 2019

Performance Report

Author: Sponsoring Director: Paul Dunlop, Senior Performance Officer Kirstin Dickson, Director for Transformation Steven Fowler, Senior Performance Officer & Sustainability Donna Mikolajczak, Performance Manager

Date: 2 August 2019

Recommendation

The NHS Board is asked to note Performance across NHS Ayrshire & Arran based on key measures of Unscheduled and Planned Care.

Summary

This is the second consolidated report to NHS Board on overall Performance across NHS Ayrshire & Arran. A set of two infographics are provided in Sections 1.1 and 2.1 to provide NHS Board members with an overview of Performance ‘At a Glance’ in relation to Unscheduled Care and Planned Care; and to ensure that Board members are sighted on the corresponding impact of underperformance across the system as a whole.

Section 1 includes a summary of performance in relation to Unscheduled Care across Health and Social Care. Appendix 1 includes detailed analysis on a range of Unscheduled Care measures:

• ED 4hr Compliance • ED Attendances • CAU Presentations • Medical and Surgical Admissions from Emergency Department (ED) and Combined Assessment Unit (CAU) • Delayed Discharges • Ministerial Strategic Group (MSG) for Health and Community Care Indicators

Section 2 summarises performance against the National Waiting Times and Access targets and also provides an update on progress in relation to the Scottish Government Waiting Times Improvement Plan. Appendix 2 includes detailed analysis on the following targets and measures: • Inpatient and Day Case 12 Weeks Treatment Time Guarantee • New Outpatient 12 Weeks Access Target

1 of 43 • 18 Weeks Referral to Treatment • Diagnostics Waiting Times • Cancer Waiting Times • Mental Health Services • AHP MSK Waiting Times

Key Messages

The number of NHS Ayrshire & Arran patients who were delayed in their discharge from hospital reached its highest recorded position of 72 in May 2019. This, combined with increased levels of ED attendances and CAU presentations, continue to impact on compliance against the Emergency Department (ED) 4 hour standard.

Although below target, and the compliance recorded in May 2018, there has been an improvement against the 62 day Cancer target between April 2019 and May 2019. Inpatient and Day Case compliance against the National 12 week Treatment Time Guarantee continues on a positive trajectory. However, challenges continue in relation Child and Adolescent Mental Health Services (CAMHs) despite an improvement between April 2019 and May 2019.

NHS Ayrshire & Arran recently submitted their Annual Operational Plan (AOP) for 2019/20 to the Scottish Government. NHS Boards were asked by the Scottish Government to include the key planning assumptions and expected levels of performance against a suite of Unscheduled Care and Planned Care measures, including Mental Health. The AOP sets out the planned deliverables over the next year and highlights how these will lead to improvements throughout this period.

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Glossary of Terms

ABIs Alcohol Brief Interventions ACE Acute Care of the Elderly AEC Ambulatory Emergency Care AHP Allied Health Professional AMG Access Monitoring Group AOP Annual Operational Plan CAMHS Child and Adolescent Mental Health Services CAU Combined Assessment Unit CMT Corporate Management Team DDD Daily Dynamic Discharge ED Emergency Department EDD Estimated Discharge Date GJNH Golden Jubilee National Hospital HIS Health Improvement Scotland HSCP Health and Social Care Partnership IHO Institute of Healthcare Optimisation IP/DC Inpatient/Daycase ISD Information Services Division LDP Local Delivery Plan MDT Multi-Disciplinary Team MSG Ministerial Strategic Group (for Health and Community Care) MSK Musculoskeletal NES NHS Education for Scotland OT Occupational Therapy PGC Performance Governance Committee PR Pulmonary Rehabilitation RTT Referral to Treatment SHREWD Single Health Resilience Early Warning Database SMR Scottish Morbidity Record TTG Treatment Time Guarantee UCD Unscheduled Care Delivery UGI Upper Gastrointestinal UHA University Hospital Ayr UHC University Hospital Crosshouse WTIP Waiting Times Improvement Plan

3 of 43 1. Unscheduled Care

1.1 Unscheduled Care – At a Glance To evidence progress and to give assurance to the NHS Board in relation to Unscheduled Care, performance monitoring is based on the following three main themes: • reducing emergency admissions by providing accessible community alternatives; • reducing occupancy and length of stay by improving systems and processes within the acute hospital; and • reducing delays in discharge by providing appropriate community capacity.

* Inpatient Admissions from the ED admitted directly into Medical or Surgical ward (excluding CAU) and Inpatient admissions from the CAU admitted to CAU (regardless of source) who are transferred to a medical or surgical ward (excluding discharges directly from the CAU)

4 of 43 • ED Attendances at UHC have returned to levels comparable with pre-CAU activity. Attendances at University Hospital Ayr (UHA) ED remain lower than pre-CAU levels despite an increase over the past year. At UHA, there has been a marginal 0.5% increase in the number of ED attendances between June 2018 (3,440) and June 2019 (3,456); and a 3.3% increase at UHC between June 2018 (6,277) and June 2019 (6,486). (Appendix 1: Figures 1.2 and 1.3)

• ED 4-Hour Wait 95% target has been achieved in only 2 of the past 12 months (June 18 and July 18). Compliance at UHA ED has decreased by 6.6 percentage points between June 2018 (95.1%) and March 2019 (82.2%), and at UHC ED there has been a decrease of 5.8 percentage points between June 2018 (96.7%) and June 2019 (90.9%), against a 95% target. (Appendix 1: Figures 1.1,1.2 and 1.3)

• CAU Presentations have risen at both sites over the past year, with a greater increase at UHA than UHC. This increase has predominantly been in the numbers of referrals from ‘Other’ sources. ‘Other’ includes referrals from out-patient clinics, the national cancer treatment helpline, and abnormalities in radiology requiring immediate attention. At UHA, there has been a 5.8% increase in the number of presentations at CAU between June 2018 (1,528) and June 2019 (1,617), as well as a 4.0% increase at UHC between June 2018 (1,438) and June 2019 (1,496). (Appendix 1: Figures 2.1 and 2.2)

• Analysis of Medical and Surgical Inpatient Admissions from the EDs and CAUs for the period since the opening of their respective CAUs had shown a slight decreasing trend at both sites; however activity has been increasing recently and is higher than for the same period last year. When comparing the numbers of medical and surgical admissions for June 2019 with June 2018, there has been a 13.8% increase at UHA and a 6.8% increase at UHC. (Appendix 1: Figure 3.1)

• Comparing March 2019 to March 2018, analysis of Unscheduled Bed Days for Acute Specialties from the MSG Indicator data suggests a significant reduction across Ayrshire and Arran over the past year, with a 18.4% decrease reported for East Ayrshire residents (from 9,334 to 7,614); a 30.0% decrease reported for North Ayrshire residents (from 12,506 to 8,757) and a 22.1% reduction reported for South Ayrshire residents (from 10,745 to 8,368). The scale of this decrease is primarily as a result of the closure of unfunded acute beds at both UHA and UHC. (Appendix 1: Figure 5.2.3)

• Delayed Discharge >2 Weeks (excluding complex code 9 delays) have steadily been increasing since May 2017, reaching their highest recorded position of 72 delays in May 2019 (previous highest was 71 delays in November 2018). Across the HSCPs, the increase has predominantly been in South Ayrshire HSCP, with delays reaching an all-time peak of 51; delays from East Ayrshire residents continue to remain at 0. (Appendix 1: Figure 4.1)

• Delayed Discharge Occupied Bed Days (OBDs) for all delays have been increasing continually since March 2017, with an increase of 13% experienced between May 2018 (3,924) and May 2019 (4,432). Delays from South HSCP residents have contributed most to this, with South OBDs reaching their highest recorded position in May 2019, whilst for North HSCP residents there has been a recent decrease following a 6-month period of continued increase. OBDs due to delayed discharge for East HSCP residents have remained consistently at or below 500 per month, and are mostly as a result of code 9 delays. (Appendix 1: Figure 4.2)

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1.2 Unscheduled Care Priority Actions

A number of prioritised transformational projects were undertaken in 2018/19 as part of whole system planning to improve performance of unscheduled care. The priority actions were summarised in the previous performance report for the Board’s consideration https://www.nhsaaa.net/media/7243/20190527bmp24.pdf .

NHS Ayrshire & Arran recently submitted their Annual Operational Plan for 2019/20 to the Scottish Government (SG). NHS Boards were asked by the Scottish Government to include the key priority actions and improvement plans over the next year for Unscheduled Care. To support this, a suite of key performance measures have been agreed and performance scrutiny and appropriate action to address areas of underperformance will be discussed through the Unscheduled Care Delivery Group at both University Hospital Ayr and University Hospital Crosshouse.

Delivery of the AOP will be driven by the Six Essential Actions plans. The key measures within the AOP include improving compliance with the 4 hour standard, reducing occupancy levels within UHA and UHC, and eliminating 12 hour breaches. Occasionally waits to move from ED not only extend past the 4 hour access and treatment standard but exceed 8 and 12 hours. ED waits over 8 and 12 hours have been shown to produce poor patient experiences, adverse outcomes and potential safety issues. NHS Ayrshire & Arran has recently become an outlier with regard to 12 hour breaches. This is now a focus of improvement work. In addition to this, each acute site has a number of priorities supported by detailed project plans.

For UHA, the priority areas within the action plan include:

• Increasing Ambulatory Emergency Care • Phase 2 of Frailty at the Front Door Collaborative September 2019 - March 2021 • Review of the Safety Huddle • Improving Discharge • Reducing the number of 12 hour breaches • Daily Dynamic Discharge(DDD)/ Institute of Healthcare Optimisation (IHO) • Carer Support at Discharge • Single Health Resilience Early Warning Database (SHREWD),

The priority areas for UHC are similar and include:

• Frailty Pathway • Review of the Safety Huddle • Increasing attendance at the Discharge Lounge • Reducing the number of 12 hour breaches • DDD/IHO • Carer Support at Discharge • SHREWD

There may be additions to the UHC action plan as projects are identified and prioritised by the USC Exemplary Leadership Group.

6 of 43 • Increasing Ambulatory Emergency Care at UHA UHA is working alongside the Ambulatory Emergency Care Network to review the current ambulatory emergency care model and to identify any potential opportunities to improve the service and maximise ambulatory care as an alternative to admission. An AEC Project team has been established which is meeting weekly to accelerate improvement.

