Mid Essex Clinical Commissioning Group Board Meeting Thursday, 26 March 2015 Commencing 1.30 Pm Town Hall, Market Hill, Maldon, Essex, CM9 4RL

Mid Essex Clinical Commissioning Group Board Meeting Thursday, 26 March 2015 Commencing 1.30 pm Town Hall, Market Hill, Maldon, Essex, CM9 4RL

AGENDA – Part 1

Item Time Title Lead Action Papers Page No 1. 1.30 – Welcome and Apologies for Caroline Dollery For noting Verbal - 1.35 pm Absence

2. 1.35 – 2.1 Declarations of Interests Caroline Dollery To note Verbal - 1.40 pm 2.2 Register of Interests Viv Barnes Attached 3-6 3. 1.40 – Maldon Commissioning Strategy Dan Doherty To review Attached 7-31 1.50 pm 4. 1.50 – Questions from the Public Caroline Dollery To Verbal - 2.00 pm receive 5. 2.00 – Minutes of Previous Meeting Caroline Dollery To Attached 32-44 2.05 pm approve 6. 2.05 – Action Log from Previous Meetings Caroline Dollery To Attached 45-47 2.10 pm approve 7. 2.10 – Matters Arising from Last Meeting Caroline Dollery To note Verbal - 2.15 pm (not on agenda)

8. 2.15 – Chair’s Update Caroline Dollery To note Attached 48-52 2.25 pm 9. 2.25 – Accountable Officer Update Caroline Rassell To note Attached 53-59 2.35 pm 10. 2.35 – Patient Story Carol Anderson To note Audio - 2.45 pm Standing Items

11. 2.45 – Performance Overview: 3.15 pm 11.1 Quality Report Carol Anderson To review Attached 60-106

11.2 Performance Report Dan Doherty To review Attached 107-127

11.3 Financial Recovery Report Caroline Rassell To review Attached 128-139

11.4 Finance Report Dee Davey To review Attached 140-148

11.5 Local Authority Performance Sheila Norris To review Attached 149-173 Report and Scorecard Krishna Ramkhelawon 12. 3.15 – Reporting from Committees Caroline Dollery 3.30 pm 12.1 Audit Chair Report To note Attached 174-175

12.2 Quality & Governance To note Attached 176-178 Committee Minutes

Item Time Title Lead Action Papers Page No 12.3 Finance & Performance To note Attached 179-183 Committee Action Notes

12.4 Financial Recovery, Innovation To note Attached 184-199 & Transformation Committee Action Notes

13. 3.30 – Patient & Public Engagement Report Anne-Marie To note Attached 200-209 3.35 pm Garrigan 14. 3.35 – Policies Update Carol Anderson To Attached 210-214 3.40 pm approve 15. 3.40 – Risk Assurance Report Viv Barnes To note Attached 215-227 3.45 pm 16. 3.45 – Any further questions from the Caroline Dollery - 3.50 pm public

17 3.50 – BREAK 4.00 pm Non-Standard Items 18. 4.00 – 2015/16 Budget and Refresh of the Dee Davey To Attached 228-241 4.05 pm Medium Term Financial Plan approve

19. 4.05 – 2015/16 Operational Plan Caroline Rassall To Attached 242-243 4.15 pm Dee Davey approve 20. 4.15 – Essex Joint Health & Wellbeing Sheila Norris To Attached 244-267 4.25 pm Strategy approve 21. 4.25 – Mental Health Crisis Care Concordat Amanda Swift To Attached 268-289 4.35 pm Action Plan NEECCG approve 22. 4.35 – Organisational Development Viv Barnes To Attached 290-317 4.45 pm Strategy approve 23. 4.45 – Communications & Engagement Viv Barnes To Attached 318-343 4.55 pm Strategy approve 24. 4.55 – MECCG Constitution Viv Barnes To Attached 344-349 5.00 pm approve 25. 5.00 – Any Other Business Caroline Dollery 5.10 pm 26. Date and time of next Board Meeting in Public:

1.30 pm, Thursday, 4 June 2015. Council Chamber, Braintree Town Hall, Market Place, Braintree, Essex, CM7 3YG.