• Phase 2 of Frailty at the Front Door Collaborative September 2019 - March 2021 The population of Ayrshire & Arran is projected to change considerably over the coming years with growth in over 75s having the greatest impact on the demand for health and social care services. Evidence confirms that each day a person spends in hospital where their care needs are complex increases their risks of losing personal independence and mobility, especially if people are aged over 65 and more so if aged over 75. A significant amount of work has already been progressed with regard to this service and pathway - development of a frailty screening tool, establishment of a mechanism to ‘follow’ frail patients throughout their journey, and the introduction of new Acute Care of the Elder (ACE) posts. An application to be considered for phase 2 of the HIS Collaborative supporting implementation of the frailty pathway was successful. Phase 2 will be launched in mid-September.

• Review of the Safety Huddles at UHA and UHC Hospital Safety Huddles are an ideal opportunity to develop an environment of psychological safety and collective responsibility. When structured and chaired well, they provide real time information to inform critical decisions and opportunities. Improved communication and more effective team working highlights risk and reinforces a mechanism to resolve issues before they impact on patient flow and safety. It is planned that work will be undertaken to support improvements of Safety Huddles on both sites.

• Improving Discharge at UHA This is multi-factorial involving changes to ward processes and systems. The most recent Day of Care survey showed that awaiting Allied Health Professional assessment or finish of treatment was the highest delay in the acute setting. Work is presently being undertaken to reduce the number of unnecessary referrals to Allied Health Professionals (AHPs), to improve communication between AHPs and ward staff, and to better understand the unique contribution that the Acute Care of the Elder (ACE) Practitioner makes to the patient journey to avoid duplication.

• Increasing attendance at the Discharge Lounge at UHC The importance of optimising the use of the Discharge Lounge to free capacity earlier in the day is key to improving flow. Attendance at the UHC lounge has recently decreased. A small project team will be supported to drive improvement.

• Reducing the number of 12 hour breaches Establishment of 2 hourly board rounds in ED, and review of escalation thresholds and triggers are being supported to eliminate 12 hour breaches.

• Daily Dynamic Discharge(DDD)/ Institute of Healthcare Optimisation (IHO) Daily Dynamic Discharge is a framework for good practice which incorporates setting Estimated Discharge Dates (EDD) for all patients admitted to hospital, undertaking a daily ward Board Round, and using Criteria-Led Discharge (CLD)

7 of 43 where appropriate. In March 2019, the proportion of patients at UHA with an EDD set was 97.69%, against a target of 97%. Performance for this measure at UHA has exceeded the target in 10 out of the last 11 months. In terms of discharge times, the drive for improvement has focused on ‘earlier in the day’ discharges and ‘shifting the curve’. Pre-2pm discharges have improved to approximately 30% on both sites. Numbers of ward discharges pre-1pm and pre-2pm are now routinely shared with ward staff to promote ownership of data and reflect on changes they could make. The establishment of daily board rounds in wards works well where there is strong nursing and medical leadership.

The IHO re-engineering medical pathways work focuses on the importance of ensuring the patient is in the right place first time. Establishing criteria for medical specialties on each acute site ensures that patients requiring specialist care and treatment receive that first time. Improved outcomes at UHA have included reduced inter-ward transfers and reduced overnight transfers.

• Carer Support at Discharge Section 28 of the Carers (Scotland) Act 2016 makes it incumbent upon services to involve carers in discharge planning. A group has been established to bring together the 3 local Carers Centres to offer support to people identified as carers whilst their relative is in acute care. Evidence shows that good support and information for carers can lead to reduced hospital admissions for their relative. Carers Support Workers on both acute sites attend to referrals from wards alongside each Carers Centre agreeing to accept referrals directly from the acute setting. These referrals and outcomes for carers are being monitored and evaluated locally, and also as part of a national work stream.

• Single Health Resilience Early Warning Database (SHREWD) Single Health Resilience Early Warning Database (SHREWD) is a real-time data platform which gives a view of whole system pressure. The aim is to proactively tackle the causes of pressure as it develops, rather than be reactive. Escalation thresholds and triggers are built into the system which then automates escalation actions to alleviate the pressure.

Scottish Government has provided financial support for the implementation of SHREWD in Ayrshire, this being a pilot site for Scotland. There is a comprehensive and ambitious project plan which concludes July 2019. Whilst approximately 40- 50% of the data can be automated in SHREWD and is largely populated for the acute setting, work with partners is ongoing to agree their key indicators and how these data will be input to the system.

There may be additions to the UHC action plan as projects are identified and prioritised by the USC Exemplary Leadership Group.

The three Health and Social Care Partnerships are also developing their priority action plans to support Unscheduled Care.

• Within South Ayrshire HSCP, engagement sessions facilitated by iHub were held throughout May and June 2019. Information gathered from the engagement sessions is being collated and a Transformational Change Strategy for Adults and Older People’s Services based on a performance management approach is being developed. It is intended that this will be available for consultation in early August.

8 of 43 • Within North Ayrshire HSCP, the Joint Inspection (adults) highlighted the need to develop a system wide commissioning strategy for older people, which will include unscheduled care priority areas. The Health and Community Care leads are meeting on the 25 July 2019 to agree key priorities.

• East Ayrshire Health and Social Care Partnership’s focus is to maintain high performance in transfers of care out of hospital and further improve the experience of transfer of care for those patients involved in Adults with Incapacity processes. Work will take place across Primary Care / Intermediate Care Rehabilitation and Acute to reduce hospital admissions and also improve end of life care enabling more people to spend more time at home or in a homely environment in their last six months of life.

1.3 Delayed Discharges

1.3.1 East Ayrshire Health and Social Care Partnership

The number of East Ayrshire HSCP patients who are delayed over 2 weeks remain at 0. Local stretch targets are being applied to reduce delays to discharge beyond seven days except for very complex cases and a continued focus is to improve the patient experience of people who are potentially delayed through Adults with Incapacity process.

1.3.2 North Ayrshire Health and Social Care Partnership

Within North Ayrshire HSCP, the number of patients delayed over 2 weeks have noticeably reduced in recent months, having previously reached their highest ever recorded position in February 2019. Joint working between acute colleagues and the HSCP are having a positive effect and includes: • Supporting and involving carers at the point of hospital discharge. Two Carer Support Workers (Hospital Discharge) are supporting carers in the Acute sites of University of Crosshouse Hospital and University of Ayr Hospital, in partnership with Carers Trust, Unity and the three Ayrshire HSCPs. The Carer Support Worker identifies unpaid carers and provides them with the right information and advice at the right time. They also ensure that carers are involved in the discharge conversation before their family member or friend goes home; • A Care at Home re-ablement approach is releasing additional hours for care at home to be used to support hospital discharges; • North Ayrshire HSCP have formed a discharge to assess model, enhanced the hospital social work team and established criteria led discharge in inpatient intermediate care; • No decisions are taken to restrict community care packages for financial reasons and number of patients waiting for a Care at Home package (Hospital) target is being consistently met; • The redesign of the model of care at Ward 1 and Ward 2, Woodland View has created additional community-based beds to assist acute hospital discharges.

Work continues with acute colleagues to improve the numbers of care at home packages which are cancelled by hospital staff at short notice. In the last quarter of 2018/19 - 6,907 care at home hours were lost and these could have facilitated additional discharges.

9 of 43 There has also been a reduction in the total number of bed days occupied each month by North Ayrshire HSCP patients whose discharge from hospital was delayed due to non- medical reasons. In addition to the joint working described above, the following actions have also had a positive impact:

• North Ayrshire Council is acting as financial guardian to expedite AWI cases, • A new Care Home commissioning strategy is being developed with the sector to look at models to further facilitate discharge, including step up/down beds, planned respite, Palliative care and a model to support those with AWI needs.

1.3.3 South Ayrshire Health and Social Care Partnership

The number of South Ayrshire HSCP patients whose discharge from hospital was delayed by 2 weeks or more reached 51 in May 2019.

Demand for care services continues to rise, set against a background of reducing service availability as a result of financial constraints. A number of operational arrangements are in place to mitigate against associated service pressures as far as is possible. These include: • Biggart Hospital- opening additional capacity during the winter to meet operational pressure. • Care at Home have introduced a range of measures that have improved efficiency, resulting in more people being supported in their own home and waiting times remaining static despite a reduction in the number of hours being delivered. • Work is ongoing to redesign and rebalance the health and care system in the medium to long term. An improvement plan will be published in September 2019 and much of the work is already in progress.

Budget monitoring information is being regularly reviewed on an ongoing monthly basis to ensure budget remains balanced and maximum service can be offered within resources available.

1.4 Enhanced Intermediate Care and Rehabilitation Service

The new model was developed around Intermediate Care and Rehabilitation Hubs which provide a single point of access, with screening and clinical triage, ensuring the person is seen by the right service, first time and includes 7 day working. The model supports people at different stages of their recovery journey and links up and builds on existing intermediate care and rehabilitation services reducing duplication and fragmentation of services across Ayrshire and Arran and offering better outcomes for people. The new Enhanced Intermediate Care and Rehabilitation Service went live on 19 November 2018.

For the period November 2018 to May 2019, the total number of Intermediate Care Team (ICT) referrals received increased by 16.3% when compared to the same period of the previous year (2017/18). The number of prevented admissions increased by 48.5% and early / supported discharges increased by 12.8% when compared to the previous year.

The Pan Ayrshire Enhanced Intermediate Care and Rehabilitation Operational Group remains critical in progressing and sharing good practice across the areas. Learning and benchmarking continues across the three HSCP areas, in terms of sharing the key factors that are having an impact in the differing models across the three HSCPs. In addition,

10 of 43 data validation exercises continue to ensure that there is consistency in recording across the three HSCP areas. Plans are underway to facilitate robust evaluation of the investment associated with the new model by autumn 2019.

1.5 Ministerial Strategic Group for Health and Community Care

In January 2018, the Ministerial Strategic Group for Health and Community Care required integration authorities to set out local performance improvement trajectories in respect of six indicators to enable more care to be shifted towards community. The indicators are intended to demonstrate progress under integration and how the component parts of the health and social care system are working together for improvement.

For 2018/19, trajectories were required for:

1. Unplanned admissions; 2. Occupied bed days for unscheduled care; 3. Emergency Department performance; 4. Delayed discharges; 5. End of life care; and 6. The balance of spend across institutional and community services.

A summary of the trends and performance against the trajectories in relation to the MSG indicators for 2018/19 are included in Sections 5.1 and 5.2 in Appendix 1. Trajectories for the forthcoming financial year 2019/20 have been submitted to the Ministerial Strategic Group by each partnership and are pending ratification. A summary from each of the HSCPs on their improvement plans in 2018/19 and their ongoing plans are described in section 5.3 of Appendix 1.

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2. Planned Care

2.1 At a Glance - Latest Performance against Scottish Government National Targets

NHS Ayrshire & Arran – At a Glance Planned Care

Latest performance, with comparison to previous year where: Improving No change Worsening against the Scottish Government target ( ) ,where applicable Service Access

81.5% waited fewer than 12 weeks for a New Outpatient appointment 95% Jun 2019

80.1% waited fewer than 18 weeks from Referral to Treatment 90% May 2019

80.1% waited fewer than 12 weeks for inpatient or daycase treatment 100% Jun 2019

Child and Adolescent Mental Health Psychological Therapies

78.6% 90% 73.6% 90% May 2019 May 2019 of children and young people started treatment within of patients started treatment 18 weeks of initial referral within 18 weeks of their initial to CAMH services referral for psychological therapy MSK Drug and Alcohol Treatment

47.0% 90% 98.7% 90% Jun 2019 May 2019 of adult patients waiting of clients waited no longer than 3 weeks from fewer than 4 weeks for referral to appropriate drug or alcohol treatment MSK services that supported their recovery Cancer

96.1% 95% 82.1% 95% May 2019 May 2019 started treatment within 31 days following of patients with suspicion of cancer started decision to treat treatment within 62 days

Diagnostics

50.9% of patients waiting fewer than 6 weeks for Endoscopy 100% May 2019

70.4% of patients waiting fewer than 6 weeks for Imaging 100% May 2019

12 of 43 • New Outpatient compliance against the National Target of 95% continues to remain below the 95% target, with a reduction of 1.2 percentage points from a position of 82.7% at May 2019 to 81.5% at June 2019. This is lower when compared to the June 2018 position of 86.3%. (Appendix 2: Figure 2.1 and Table 2.1);

• 18 week RTT performance remains below target, with compliance recorded at 80.1% in May 2019, an increase of 3.9 percentage points from the 76.2% recorded in April 2019. This is lower than 81.6% recorded in May 2018. (Appendix 2: Figure 2.2);

• Inpatient and Day Case compliance against the National 12 week Treatment Time Guarantee is below the 100% target, although has shown an increase of 0.6 percentage points from a position of 79.5% at May 2019 to 80.1% at June 2019. This is higher than the 74.4% recorded in June 2018. (Appendix 2: Figure 1.1);

• Within Diagnostics, compliance against the 6 week Access Target of 100% for Endoscopy decreased by 1.7 percentage points from 52.6% in April 2019 to 50.9% in May 2019. There was also a 3 percentage point decrease in Imaging, from 73.4% in April 2019 to 70.4% in May 2019. This is higher than the 67.8% compliance reported in May 2018 (Appendix 2: Figures 3.1 and 3.2);

• The 31 day Cancer target of 95% continues to be exceeded in May 2019, with performance of 96.1%, although this is a decrease of 2 percentage points from 98.1% in April 2019. Compliance against the 62 day Cancer target of 95% continues to prove challenging to meet. There was however a 3.7 percentage point increase from 78.4% in April 2019 to 82.1% in May 2019. Although this is lower than the 89.5% reported in May 2018, compliance remains higher than the 81.1% reported for NHS Scotland in May 2019 (Appendix 2: Figures 4.1 and 4.2);

• Psychological Therapies waiting times continues to remain below the 90% target, with compliance of 73.6 % at May 2019 similar to April 2018. This is lower than the 80.3% recorded in May 2018 (Appendix 2: Figure 5);

• The Mental Health waiting times target of 90% for CAMHs remains below the 90% target, although there has been an improvement of 11 percentage points from a low of 67.6% at April 2019 to 78.6% at May 2019. This is the third time compliance has fallen below 80% in 2019 and is significantly lower than the 93.4% recorded in May 2018. (Appendix 2: Figure 5);

• Drug and Alcohol Treatment continues to meet and exceed the target of 90% with performance of 98.7% in May 2019 (Appendix 2: Figure 5);

• MSK performance continues to be below the target of 90% of patients being seen within 4 weeks from referral to first clinical outpatient appointment, with performance at the end of June 2019 remaining at 47%. This is however higher than the local trajectory of 45.4%. Against the published data for the quarter ending March 2019, NHS Ayrshire & Arran was the 3rd highest performing mainland NHS Board (Appendix 2: Figure 6).

13 of 43 2.2 Waiting Times Improvement Plan

In October 2018, the Scottish Government published the Waiting Times Improvement Plan (WTIP) for NHS Scotland https://www.gov.scot/publications/waiting-times-improvement- plan/ . The Improvement Plan is phased and outlined that:

By October 2019

• 75% of inpatients/day cases will wait less than 12 weeks to be treated • 80% of outpatients will wait less than 12 weeks to be seen • 95% of patients for cancer treatment will be continue to be seen within the 31-day standard

By October 2020

• 85% of inpatients/day cases will wait less than 12 weeks to be treated • 85% of outpatients will wait less than 12 weeks to be seen

By Spring 2021

• 100% of inpatients/day cases will wait less than 12 weeks to be treated • 95% of outpatients will wait less than 12 weeks to be seen • 95% of patients for cancer treatment will be seen within the 62-day waiting-time standard.

At June 2019, NHS Ayrshire & Arran were exceeding the Scottish Government Improvement Plans set out for October 2019 for Inpatient/Day Cases and Outpatients. Across NHS Ayrshire &Arran, 80.1% of Inpatient/Day Case patients waited less than 12 weeks to be treated, with 81.5% of Outpatients waiting less than 12 weeks to be seen. In addition to this, at May 2019, 96.1% of patients for cancer treatment were seen within the 31 day standard.

NHS Ayrshire & Arran recently submitted their Annual Operational Plan (AOP) for 2019/20 to the Scottish Government. As part of the Waiting Times Improvement Plan (WTIP) component of the AOP, NHS Boards were asked by the Scottish Government to include the key planning assumptions and expected levels of performance against a suite of waiting times measures including Inpatient/Day Cases, Outpatients, Cancer, diagnostics and CAMHs. The Waiting Times Improvement Plan for Ayrshire and Arran sets out the planned deliverables over the next year and highlights how these will lead to improvements throughout this period and into the following two years to meet the National Improvement Plan commitments and improve performance against the National Targets.

Performance scrutiny and appropriate action to address areas of underperformance will be discussed through the Acute Services Waiting Times Group.

Appendix 2 includes detailed analysis on the progress towards achieving national waiting times and access targets.

14 of 43 Monitoring Form

Policy/Strategy Implications The Patients’ Rights Act and the Treatment Time Guarantee place requirements on NHS Boards on waiting time management and monitoring.

Workforce Implications Workforce implications identified relate to recruitment of staff to ensure appropriate levels of capacity are maintained to manage demand.

Financial Implications There is growth in referrals across a number of specialties in Acute Services. This, along with current financial challenges, has led to bids for Waiting List Initiatives and ongoing service enhancements being reviewed and resubmitted, where appropriate, by service managers.

Bids for all further investment are reviewed in light of available funding and the implication of levels of investment on waiting times targets. Additional Scottish Government support is being provided.

Consultation (including This report is compiled by summarising information Professional Committees) from a variety of sources and other NHS Ayrshire & Arran reports. These reports are presented to CMT and Governance Committees of the NHS Board.

Risk Assessment There is a significant risk to the organisation in failing to improve against the waiting times targets, with action plans in place to ensure safety of patient care is prioritised.

Risks remain that unforeseen circumstances, e.g. ward closures due to illness, could adversely affect any recovery programme. As all internal relevant staff and facilities are already committed to this effort no contingency plans are possible. Risk mitigation is being delivered by close scrutiny and management.

Best Value Successful management of waiting times requires - Vision and leadership leadership, and engagement with clinical staff. - Effective partnerships - Governance and The Health and Social Care Partnerships have accountability increasing influence on Delayed Discharge - Use of resources performance through patient flow. - Performance management Local performance management information is used to provide as up to date a position as possible in this report. Some information may change when the data is quality assured by ISD in readiness for publication.

15 of 43 Compliance with Corporate The achievement of the waiting times targets set out Objectives within this paper complies with a number of the corporate objectives: improving health; safety/outcomes; quality of experience; equality; transforming and patient flow; supply and demand.

Single Outcome Agreement The achievement of the targets provides better access (SOA) to healthcare services and should therefore have a positive effect on the health inequalities priority within local SOAs.

The achievement of the patients awaiting discharge targets will have a positive contribution towards the Outcomes for Older People priority. Impact Assessment An Equality and Diversity Impact Assessment is not required for this paper. Service improvement plans referred to within the paper will be assessed as appropriate.

16 of 43 Appendix 1 Unscheduled Care

1. Emergency Department data

ED Attendances at UHC had initially reduced following the opening of CAU, however have since returned to levels comparable with pre-CAU activity (there were 0.7% more attendances in Q1 2019/20 than in Q1 2015/16). Attendances at UHA ED remain lower than pre-CAU levels despite an increase over the past year. This increase in UHA ED attendances has primarily been from flow 2 (Acute assessment – includes major injuries) attendances, which have shown continued increase since January 2017.

ED 4-Hour Wait 95% target has been achieved in only 2 of the past 12 months (June 18 and July 18). However the most recent published national data also shows that in May 2019, NHS Ayrshire & Arran performance has risen above the Scotland average for the first time since December 2018. This is shown in Figure 1.1 below.

Figure 1.1 ED 4-hr Wait Compliance, NHS Ayrshire & Arran: May 2016 – May 2019

100.0%

95.0%

90.0%

85.0%

80.0% Jul-18 Jul-17 Jul-16 Oct-18 Apr-19 Oct-17 Apr-18 Oct-16 Apr-17 Jun-18 Jan-19 Jun-17 Jan-18 Jun-16 Jan-17 Mar-19 Mar-18 Feb-19 Mar-17 Feb-18 Feb-17 Nov-18 Dec-18 Nov-17 Dec-17 Aug-18 Sep-18 Nov-16 Dec-16 Aug-17 Sep-17 Aug-16 Sep-16 May-19 May-18 May-17 May-16

95% Target NHS A&A Scotland

Source: ISD Scotland, Emergency Department activity – AE_activity_waiting_Times_Jul19

ED attendances and 4 hour wait compliance at UHA (Figure 1.2) and UHC (Figure 1.3) are shown for the period June 2016 to June 2019.