Declarations of Interest 2014/15 – CCG Board

Name Role Declaration of Interests Start Date End Date Date of dec. Clinical Board Nil Carol Anderson Member 1/04/12 26/06/12 Director of Nursing and Quality

Owner Keith Andrew Associates

Lay Board Non-Executive Director/Trustee Chelmer Housing Keith Andrew Member Partnership Ltd Lay Board Member 1/06/12 25/06/12 Deputy Board Chair (non-clinical) Local Consumer Advocate The Consumer Council for Audit Committee Chair Water

Chairman/ Trustee Farleigh Hospice

Vivienne Barnes Non-voting Nil 4.08.14 4/08/14 Director of Corporate Services Board member Voting Board Trustee Age UK Norwich Member James Bullion Director at Essex County Council Essex County Council Board 02/09/13 01/02/2015 24k/4/14

Representative Member of ADASS (Association of Directors of Social Services) Vice Chair of Trustees of Basildon Women’s Aid 14/09/12 Dee Davey Board Member 1/04/12 Last updated Chief Finance Officer Daughter employed by Countess of Chester Hospital 19/11/14 NHS Foundation Trust

Name Role Declaration of Interests Start Date End Date Date of dec. Director DNA Physiotherapy Ltd Casual lecturing work with Essex University Health Unit Clinical Board Dan Doherty Honorary contract with Provide Member 1/04/12 26/06/12 Director of Clinical Commissioning Wife works for North East London Foundation Trust

GP Partner Danbury Medical Centre Clinical Board Member Member of EGPC LLP Clinical Director for East of England Strategic Clinical Network for Mental Health, Learning Disability and Neurology 18/07/12 Dr Caroline Dollery Clinical Director of SCN (NHS England). As part of SCN 1/04/12 Elected GP – CCG Chair role, Caroline is working on national mental health Updated: projects on outcomes and urgent care; including with 11/11/14 health minister and director of social care.

Permission: 2 days per week for SCN. Permission from Chair and AO.

Shareholder of Chelmer Healthcare Ltd Children’s Centre Area Manager at Pre-School Learning Lay Board Alliance, Rochford Ann Marie Garrigan Member 1/06/12 25/06/12 Lay Board Member (PPE Lead) AVA Collectables (Art Vintage Antiques) a sole trader company

Name Role Declaration of Interests Start Date End Date Date of dec. Alan Hubbard Lay Board Lead Non-Executive Director of the Essex Community 1/04/13 25/06/12 Lay Board Member (Commercial) Member Rehabilitation Company Updated: 27/9/14

Independent Joint Audit Committee Member for Essex 03/03/2015 Police & Crime Commissioner & Chief Constable.

GP Partner Fern House Surgery 3/07/12 Dr Ahmed Mayet Elected GP On sabbatical from Eli Lilly National Primary Care 1/04/12 Elected GP (Board Member) Board Member Diabetes Board Updated: 11/11/14 Shareholder of Chelmer Healthcare Ltd Part time salaried GP and GPWSI employed by ‘The Dr Donald McGeachy Clinical Board Practice PLC’ Medical Director 1/04/12 26/06/12 Member Spouse is a partner at Tillingham Medical Centre

Sheila Norris Voting Board Director of Integrated Commissioning and Vulnerable Essex County Council Board Member People at Essex County Council. 01/02/15 12/03/2015 Representative

Employee of Essex County Council with Financial Voting Board management of the Public Health grant to ECC Krishna Ramkhelawon Member 1/04/12 Sept 2013 Consultant in Public Health Spouse works for NHS England Essex Area Team

Name Role Declaration of Interests Start Date End Date Date of dec.

Caroline Rassell Board Member Spouse is an employee of Care UK 7/1/14 27/01/15 Accountable Officer

Vacant Secondary Care Doctor Board Member

Salaried GP employed at Elizabeth Courtauld Elected GP Partnership, Halstead Dr Bryan Spencer Board Member 26/06/12 Elected GP and Deputy Chair 1/04/12 Committee member of League of Friends Halstead (Clinical) Hospital

MID ESSEX CLINICAL COMMISSIONING GROUP

Report to Mid Essex Formal Board Meeting

Meeting Date: 26 March 2015

Agenda No: 3

: DRAFT Maldon Commissioning Strategy Report Title

: Dan Doherty Written By

Purpose of Report : To inform the Board of the emerging Maldon Commissioning Strategy

Previous Agenda : N/A Reference

Approval Route : N/A

Clinical Implication(s) : Aligned to CCG transformational vision

Financial Implication(s) : To be defined. Financial envelope for defined services to be calculated