17 of 43 Figure 1.2 ED Attendances and 4-hr Wait Compliance, UHA: Jun 2016 – Jun 2019

6,000 UHA CAU 100.00% (Jun 2017) 95.00% 5,000 90.00%

85.00% 4,000 80.00%

3,000 75.00%

70.00% 2,000 65.00%

60.00% 1,000 55.00%

0 50.00%

ED Attendances Standard (95%) 4 hr wait %

Source: NHS Ayrshire & Arran Pentana System, local validated data from Business Intelligence report - extracted July 2019

Figure 1.3 ED Attendances and 4-hr Wait Compliance, UHC: Jun 2016 – Jun 2019

9,000 100.00%

8,000 95.00%

7,000 90.00% 85.00% 6,000 80.00% 5,000 75.00% 4,000 70.00% 3,000 65.00%

2,000 60.00%

1,000 55.00%

0 50.00%

ED Attendances Standard (95%) 4 hr wait %

Source: NHS Ayrshire & Arran Pentana System, local validated data from Business Intelligence report - extracted July 2019

18 of 43 2. Combined Assessment Unit data

CAU Presentations have risen at both sites over the past year, with a greater increase at UHA than UHC. This increase has predominantly been in the numbers of referrals from ‘Other’ sources, i.e. not from GPs or EDs. UHA CAU receives a higher percentage of its referrals from ED, whilst at UHC CAU there is a near 50/50 split in GP/ED referrals. Note: ‘Other’ includes referrals from out-patient clinics, the national cancer treatment helpline, and abnormalities in radiology requiring immediate attention.

CAU referral numbers by source at UHA for the period July 2017 to June 2019 are shown in Figure 2.1 and at UHC for the period June 2017 to June 2019 in Figure 2.2.

Figure 2.1 CAU Referrals by Source, UHA: Jul 2017 – Jun 2019 2,000 1,800 1,600 1,400 1,200 1,000 800 600 400 200 0 Jul-18 Jul-17 Oct-18 Apr-19 Oct-17 Apr-18 Jun-19 Jan-19 Jun-18 Jan-18 Mar-19 Mar-18 Feb-19 Feb-18 Nov-18 Dec-18 Nov-17 Dec-17 Aug-18 Sep-18 Aug-17 Sep-17 May-19 May-18

Other ED GP

Source: NHS Ayrshire & Arran Pentana System, local validated data from Business Intelligence report - extracted July 2019

Figure 2.2 CAU Referrals by Source, UHC: Jun 2017 – Jun 2019 2,000 1,800 1,600 1,400 1,200 1,000 800 600 400 200 0 Jul-18 Jul-17 Oct-18 Apr-19 Oct-17 Apr-18 Jun-19 Jun-18 Jan-19 Jun-17 Jan-18 Mar-19 Mar-18 Feb-19 Feb-18 Nov-18 Dec-18 Nov-17 Dec-17 Aug-18 Sep-18 Aug-17 Sep-17 May-19 May-18

Other ED GP

Source: NHS Ayrshire & Arran Pentana System, local validated data from Business Intelligence report - extracted July 2019

19 of 43 3. Medical and Surgical Emergency Admissions

Analysis of admissions to medical and surgical inpatient wards following attendance at ED or CAU shows a similar trend at both sites, with the number steadily reducing to September 2018, steadily increasing thereafter. When comparing the number of medical and surgical admissions for June 2019 with June 2018, there has been a 13.8% increase at UHA and a 6.8% increase at UHC. Note: these admission figures do not include patients who remain overnight within CAU and are discharged directly from there.

Medical and Surgical emergency admission numbers at UHA and UHC for the 3-year period June 2016 to June 2019 are shown in Figure 3.1.

Figure 3.1 Medical and Surgical Emergency Admissions, UHA & UHC: Jun 2016 – Jun 2019 1,800 1,600 1,400 1,200 1,000 800 600 400 200 0 Jul-18 Jul-17 Jul-16 Oct-18 Apr-19 Oct-17 Apr-18 Oct-16 Apr-17 Jun-19 Jun-18 Jan-19 Jun-17 Jan-18 Jun-16 Jan-17 Mar-19 Mar-18 Feb-19 Mar-17 Feb-18 Feb-17 Nov-18 Dec-18 Nov-17 Dec-17 Aug-18 Sep-18 Nov-16 Dec-16 Aug-17 Sep-17 Aug-16 Sep-16 May-19 May-18 May-17 UHA UHC Source: NHS Ayrshire & Arran Pentana System, local validated data from Business Intelligence report - extracted July 2019

4. Delayed Discharge data

Delayed discharges over 2 weeks (excluding code 9 complex delays) have been on a steadily increasing trend over the past 2 years, reaching their highest recorded position of 72 delays in May 2019 (previous highest was 71 in November 2018). Across the HSCPs, this has been most problematic in South Ayrshire.

North Ayrshire delays over 2 weeks have noticeably reduced in recent months, having previously reached their highest ever recorded position in February 2019. South Ayrshire delays have increased exponentially, reaching their highest ever recorded position of 51 delays in May 2019. Delays from East Ayrshire residents continue to remain at 0.

Figure 4.1 details the monthly trend in the numbers of patients whose discharge from hospital was delayed for over two weeks due to non-medical reasons, excluding those delayed for a ‘code 9’ reason (e.g. delays due to requirements of the Adult with Incapacity Act). These have been split by the patient’s HSCP of residence.

20 of 43 Figure 4.1 Total number discharges delayed over 2 weeks, excluding code 9 delays, by Health & Social Care Partnership of residence (May 2016 – May 2019) 80 70 60 50 40 30 20 Number of of Number patients 10 0 Jul-18 Jul-17 Jul-16 Oct-18 Apr-19 Oct-17 Apr-18 Oct-16 Apr-17 Jun-18 Jan-19 Jun-17 Jan-18 Jun-16 Jan-17 Mar-19 Mar-18 Feb-19 Mar-17 Feb-18 Feb-17 Nov-18 Dec-18 Nov-17 Dec-17 Aug-18 Sep-18 Nov-16 Dec-16 Aug-17 Sep-17 Aug-16 Sep-16 May-19 May-18 May-17 May-16

EA H&SCP NA H&SCP SA H&SCP Total

Source: ISD Scotland, Delayed Discharges – Census_Tables_To_May_2019 – published Jul 2019

Figure 4.2 charts the total number of bed days occupied each month by patients whose discharge from hospital was delayed due to non-medical reasons.

East Ayrshire HSCP has experienced an increase in occupied bed days since the previous month, with numbers up from 164 in April 2019 to 264 in May 2019. South HSCP has also seen an increase in this measure, from 2,211 in April 2019 to 2,593 in May 2019, reaching their highest ever recorded position. North HSCP has experienced the only decrease in this measure, down from 1,646 in April 2019 to 1,575 in May 2019.

Figure 4.2 Monthly occupied bed days associated with delayed discharges (all delay types), by Health & Social Care Partnership of residence (Feb 2016 – Feb 2019)

5,000 4,500 4,000 3,500 3,000 2,500 2,000

Occupied bed days bed Occupied 1,500 1,000 500 0 Jul-18 Jul-17 Jul-16 Apr-19 Oct-18 Apr-18 Oct-17 Apr-17 Oct-16 Jan-19 Jun-18 Jan-18 Jun-17 Jan-17 Jun-16 Mar-19 Feb-19 Mar-18 Feb-18 Mar-17 Feb-17 Nov-18 Dec-18 Aug-18 Sep-18 Nov-17 Dec-17 Aug-17 Sep-17 Nov-16 Dec-16 Aug-16 Sep-16 May-19 May-18 May-17 May-16

EA H&SCP NA H&SCP SA H&SCP Total

Source: ISD Scotland, Delayed Discharges – BedDays_Occupied_Tables_To_May_2019 – published Jul 2019

21 of 43 5. Ministerial Strategic Group for Health and Comminute Care (MSG) Indicators

For 2018/19, each HSCP submitted trajectories for:

Monthly trends on unplanned admissions, occupied bed days for unscheduled care and emergency department performance are detailed in section 5.1. A summary of performance in relation to trajectories and objectives are described in section 5.2.

5.1 MSG Indicators - Trends

5.1.1 ED attendance rates and ED 4 hour compliance

• ED attendance rates have historically been highest for South Ayrshire residents and lowest for North Ayrshire residents, however following the opening of UHA CAU in June 2017, there have since been a number of months in which East Ayrshire residents have had the highest attendance rates. Rates for all three partnerships have converged in recent months and were broadly similar as at March 2019. • Despite an initial reduction in rates following the opening of CAUs, attendance rates for all three areas have since increased. Long term trends for each area are shown in Figure 5.1.1a. • Rates for all three partnership areas have consistently been higher than the national rate, although the gap has narrowed significantly following the opening of both UHA and UHC CAUs.

Figure 5.1.1a ED attendance rate per 1000 population 35.0

30.0

25.0

20.0

15.0

10.0

5.0

0.0 Jul-18 Jul-17 Jul-16 Jul-15 Jan-19 Jan-18 Jan-17 Jan-16 Jun-18 Jun-17 Jun-16 Jun-15 Oct-18 Oct-17 Oct-16 Oct-15 Apr-18 Apr-17 Apr-16 Apr-15 Feb-19 Sep-18 Feb-18 Sep-17 Feb-17 Sep-16 Feb-16 Sep-15 Dec-18 Dec-17 Dec-16 Dec-15 Aug-18 Aug-17 Aug-16 Aug-15 Nov-18 Nov-17 Nov-16 Nov-15 Mar-19 Mar-18 Mar-17 Mar-16 May-18 May-17 May-16 May-15 East Ayrshire North Ayrshire South Ayrshire Scotland

Source: ISD Scotland, Monthly actual - Integration-performance-indicators-v1.18 - issued June 2019

• ED 4 hour compliance has typically been higher for North and East Ayrshire residents than for South Ayrshire residents. This is primarily as a result of the

22 of 43 geographical locations of both UHA and UHC, with ED 4hr performance at UHC generally higher than that at UHA. Trends for these are shown in Figure 5.1.2. • Following the opening of both CAUs at UHA and UHC, compliance rates for the three partnerships had tended to exceed the national average despite failing to maintain compliance with the 95% target. This, however, is no longer the case with compliance for all three partnership areas falling below the national average from January 2019 onwards. • Comparing performance in March 2019 with that in March 2018, there has been a 1.1 percentage point decrease for North Ayrshire residents, a 3.4 percentage point decrease for East Ayrshire residents, and a 6.6 percentage point decrease for South Ayrshire residents.

Figure 5.1.1b ED % seen within 4 hours 100.0% 95.0% 90.0% 85.0% 80.0% 75.0% 70.0% 65.0% 60.0% Jul-18 Jul-17 Jul-16 Jul-15 Jan-19 Jan-18 Jan-17 Jan-16 Jun-18 Jun-17 Jun-16 Jun-15 Oct-18 Oct-17 Oct-16 Oct-15 Apr-18 Apr-17 Apr-16 Apr-15 Sep-18 Feb-19 Sep-17 Feb-18 Sep-16 Feb-17 Sep-15 Feb-16 Dec-18 Dec-17 Dec-16 Dec-15 Aug-18 Aug-17 Aug-16 Aug-15 Nov-18 Nov-17 Nov-16 Nov-15 Mar-19 Mar-18 Mar-17 Mar-16 May-18 May-17 May-16 May-15 East Ayrshire North Ayrshire South Ayrshire Scotland

Source: ISD Scotland, Monthly actual - Integration-performance-indicators-v1.18 - issued June 2019

5.1.2 Emergency admission rates

• Emergency admission rates have been on a long term increasing trajectory for the three partnership areas, with rates per population tending to be highest for South Ayrshire residents. Four year trends for these rates are shown in Figure 5.1.3. • In March 2019, the rate for South Ayrshire reached its highest point for the past four years, surpassing the previous peak for January 2019. • Whilst the ISD SMR01 data shows high levels of emergency admissions in NHS Ayrshire & Arran, it should be noted that this includes CAU presentations that may not result in a hospital admission to a medical or surgical inpatient ward. CAU presentations have risen at both UHA and UHC and may explain some of the increase. • By overlaying local emergency admission and CAU arrivals data, it can be seen that by removing the CAU component, ‘true’ emergency admission activity is relatively low, and decreasing. These comparisons are demonstrated for UHA and UHC in Figures 5.1.2b and 5.1.2c respectively.

23 of 43 Figure 5.1.2a Emergency admission rates per 1000 population 16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0 Jul-18 Jul-17 Jul-16 Jul-15 Jan-19 Jan-18 Jan-17 Jan-16 Jun-18 Jun-17 Jun-16 Jun-15 Oct-18 Oct-17 Oct-16 Oct-15 Apr-18 Apr-17 Apr-16 Apr-15 Feb-19 Sep-18 Feb-18 Sep-17 Feb-17 Sep-16 Feb-16 Sep-15 Dec-18 Dec-17 Dec-16 Dec-15 Aug-18 Aug-17 Aug-16 Aug-15 Nov-18 Nov-17 Nov-16 Nov-15 Mar-19 Mar-18 Mar-17 Mar-16 May-18 May-17 May-16 May-15

East Ayrshire North Ayrshire South Ayrshire

Source: ISD Scotland SMR01, Monthly actual - Integration-performance-indicators-v1.18 - issued June 2019

Figure 5.1.2b National SMR01 data compared with local Emergency Admissions and CAU Arrivals, UHA: Jun 2017 – Sep 2018 2,000

1,500

1,000

500

0 Jul-17 Jul-18 Jan-18 Jun-17 Jun-18 Oct-17 Apr-18 Sep-17 Feb-18 Sep-18 Dec-17 Aug-17 Aug-18 Nov-17 Mar-18 May-18

Local - True Emergency Admissions Local - CAU Arrivals SMR01 - Emergency Admissions

Source: Local data from NHS Ayrshire & Arran Pentana System, local validated data from Business Intelligence report - extracted February 2019. SMR01 data sourced from ISD publication.

Figure 5.1.2c National SMR01 data compared with local Emergency Admissions and CAU Arrivals, UHC: May 2016 – Sep 2018 4,000

3,000

2,000

1,000

0 Jul-16 Jul-17 Jul-18 Jan-17 Jan-18 Jun-16 Jun-17 Jun-18 Oct-16 Oct-17 Apr-17 Apr-18 Sep-16 Feb-17 Sep-17 Feb-18 Sep-18 Dec-16 Dec-17 Aug-16 Aug-17 Aug-18 Nov-16 Nov-17 Mar-17 Mar-18 May-16 May-17 May-18

Local - True Emergency Admissions Local - CAU Arrivals SMR01 - Emergency Admissions

Source: Local data from NHS Ayrshire & Arran Pentana System, local validated data from Business Intelligence report - extracted February 2019. SMR01 data sourced from ISD publication.

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5.1.3 Unscheduled hospital bed days rates for acute specialties

• Unscheduled hospital bed days rates for acute specialties have shown significant reduction over the past 12 months, primarily as a direct impact from the closure of unfunded beds at both UHA and UHC. Prior to these closures, rates for South and East residents had remained largely consistent, whilst rates for North Ayrshire residents had been steadily increasing. • Rates increased in January 2019 for all three partnership areas, however have subsequently decreased as at March 2019.

Figure 5.1.3 Unscheduled hospital bed day rates per 1,000 population; acute specialties 120.0

100.0

80.0

60.0

40.0

20.0

0.0 Jul-18 Jul-17 Jul-16 Jul-15 Jan-19 Jan-18 Jan-17 Jan-16 Jun-18 Jun-17 Jun-16 Jun-15 Oct-18 Oct-17 Oct-16 Oct-15 Apr-18 Apr-17 Apr-16 Apr-15 Sep-18 Feb-19 Sep-17 Feb-18 Sep-16 Feb-17 Sep-15 Feb-16 Dec-18 Dec-17 Dec-16 Dec-15 Aug-18 Aug-17 Aug-16 Aug-15 Nov-18 Nov-17 Nov-16 Nov-15 Mar-19 Mar-18 Mar-17 Mar-16 May-18 May-17 May-16 May-15

East Ayrshire North Ayrshire South Ayrshire

Source: ISD Scotland, Monthly actual - Integration-performance-indicators-v1.19 - issued July 2019

25 of 43

5.2 MSG Indicators – Summary of Trajectory Performance 2018/19

The three HSCPs set improvement trajectories for 2018/19 based on the key themes of reducing emergency admissions by providing additional capacity for accessible community alternatives; reducing occupancy and length of stay by improving systems and processes within the acute hospital; and reducing delays in discharge by providing appropriate community capacity. The plans to achieve this included further increasing community rehabilitation and enablement capacity to allow people to be treated/supported at home with increased independence and wellbeing supported by technology which commenced in November 2018.

The HSCPs were asked by the MSG to set their improvement trajectories against a baseline year to demonstrate progress under integration. It is important to note that when interpreting the data, South Ayrshire HSCP selected a different baseline year to East and North Ayrshire HSCPs in relation to some of the MSG indicators. All three HSCPs used a baseline year of 2016/17 for delayed discharge measures however North and East Ayrshire HSCPs used a baseline of 2014/15 (pre-integration) for all other measures whereas South Ayrshire HSCP used a baseline year of 2015/16.

The following is a brief end of year performance summary for 2018/19 for a selection of indicators.

5.2.1 Unscheduled Hospital Bed Days, acute specialties

Comparing March 2019 to March 2018, analysis of Unscheduled Bed Days for Acute Specialties from the MSG Indicator data suggests a significant reduction across Ayrshire and Arran over that period. The scale of this decrease is primarily as a result of the closure of unfunded acute beds at both UHA and UHC, supported by HSCPs exceeding their trajectories for emergency bed days. End of year totals for 2018/19 show that the numbers of acute emergency bed days have reduced significantly in comparison against the baseline year. Trajectory targets were met by all three partnerships for this measure.

• East Ayrshire HSCP: there was a 7.6% reduction when compared with 2014/15, against a 4% reduction target.

• North Ayrshire HSCP: there was a marginal 0.1% increase when compared with 2014/15, which was well below the 8% increase target that was set.

• South Ayrshire HSCP: there was 10.7% decrease compared with 2015/16, against an anticipated increase target of 1%.

5.2.2 Delayed Discharge Bed Days, all delay reasons

Figures for 2018/19 demonstrate that there has been a significant increase in the numbers of delayed discharge bed days (all delay reasons) compared to the baseline year. None of the partnerships met their trajectory targets for this measure, although the rates in East Ayrshire HSCP are considerable lower than Scotland (Figure 5.2.2).

26 of 43 • East Ayrshire HSCP: there was a 14.6% reduction when compared with 2016/17, however this fell short of the 20% reduction target set.

• North Ayrshire HSCP: there was a 106.9% increase when compared with 2016/17, which was well in excess of the anticipated increase target of 86%.

• South Ayrshire HSCP: there was 14.4% increase when compared with 2016/17, despite the partnership setting a target to reduce this measure by 25%.

Figure 5.2.2 Delayed discharge bed day rate (all reasons) per 1,000 population

30.0

25.0

20.0

15.0

10.0

5.0

East Ayrshire North Ayrshire South Ayrshire Scotland

5.2.3 Delayed Discharge Bed Days, code 9 reasons

Figures for 2018/19 show that the bed days associated with code 9 delayed discharges (e.g. patients with complex care needs, Adults with Incapacity, etc.) have reduced significantly when compared with the baseline year. Both North and East Ayrshire HSCPs met their trajectory targets for this measure, whilst South Ayrshire HSCP did not set a target.

• East Ayrshire HSCP: there was a 39.5% reduction when compared with 2016/17, exceeding the 25% reduction target set.

• North Ayrshire HSCP: there was a marginal 0.05% increase when compared with 2016/17, which was significantly below the anticipated increase target of 125% set.

• South Ayrshire HSCP: although no target was set, the figures demonstrate that there was a 13.6% decrease in this measure when compared to 2016/17.