Workforce To be defined. Possible discrepancy between current available workforce and : Implication(s) required workforce for strategy delivery

Legal Implication(s) : None defined

Have the details of this paper been assessed for all of the protected characteristics under the Equality Act 2010? Yes (√) No (√) x If No, please outline why : : Equality & Diversity If Yes, please provide details of the outcome of the assessment, including how any adverse effects will be monitored:

Is the equality analysis on the CCG website? Yes (√) No (√) x

7 : None at present Risk(s) Identified

Significance to Key : None Target(s)

Patient & Public Locality PPGs have been significantly involved in the drafting. Further PPG / locality : Involvement feedback is being gathered on draft.

Does this item go against rights or pledges of NHS Constitution? If yes, please outline how and reasons why this is necessary: Constitution : Yes (√) No (√) x

Sustainability : To be determined

Board is asked to note the draft strategy and feedback any comments and suggestions to Recommendation(s) : the author within the next 2 weeks.

MALDON COMMISSIONING STRATEGY

9 Contents

TO BE COMPLETED

10 1.0 Introduction

1.1 Purpose of document

This document details the services that Mid Essex CCG intends to commission locally in the Maldon District for 2015/16 and beyond. The document details four distinct phases of work that, if completed, will inform the CCG commissioning strategy plus any estates options facilitating its delivery.

This document focuses on the first phase of this programme, a commissioner-led specification of those health and social care services that need to be delivered within the Maldon District. These services are specified to meet the immediate health and social care needs of the local population whilst aligning to the CCG 5-year Transformational Strategy to ensure these services transform to meet the evolving needs of the public in the future.

1.2 History of Maldon Project

St. Peter’s Hospital has been a focal point of discussion for many years, if not decades. St. Peter’s was originally erected as a workhouse in 1873. It became a Public Service Institution in 1930 and was designated as a Hospital for the NHS in 1948. St. Peters is currently owned by Mid Essex Hospital NHS Trust. Whilst the hospital is held in high regard by locals, in recent years it has demanded an increasingly high level of maintenance in order to keep pace with the ever increasing estates requirements of a modern healthcare facility. In 2004, a business case was developed by the then Maldon and South Chelmsford PCT to re-provide services from a brand new, state-of-the-art purpose built facility on a Greenfield site on the outskirts of Maldon. A preliminary Strategic Outline Case was produced and approved. However, the plans failed to progress following disputes over ownership of land and an eventual reorganisation of the NHS that led to the merger of Maldon and South Chelmsford PCT with its neighbours.

Health services within the Maldon District, including those provided from St. Peters Hospital are now primarily commissioned by NHS Mid Essex Clinical Commissioning Group (MECCG). MECCG has been operational since 2012.

In the later part of 2013, CCGs were required nationally to develop both 2 year operational plans and 5 year strategic plans. During this time, MECCG was developing a new clinical commissioning model that focuses on the differing health services required by its population throughout the various phases of life. This service model started to define radically transformed health services that are better equipped to deal with the changing demands of an ageing patient demographic whilst ensuring sustainable service provision within a constrained financial environment.

At the start of 2014, Mid Essex CCG was named as one of the 11 most financially challenged health systems in the country and increased external and national scrutiny was given to these transformational plans to ensure that they not only delivered appropriately commissioned health services but that this provision was delivered in a financially sustainable way into the future.

11 In early 2014, MECCG made a decision to ‘pause’ the ongoing Maldon Hospital Project in order to focus on refining its 5 year transformational plans for health services throughout the entirety of mid- Essex. Ongoing scrutiny of the CCGs transformational plans and financial sustainability demanded solutions for the entire mid-Essex health system. This was to ensure any plans for specific Districts were aligned to this over-arching system vision.

The CCG is now at the end of consultation period for its five year plan and the transformation programme is progressing at scale. At this stage the CCG is able to specify the commissioned services required for the Maldon District with confidence that these services align to the overall CCG vision of a transformed mid-Essex health and social care system. Ultimately, these commissioned services should inform any future estates provision planning within the District.

1.3 Project Framework

MidEssex CCG does not hold statutory responsibility for estates development and management. As such, MECCG cannot proceed with a Maldon development project in the same way as its predecessor PCTs.

As a result a new project structure is proposed which, working with partner organisations, will develop and confirm the CCGs commissioning intentions for local service delivery in the Maldon District but will then pass the lead responsibility for the development of an appropriate estate solution to support these services to an agreed provider lead.