27 of 43 Figure 5.2.3 Delayed discharge bed day rate (code 9) per 1,000 population

7.0

6.0

5.0

4.0

3.0

2.0

1.0

0.0 Jul-15 Jul-16 Jul-17 Jul-18 Jan-16 Jan-17 Jan-18 Jan-19 Jun-15 Jun-16 Jun-17 Jun-18 Oct-15 Oct-16 Oct-17 Oct-18 Apr-15 Apr-16 Apr-17 Apr-18 Sep-15 Feb-16 Sep-16 Feb-17 Sep-17 Feb-18 Sep-18 Feb-19 Dec-15 Dec-16 Dec-17 Dec-18 Aug-15 Aug-16 Aug-17 Aug-18 Nov-15 Nov-16 Nov-17 Nov-18 Mar-16 Mar-17 Mar-18 Mar-19 May-15 May-16 May-17 May-18

East Ayrshire North Ayrshire South Ayrshire Scotland

5.2.4 Emergency Admissions

Although the ISD SMR01 data shows high levels of emergency admissions in NHS Ayrshire & Arran, this includes CAU presentations that may not result in a hospital admission to a medical or surgical inpatient ward. All three HSCPs used a baseline year prior to the opening of both CAUs at UHC and UHA therefore an increasing trajectory for emergency admissions was submitted to the Scottish Government because the MSG data are based on the SMR01 data.

End of year totals for this measure show that there has been a significant increase in emergency admissions from residents of all three partnership areas. None of the HSCPs met their trajectory targets for this measure.

• East Ayrshire HSCP: there was a 10.7% increase in emergency admissions when compared to 2014/15, exceeding the anticipated increase target of 5%.

• North Ayrshire HSCP: there was an 8.2% increase when compared with 2014/15, exceeding the anticipated increase target of 5%.

• South Ayrshire HSCP: there was a 10.4% increase when compared with 2015/16, exceeding the anticipated increase target of 8%.

5.2.5 Emergency Department Attendances

All three HSCPs used a baseline year prior to the opening of both CAUs at UHC and UHA which does impact on the interpretation of these data. Prior to the opening of the CAU, GP referrals would have been counted as an ED attendance. Figures for 2018/19 demonstrate that whilst there has been a significant reduction in ED attendances from residents of all three partnerships against their chosen baseline year, the reduction has not been of the scale expected. None of the HSPCs met their trajectory targets for this measure.

• East Ayrshire HSCP: there was a 5.7% reduction when compared with 2014/15, however this fell short of the 9% reduction target set.

28 of 43

• North Ayrshire HSCP: there was a 4.2% reduction when compared with 2014/15, against a trajectory target of 9% reduction.

• South Ayrshire HSCP: there was an 8.4% reduction when compared with 2015/16, however this did not meet the 12% reduction target that had been set.

5.3 MSG Indicators – Summary of Improvement Objectives

5.3.1 East Ayrshire Health and Social Care Partnership

East Ayrshire Health and Social Care Partnership focus is to: • Maintain high performance in transfers of care out of hospital; • Further improve experience of transfer of care for those patients involved in Adults with Incapacity processes; • Work across Primary Care / Intermediate Care Rehabilitation and Acute to reduce hospital admissions and • Improve end of life care enabling more people to spend more time at home or in a homely environment in their last six months of life.

5.3.2 North Ayrshire Health and Social Care Partnership

North Ayrshire Health and Social Care Partnership recognised the system challenges and submitted increasing trajectories for all three bed day measures (acute, mental health and geriatric long stay specialties); and delayed discharges. It has managed to exceed its targets for geriatric long stay specialties, due to an increase in community-based supports for people affected by dementia. The Partnership has also stabilised activity for Delayed Discharge Bed Days, for code 9 reasons and admissions following Emergency Department attendance.

Section 1.3.2 describes a range of new approaches that have been developed to support improvements in reducing delayed discharges. Additional approaches to support improvements across the other MSG indicators include:

• Additional investment in community link workers to identify community-based supports rather than hospital admission; • ‘Thinking Different; Doing Better’ approach to free up capacity in community supports and avoid hospital admissions; • Implementation of the Primary Care Improvement plan, building additional community-based pharmacy, mental health practitioners and MSK physiotherapy support;

5.3.3 South Ayrshire Health and Social Care Partnership

Ongoing work in relation to Technology Enabled pulmonary rehabilitation-continues to contribute to a reduction in the numbers of admissions to hospital. A pilot to evaluate the ‘my COPD’ application commenced in July 2019 and an evaluation is due in October 2019.

Multidisciplinary teams continue to provide intensive support and development to Care Homes to reduce the threshold for admission. Further developments in relation to this include:

29 of 43

• Establishment of a Care Home Clinical and Care Group to oversee this programme and monitor intended outcomes; • Proactive work is being targeted at homes with high rates of hospital admissions • Alignment of Care Homes and residents to GP Practices and wider MDT/aligned staff at GP Practice level with care homes; • Support for technology enabled care interventions such as Attend Anywhere; • A range of AHP interventions to support rehabilitation/re-ablement (including Physiotherapy, Occupational Therapy, Dietetics, Podiatry and Speech and Language Therapy) is being implemented; • Direct support from the Intermediate Care Team is in place.

At Biggart Hospital, South Ayrshire HSCP committed to increase the number of patients transferred each week from UHA. Currently the number of delayed discharges is creating difficulty in flow and there is further engagement work to review the model of care at Biggart to maximise its contribution to the health and care system in South Ayrshire.

Within South Ayrshire HSCP, the Re-ablement and Care at Home pathway has been reviewed and following a test in Troon/Prestwick has now been rolled out across South Ayrshire. This has already resulted in increased efficiency and reduced overspend in this area.

A new scheduling system for in house care at home and call monitoring system for external care at home will also be introduced to improve efficiency of the service, increase capacity, and ensure that more people can be seen despite resources remaining static. In addition to this, new permanent and full time contracts have been offered to in house Care at Home staff with the aim of improving recruitment and retention of staff and so improving stability and efficiency. Care is now only being provided to those being assessed as having critical care needs. This ensures that only those most in need receive care and that resources are prioritised appropriately. Care packages are also being reviewed to ensure that the level of care being provided is proportionate to the individual’s needs. It is anticipated that this will free care hours up to reallocate to others who require care.

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Appendix 2

1. Inpatient and Day Case

The National Target is that no patient should wait longer than 12 weeks from agreeing treatment with the hospital, to treatment as an Inpatient or Day Case (Treatment Time Guarantee). The National Waiting Times Improvement plan states that by October 2019, 75% of Inpatients/Day Cases will wait less than 12 weeks to be treated, increasing to 100% by Spring 2021.

Within NHS Ayrshire & Arran, compliance against the National Target has increased from a position of 74.4% at June 2018 to 80.1% at June 2019. After a period of decrease from 724 patients in January 2019 to 582 in March 2019, there has been a month on month increase in the number waiting over 12 weeks. Between May 2019 (652) and June 2019 (670), there was a 2.8% increase in the number of waits. However compliance has remained broadly stable over this period.

The trend in compliance against the Inpatient and Day Case National 12 week access target for NHS Ayrshire & Arran, between June 2017 and June 2019, is shown in Figure 1.1. Figure 1.1 IPDC 12 Weeks Access Target (excludes unavailable patients) June 2017 – June 2019

100.0% 900

90.0% 800

80.0% 700

70.0% 600

60.0% 500 50.0% 400 40.0%

300 >12Wks Waits Number 30.0% Percentage (%) <12Wks (%) Compliance Percentage 200 20.0%

10.0% 100

0.0% 0

Number >12Wks % Compliance <12 Weeks Target (100%)

Source: NHS Ayrshire & Arran Pentana System, local validated data from Business Intelligence report - extracted July 2019

Trauma and Orthopaedics (63.2%) and Oral and Maxillofacial Surgery (72.7%) continue to be the two specialties with the lowest levels of compliance against the 12 weeks access target. Compared to the previous recorded position at May 2019, Trauma and Orthopaedics (64.8%) has shown a reduction in compliance of 1.6 percentage points, compared to Oral and Maxillofacial Surgery (66.6%) which showed an improvement in compliance of 6.1 percentage points.

31 of 43 Within Trauma and Orthopaedics, a number of actions are being taken forward to improve performance as part of the WTIP. Additional operating activity is planned at both UHC and UHA. There is some risk associated with this as it depends on existing staff willingness to undertake additional paid duties. Recent changes to the Work and Pensions rules linked to payment for additional work such as this, have resulted in some reluctance amongst senior medical staff to take on this work. This has so far had some limited impact and further impact on the likelihood of delivering this additional operating activity is as yet uncertain. During May and June, delivery of some of this additional activity has also been constrained by excessive trauma demand, which has in turn led to the cancellation of some elective work. Additional Trauma and Orthopaedics operating activity is also being delivered through Golden Jubilee National Hospital (GJNH) and several independent sector hospitals. This activity has been commissioned by the Scottish Government Access Support Team and has been allocated to Boards based on relative need. The majority of this additional capacity will come into play in the second half of 2019/20. In March 2019 The Trauma and Orthopaedics service had a Peer Review. A number of recommendations were made as part of this review, and although separate from the WTIP, progress of these recommendations will also assist in driving improved waiting times performance.

Oral and Maxillofacial Surgery shows an improving performance. The main action in the WTIP is the delivery of additional operating activity through extra waiting list initiative sessions. There has been little impact of the new Work and Pensions rules within this specialty, and all additional operating lists between April and May 2019 have taken place as per the plan.

2. Outpatients

2.1 New Outpatient Access Target

The National Target is that 95% of patients will wait no longer than 12 weeks from referral (all sources) to a first Outpatient appointment (measured on month end Census). The National Waiting Times Improvement plan states that by October 2019, 80% of Outpatients will wait less than 12 weeks to be seen, increasing to 95% by Spring 2021.

Within NHS Ayrshire & Arran, compliance against the National Target has decreased from a position of 86.3% at June 2018 to 81.5% at June 2019. Additionally, there has been a reduction of 1.2 percentage points from a position of 82.7% at May 2019 to 81.5% at June 2019.

This decrease in compliance correlates with a 5.8% increase in the number of waits between May 2019 (3,993) and June 2019 (4,226).

Trends in compliance against the new outpatient 12 Weeks Access Target for NHS Ayrshire & Arran between June 2017 and June 2019 are shown in Figure 2.1.

32 of 43 Figure 2.1 New OP 12 Weeks Access Target (excludes unavailable patients) June 2017 – June 2019 100.0% 6,000

90.0%

5,000 80.0%

70.0% 4,000

60.0%

50.0% 3,000

40.0%

2,000 Weeks >12 Waits Number 30.0% Percentage (%) Compliance <12 Weeks <12 Compliance (%) Percentage 20.0% 1,000

10.0%

0.0% 0

Number >12Wks % Compliance <12 Weeks Target (95%)

Source: NHS Ayrshire & Arran Pentana System, local validated data from Business Intelligence report - extracted July 2019

The number of specialties with performance lower than 90% (target is 95%) has remained the same, with 12 in June 2019.

Gastroenterology (59.8%) has the lowest level of compliance against the new outpatient 12 week access target, with a 2.6 percentage increase from May 2019 (57.2%). Neurology, which continues to be amongst the specialities with the lowest level of compliance, has shown the largest increase in compliance, with an improvement of 7.7 percentage points from May 2019 (66.7%). Cardiology (82.8%) compliance experienced the largest decrease, down by 6.4 percentage points from a position of 89.2% in May 2019.

Gastroenterology is recognised as one of the most fragile services with 40% vacancies at Consultant level. One locum Consultant is in post, and unfortunately recent advertisement for substantive consultant posts was unsuccessful. This has a direct impact on the service capacity. The remaining staff are delivering a large amount of extra activity through Waiting List Initiative sessions. As yet there has been little impact of the new Work and Pensions rules and the service has been able to deliver the planned number of additional sessions, although this remains a significant risk in this service.

The Cardiology service has also experienced 2 consultant vacancies, and some consultant sickness absence since the start of the financial year. However this service has been taking forward some transformation work, seeking to reduce the workload associated with review patients and re-prioritise that clinical time to increase the capacity for new outpatients. The WTIP for Cardiology includes both additional waiting list initiative sessions as well as sessions of clinical time associated with the transformational work, and although the last few months have not shown as much improvement as expected due to consultant sickness, it is anticipated that this will become more apparent in future months.

33 of 43 The Neurology service is delivered in NHSAA by visiting consultant staff from NHS Greater Glasgow. Recent vacancies and consultant sickness have seen a detrimental impact. There is currently one locum consultant in post, and this locum is due to finish in September, with little prospect of a replacement. The WTIP for Neurology is based around independent sector activity. In anticipation of the future gap, the service has been commissioning as much additional independent sector capacity as possible. The Neurology service is currently quite well ahead of the Quarter 1 trajectory, in order to build in some contingency for the expected service gap in the autumn. Meantime efforts to secure a replacement locum continue.

Compliance against new outpatient access target by specialty for NHS Ayrshire & Arran between May 2019 and June 2019 is shown in Table 2.1.

Table 2.1 New OP 12 Weeks Access Target (excludes unavailable patients) by lowest performing specialties May 2019 – June 2019

May-19 Jun-19 +/- Previous Month % Compliance No. >12Wks % Compliance No. >12Wks % Points No. >12Wks Gastroenterology 57.2% 372 59.8% 318 2.6% -54 Diabetes & Endocrinology 68.3% 185 65.3% 220 -3.0% 35 Plastic Surgery 75.1% 46 69.2% 57 -5.9% 11 ENT 68.6% 679 70.3% 605 1.7% -74 Neurology 66.7% 395 74.4% 266 7.7% -129 Respiratory Medicine 75.0% 165 74.7% 146 -0.3% -19 Anaesthetics 77.6% 95 74.8% 112 -2.8% 17 Dermatology 79.3% 503 75.6% 593 -3.7% 90 General Surgery (Including Vascular) 81.4% 606 77.7% 704 -3.7% 98 Trauma & Orthopaedics 81.0% 401 82.8% 363 1.8% -38 Cardiology 89.2% 144 82.8% 234 -6.4% 90 Ophthamology 90.7% 224 85.2% 358 -5.5% 134 Other 93.2% 87 92.2% 108 -1.0% 21 Rheumatology 94.8% 28 93.9% 33 -0.9% 5 General Medicine 97.4% 1 94.2% 3 -3.2% 2 Urology 97.2% 41 95.0% 76 -2.2% 35 Gynaecology 98.4% 21 97.8% 29 -0.6% 8 Oral & Maxillofacial Surgery 100.0% 0 100.0% 0 0.0% 0 Orthodontics 100.0% 0 100.0% 0 0.0% 0

Source: NHS Ayrshire & Arran Pentana System, local validated data from Business Intelligence report - extracted July 2019

2.2 Referral to Treatment

The national target for 18 weeks Referral to Treatment (RTT) is for 90% of planned or elective patients to commence treatment within 18 weeks of referral.

18 week RTT performance continues to remain below target, with compliance recorded at 80.1% in May 2019, which is an increase of 3.9 percentage points from 76.2% recorded in April 2019. It should be noted that the position at May 2018 was 81.6%.

Performance is linked to the issues with stage of treatment performance and recruitment difficulties. Furthermore the significant demand for imaging investigations such as MRI and CT scans and the lengthy waits for these contributes to a lower than desired performance. Improvement in performance against Stage of Treatment and Diagnostics in line with the actions being taken as part of the WTIP will result in improved RTT performance.

The roll out of the Modernising Outpatients programme includes a change in some specialties where outpatients are referred straight for a diagnostics test before their outpatient appointment. Although this can cause a delay to first outpatient appointment, it is a more efficient and effective pathway and overall decreases the time to treatment and

34 of 43 so improves the RTT. Thus far this change in practice has been implemented in Cardiology, Respiratory Medicine and Urology.

Performance against the18 weeks RTT target of 90% is shown in Figure 2.2.

Figure 2.2 18 Weeks Referral to Treatment May 2018 – May 2019

100.0%

95.0%

90.0%

85.0%

80.0%

75.0% Percentage (%) (%) Compliance Percentage

70.0%

65.0%

60.0%

18 Wks Performance Target (90%)

Source: NHS Ayrshire & Arran Pentana System, local validated data from Business Intelligence report - extracted July 2019

Neurology (61.6%) and Oral and Maxillofacial Surgery (64.4%) are the two specialties with lowest compliance against the 18 weeks RTT target of 90%. Neurology has shown an increase in performance of 16.3 percentage points from 45.3% in April 2019; while Oral and Maxillofacial Surgery compliance has reduced by 1 percentage point from 65.3% in April 2019.

3 Diagnostics

The target for NHS Ayrshire & Arran is that 100% of patients are to wait no longer than 6 weeks from referral for a diagnostic test.

3.1 Endoscopy

Within NHS Ayrshire & Arran, compliance against the target of 100% has shown a decrease of 1.7 percentage points from 52.6% in April 2019 to 50.9% in May 2019. It should be noted that the position at May 2018 was 53.3%. This decrease in compliance would normally correlate with an increase in the number waiting over 6 weeks, however between April 2019 (1,110) and May 2019 (1,073), there was a decrease of 37 in the number waiting over 6 weeks. Endoscopy waiting times for NHS Ayrshire & Arran from May 2017 to May 2019 are shown in Figure 3.1.

35 of 43 The service continues to work through implementation of the Endoscopy Action Plan, commissioned and funded by the Scottish Access Collaborative Framework. A number of the actions have required recruitment of staff and so there has been a delay in progress, but staff are now in post, and this is now moving ahead. Actions include implementation of Patient Focussed Booking, Waiting list validation and implementation of changes to protocols for surveillance procedures. Figure 3.1. Endoscopy Waiting times (6 weeks) May 2017 – May 2019

100.0% 1600

90.0% 1400 80.0% 1200 70.0% 1000 60.0%

50.0% 800

40.0% 600

30.0% Number Waits >6 Weeks 400 20.0% Percentage (%) Compliance<6 Weeks 200 10.0%

0.0% 0 Jul-18 Jul-17 Oct-18 Apr-19 Oct-17 Apr-18 Jun-18 Jan-19 Jun-17 Jan-18 Mar-19 Mar-18 Feb-19 Feb-18 Nov-18 Dec-18 Nov-17 Dec-17 Aug-18 Sep-18 Aug-17 Sep-17 May-19 May-18 May-17

Number >6Wks % Compliance <6 Weeks Target (100%)

Source: NHS Ayrshire & Arran Pentana System, local validated data from Business Intelligence report - extracted July 2019

3.2 Imaging

Within NHS Ayrshire & Arran, compliance against the target of 100% showed a decrease of 3 percentage points from 73.4% in April 2019 to 70.4% in May 2019. This decrease in compliance correlates with a 16.2% increase in the number waiting over 6 weeks between April 2019 (1,425) and May 2019 (1,656). It should be noted that the position at May 2018 was 67.8%. Imaging waiting times for NHS Ayrshire & Arran from May 2017 to May 2019 are shown in Figure 3.2.

36 of 43 Figure 3.2 Imaging Waiting times (6 weeks) May 2017 - May 2019

100.0% 3000

90.0%

2500 80.0%

70.0% 2000

60.0%

50.0% 1500

40.0%

1000 Weeks >6 Waits Number 30.0% Percentage (%) <6 Weeks (%) Compliance Percentage 20.0% 500

10.0%

0.0% 0

Number >6Wks % Compliance <6 Weeks Target (100%)

Source: NHS Ayrshire & Arran Pentana System, local validated data from Business Intelligence report – extracted July 2019

A range of WTIP actions are being taken forward within Imaging Services. A mobile MRI scanner is scheduled to deliver additional activity 15 days per month which started in May 2019, with attempts currently underway to increase this commitment to 20 days per month. The action plan also incorporates weekend working for the existing NHSAA CT and MRI scanners, although as yet this has not started due to staffing issues and lack of available locum staff. It has however been possible to engage locum staff for the Ultrasound Service. The service is currently seeking opportunities to access additional CT capacity, although approaches to GJNH and NHSDG have been unsuccessful. Opportunities around a mobile CT scanner are being explored but are more complex than for the MRI scanner due to the radiation risk. The service continues to increase the available image reporting capacity through use of the Medica external reporting bureau.

4. Cancer

The National Target is that 95% of all patients diagnosed with cancer are to begin treatment within 31 days of decision to treat and 95% of those referred urgently with a suspicion of cancer are to begin treatment within 62 days of receipt of referral.

4.1 31 Day Cancer

The National Waiting Times Improvement plan states that by October 2019, 95% of patients for cancer treatment will be continue to be seen within the 31-day standard

With the exception of January 2018, the 95% target for all patients diagnosed with cancer to begin treatment within 31 Days continues to be exceeded across NHS Ayrshire & Arran. Compliance throughout this period has also been consistently higher when compared to

37 of 43 Scotland. The 31 day Cancer target of 95% continues to be exceeded in May 2019, with performance of 96.1%, although this is a decrease of 2 percentage points from 98.1% in April 2019. It should be noted that the position at May 2019 was 98%.