The project will now take 4 distinct phases.

1. The first phase will be a commissioner led specification of those health and social care services that need to be delivered within the Maldon District. These services are specified to meet the immediate health and social care needs of the local population whilst aligning to the CCG 5-year transformational strategy to ensure these services transform to meet the evolving needs of the public in the future.

This specification determines a commissioning cost envelope that needs to cover all elements of service delivery including an estates overhead.

2. The second phase will be an estates options appraisal to identify the most appropriate configuration of estate to deliver the specified commissioned services. This will be facilitated by the CCG but involve all interested parties who may own or occupy any future facility. At the end of this stage the most appropriate option will be identified taking into account factors such as, affordability, access and deliverability. A specific organisation or organisational partnership will be identified to own and/or manage any new facility.

3. The third phase will be the detailed planning stage and will incorporate any business case approval process required by the identified owner(s) of the new estate. Detailed planning design and planning permission as well as ownership, financing, operational management and leasing structures will also be carried out within this phase.

4. The final phase will be construction and commissioning of the new building(s). This phase will determine a favoured option which would be then be progressed by the provider organisations through the formal NHS estates approval and procurement process. The CCG will remain a key stakeholder within this phase but take no lead role in its development.

This document focuses on Phase 1 of the project, articulating those health and social care services required by the Maldon District in the medium to long term.

2.0 Key challenges for Maldon

The Maldon district is home to around 61,500 people with a population structure which has a lower percentage of 20 to 35 year olds and a higher percentage of older people than the average for the MidEssex area. The Maldon district population is predicted to shift towards an older population. Although Mid Essex and Maldon district are reasonably affluent and largely rural, there are significant variations with the few areas identified as having significant socio- economic deprivation (e.g. Heybridge). Inequalities in health are reflected in the prevalence of long term conditions.

2.1 Maldon Joint Strategic Needs Assessment (JSNA)

In the summer of 2013 Essex Public Health carried out a Maldon District Strategic Needs Assessment on behalf of MidEssex CCG. Key highlights from this document are listed below and the full document is attached as Appendix 1. The findings of the JSNA have heavily influenced the commissioning planning process and CCG transformational agenda. Most specifically, the ageing population demographic within the District requires a significant focus on management of the frail elderly individual, those with multiple long-term conditions and those nearing end of life.

Maldon’s proportion of people aged 65yrs and over (20%) is higher than the Essex (18%) and mid Essex (17%) average and will experience a faster rise in the ageing population (37% or 4,681) by 2021 – the largest increase in Essex. This is significant considering that the total population growth by 2021 is estimated to be 5,300 and 7,500 by 2029. There are other growth areas around Witham and South Woodham Ferrers which may directly impact on healthcare provision in Maldon.

There are large pockets of deprivation centred around Maldon town and a 4 to 5 fold variation in income deprivation among the older age residents. Coupled with long term illnesses and the fact that nearly one fifth of Maldon residents live in fuel poverty, these reflect a high likelihood of more pronounced inequalities in health.

The level of GP provision in Maldon is deemed to be ‘insufficient’ with a physical capacity deficit of around 800m2 and ‘over-registration’ of 8,500 patients which will be further stretched by the extent of the projected population growth.

13 The local estates review points to the poor local infrastructure in primary care and an outdated community hospital in St Peter’s, with services scattered across the site, which lends itself to limited future development as it is in a conservation area.

Some of the lifestyle indicators suggest a significant proportion of the population is in need of better support and health education to minimise the risk of preventable ill-health. High rates of obesity, excessive consumption of alcohol and smoking are of concern even though overall life expectancy is good.

A large proportion of Maldon is rural. Within 15 minutes of travel, we estimate 73% of Maldon residents can reach Maldon town (St Peter’s Hospital) and 45% are able to reach Broomfield Hospital, although access is through a number of country roads for many residents, with comparatively poorer access to public transport.

More people are living with multiple morbidities and there is still a high level of undiagnosed cases of poor health in the local population. Maldon has the highest number of residents with heart conditions in mid Essex, which is likely to increase further.

The quality of care, as measured through the Quality and Outcomes Framework, is generally very good in Maldon, but with the need to improve disease ascertainment, maintaining these standards will prove challenging especially with capacity issues in primary care. Other proxy quality indicators, such as the uptake for national screening and immunisation programmes are also very favourable for Maldon.