31 day cancer percentage (%) compliance for NHS Ayrshire & Arran from May 2017 to May 2019 are shown in Figure 4.1.

Figure 4.1 31 Day Cancer Percentage (%) Compliance - All Cancer Types May 2017 – May 2019

100.0%

99.0%

98.0%

97.0%

96.0%

95.0%

94.0%

Percentage (%) (%) Percentage Compliance 93.0%

92.0%

91.0%

90.0%

% Compliance Scotland % Compliance Target (95%)

Source: NSS Discovery, LDP Dashboard - extracted July 2019

4.2 62 Day Cancer

The 95% target for those referred urgently with a suspicion of cancer to begin treatment within 62 days of receipt of referral, has not been met, and is consistently below the 95% target, with compliance in May 2019 at 82.1%. This is an increase of 3.7 percentage points compared to the April 2019 position of 78.4% and is higher than the NHS Scotland compliance of 81.1%. Previously, with the exception of the months when demand on services was high, compliance against the 95% target has regularly been higher when compared to Scotland.

The Cancer Access 62-day performance shows that there remain significant challenges in some tumour types, while others perform consistently well, largely attributable to their specific clinical pathways, and matching demand with capacity for each tumour type. In May 2019, Breast, Colorectal, Head and Neck, Lung and UGI tumour referral types failed to meet the target. However for Cervical, Melanoma, Ovarian and Urology tumour referral types, compliance was 100%.

The National Waiting Times Improvement plan states that by Spring 2021, 95% of patients for cancer treatment will be seen within the 62-day waiting-time standard. NHS Ayrshire & Arran has recently submitted their Annual Operational Plan to the Scottish Government

38 of 43 which included key planning actions and trajectories which commits to achieving the 62- day waiting time standard of 95% by Spring 2021.

The service continues to progress implementation of the Action Plan drawn up following the diagnostic visit in January 2019, with many of the actions complete. Further scrutiny is being given to the challenges associated with the Breast Cancer and Colorectal Cancer pathways where performance is most challenged. It is recognised that the waiting time for key diagnostic tests such as CT and MRI, and colonoscopy are significant factors in the current 31-day performance.

62 day cancer percentage (%) compliance for NHS Ayrshire & Arran from May 2017 to May 2019 is shown in Figure 4.2.

Figure 4.2. 62 Day Cancer Percentage (%) Compliance - All Cancer Types May 2017 – May 2019 100.0%

95.0%

90.0%

85.0%

80.0% Percentage (%) (%) Percentage Compliance

75.0%

70.0%

% Compliance Scotland % Compliance Target (95%)

Source: NSS Discovery, LDP Dashboard - extracted July 2019

5. Mental Health

The LDP target for NHS Ayrshire & Arran is that:

• 90% of patients are to commence Psychological Therapy based treatment within 18 weeks of referral; • 90% of young people are to commence treatment for specialist Child and Adolescent Mental Health services (CAMHs) within 18 weeks of referral; and • 90% of clients will wait no longer than three weeks from referral received to appropriate drug or alcohol treatment that supports their recovery.

39 of 43 5.1 Faster Access to Psychological Therapies

Psychological Therapies waiting times continues to remain below the 90% target, with compliance of 73.6% at May 2019 being similar to the April 2019 position of 73.4%. It should be noted that this is lower when compared to the same period in 2018, when compliance was 80.3%.

Currently the Access to Psychological Therapies return includes all the adult community primary care mental health and community mental health team activity, including Psychology, Psychological Therapists, Self Help Workers, Nursing and Occupational Therapists but excluding Psychiatry. Some of this activity is not Psychological Therapy as defined by the SG Matrix document. To better align with the SG Matrix and Work Force Survey of dedicated Psychological Therapy work being undertaken by the local workforce, future reports (2019/20) will focus only on the activity that is defined as evidenced based psychological therapies. This is anticipated to have an increase in the compliance with the standard.

A whole system review of psychological services has been undertaken, supported with additional Scottish Government and NES fixed term funding and investment in improving access to Psychological Therapies. A Pan Ayrshire strategic professional leadership role has been developed in addition to the integration of Psychological Services staff into operational community teams, where appropriate to do so, enabling joint accountability and co-management responsibility at an operational level, to ensure the delivery of transformational change and improving access at a local level. Service improvement plans, which are now embedded within the NHS Ayrshire & Arran Annual Operating Plans, have been developed. The actions contained within these plans aim to reduce waiting times on trajectories to meet the standard by, or before, December 2020. Actions are reviewed on a monthly basis with Scottish Government and an on-line reporting system is used to track progress.

Following re-configuration and a workforce planning review of the Service, priority posts have been agreed and approved through the vacancy recruitment process, utilising all available established and SG funds. In addition, the Government funding plan for additional psychology workforce capacity has been reviewed as a result of a challenging recruitment programme and a failure to recruit to fixed term specialist posts, due to the limited availability of specialist workforce expertise and recruitment competition with other board areas where permanent posts are available. In order to increase workforce capacity in alignment with the Government strategy and locally agreed workforce plans, there has been recent agreement to recruit to these posts on a substantive basis.

There remain a high number of vacant posts within the service and lower overall whole time equivalents from one year ago, as reported in the ISD workforce data. The majority of these posts will be filled between March and September which will return our available resource to equal and higher levels than experienced in the past year. This recruitment has focused on services such as CAMHS and Adult Community Teams where demand has exceeded capacity and waiting times have risen.

There remains considerable variation in waiting times across the different services, with some services consistently achieving the standard, some varying around the 18 week standard, and others well in excess of the standard. The major breaches are within the Child and Adult Community Teams and some Physical Health Psychology Specialties. One area of notable success is the impact of the local computerised Cognitive Behavioural Therapy service which has been utilised well above projections and is positively

40 of 43 contributing to the number of adults accessing an evidence based psychological approach within the 18 week waiting time standard.

5.2 Faster Access to Child and Adolescent Mental Health Services

The Mental Health waiting times target of 90% for CAMHs remains below the 90% target, although there has been an improvement of 11 percentage points from a low of 67.6% at April 2019 to 78.6% at May 2019. This is only the third time compliance has fallen below 80%. It should be noted that this is considerably lower when compared to the same period in 2018, when compliance was 93.4% and exceeding the 90% target.

There are currently a number of vacancies within service, including nursing and psychiatry, which has had an impact on assessment and intervention times. In addition, referral rates to CAMHs have significantly increased across all Health and Social Care Partnerships with additional demand in responding to urgent referrals, and an increase in urgent referral places placing considerable strain across the system. There has been a continuous demand in relation to urgent response, primarily driven by local suicide activity and expectations of partner agencies. CAMHs are actively recruiting to all posts and are assured that once at full complement, will be compliant with waiting times. The recruitment process places a challenge on getting people in post timeously and importantly recruiting skilled personnel.

In addition there is a review of data management at team level, administrative compliance and an increase in allotted assessments to bring the service back into compliance, it is important to appreciate a significant increase in demand with particular pressures on psychiatry.

CAMHs continue to test new ways of working across the system to build partnership responses to children and young people in need with the aim of influencing demand, in particular early intervention and low level interventions. This activity builds on national expectations in relation to service remodelling and a necessity to develop early intervention models linked to partnership.

5.3 Drug and Alcohol Treatment: Referral to Treatment.

Drug and Alcohol clients continue to wait less than three weeks from referral to appropriate treatment within NHS Ayrshire & Arran, with compliance above and exceeding the 90% target between July 2016 (96.0%) and May 2019 (98.7%).

Mental Health waiting time percentage (%) compliance for NHS Ayrshire & Arran from March 2017 to March 2019 are shown in Figure 5.

41 of 43 Figure 5. Mental Health Waits May 2017 – May 2019 100.0%

95.0%

90.0%

85.0%

80.0%

75.0% Percentage (%) (%) Compliance Percentage

70.0%

65.0%

60.0%

Psychological Therapies CAMHs Drug & Alcohol Target (90%)

Source: NHS Ayrshire & Arran Pentana System, local validated data from Mental Health Services ISD Return - extracted July 2019

6. Musculoskeletal

The Scottish Government has set a target for the NHS in Scotland that from 1st April 2016, the maximum wait for Allied Health Professionals (AHP) Musculoskeletal (MSK) Services from referral to first clinical out-patient appointment will be 4 weeks (for 90% of patients).

Four week performance for MSK services remains at 47% in June 2019, and above the trajectory of 45.4% which was agreed with CMT in June 2019.

The main improvement initiative for 2019/20 is the roll-out of opt-in review arrangements, with compliance with the agreed process in MSK Physiotherapy a key focus for service and team leads. Opt-in arrangements are being introduced in MSK Occupational Therapy (OT) in July 2019, and administrative support for introduction within MSK Podiatry is being explored. With more than half of follow-up appointments in Orthotics being to fit items of equipment, the benefits of opt-in are reduced, however options for the remaining review patients are being explored.

Plans are in place to minimise the impact of staff retiring in MSK OT and MSK Podiatry, including their pre-retirement reduction in working time. MSK Physiotherapy recruitment and staffing remains a challenge and the major risk to achievement of the trajectory over the next six months.

Figure 6 shows the MSK performance trajectory and forecast for NHS Ayrshire & Arran.

42 of 43 Figure 6 AHP MSK waiting time performance trajectories and forecast April 2017 – March 2020

100% 8000

90% 7000 80% 6000 70% 5000 60%

50% 4000

40% 3000 30% 2000 20% 1000 10%

0% 0

All MSK 4 wk performance Performance trajectory All MSK OP waiting list size Forecast WL size

Source: NHS Ayrshire & Arran MSK Service - July 2019

In the latest national publication, which covered the period January 2019 to March 2019, NHS Ayrshire & Arran was the third highest performing mainland Board with 48.9% of patients waiting less than 4 weeks, which is higher than the Scottish average performance of 41.3%. Three of the four MSK services in NHS Ayrshire & Arran perform well against average NHS Scotland Levels:

• MSK OT 46.4%, compared to 32.5% across Scotland; • MSK Physiotherapy 45.8%, compared to 38.2% across Scotland; and • MSK Podiatry 84.1%, compared to 61.5% across Scotland.

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