The evidence points to a good social/community network in Maldon, including a number of voluntary groups providing support services across Maldon and funded by statutory agencies.

People reported on the need to build social capital in local communities, enhancing local social network to support carers and promote a more informal approach to promoting self-care including “peer support groups”, “advice lines” and better engagement with the voluntary sector.

2.2 5-Year Strategic Plan

In the July 2014 the CCG produced a 5 year plan detailing the system wide service change required to deliver safe, effective, and affordable health care to the people of MidEssex. The five-year plan sets out a series of transformation programmes designed to improve health outcomes and meet the rising demands of our growing population. The main programmes cover every stage in life. All programmes are joint with local service providers and other partners. The 5 year plan is summarised on the page below. Important to all of the above is a strategy to develop GP services and other primary care services. We are working on this in partnership with NHS England (Essex), our member GP practices and other health and care partners.

14 15 2.3 National Drivers 2.3.1 Forward view

In October 2014, the NHS published the Five Year Forward View setting out how the health service needs to change over the course of the next Parliament to meet the needs of the population and take advantage of new science, technology and innovation. The document has been positioned by Chief Executive Simon Stevens not as a detailed plan but a ‘longer view’ for the NHS and how it can meet the healthcare needs of the future.

More specifically the Forward View details how the traditional divide between primary care, community services, and hospitals is a barrier to personalised and co-ordinated care, adding that long term conditions require the NHS to partner with patients over the long term rather than providing single unconnected ‘episodes’ of care. The Forward View sees a major role in delivering the change in approach coming from primary care, with planned greater investment in primary care over the next Parliament, enhanced influence for GP led commissioning over the wider NHS budget, expanding GP training and designing new incentives to encourage GPs and practices to provide care in under-doctored areas. The document notes that whilst a one-size-fits-all approach to care models will not work, letting ‘a thousand flowers bloom’ is also not an effective use of resource and what is needed is to identify the characteristics of similar health communities in England and then work jointly with them to consider which models will work most effectively.

MidEssex has identified the Multispecialty Community Provider (MCP) model identified within the Forward View as that most aligned to the CCG 5-year Transformational Plan. This identifies extended groups of GPs, federations, networks or single organisations becoming the focal point for a wider range of care, employing consultants, moving outpatient consultations and ambulatory care out of hospital and taking over the running of local community hospitals.

MidEssex CCG is seeking National Support to develop these models across the MidEssex economy and the commissioning strategy for the Maldon District directly aligns with this approach.

2.3.2 Maternity

On 3rd March 2014 NHS England announced details of a major review of the commissioning of NHS maternity services, as promised in the NHS Five Year Forward View. The review will assess current maternity care provision and consider how services should be developed to meet the changing needs of women and babies.

Recent advances in maternity care, changes in the demographics of women having babies, and preferences of where they want to give birth will form a key focus of the review. Terms of reference for the review state that it will:

16 • First, review the UK and international evidence and make recommendations on safe and efficient models of maternity services, including midwife-led units; • Second, ensure that the NHS supports and enables women to make safe and appropriate choices of maternity care for them and their babies; and • Third, support NHS staff including midwives to provide responsive care.

This review, which is expected to report in by the end of 2015, will be led by an external chair, supported by a diverse panel.

MidEssex CCG will be expected to consider the outputs of this review and utilize them in informing the commissioned model of maternity care for the Maldon District.

2.4 Local Drivers 2.4.1 Mid Essex Transformation Programme

The CCG has developed a series of transformation programmes, based on a clinical vision which tackles the requirement for health and social care services to become more preventative and targeted towards people at risk. It supports those people at risk with intensive services to avoid further crises and prevent the escalation of need, and supports recovery.

These programmes are being delivered with system partners, and aim to deliver better outcomes at lower costs. A key emphasis is on supporting individuals to self-care and self-manage long term conditions; prevention and early intervention; and developing and connecting with existing community resources. Where it makes sense to do so, services will be delivered as close to individuals as possible, with individuals only having to attend an acute hospital facility when absolutely necessary.

Integrated Multi-disciplinary working is also key to the delivery of most of the transformation programme. This requires both health and social care to work together and in partnership with the voluntary sector, to deliver seamless holistic services to meet individuals’ needs. To deliver services in this way will require new ways of working that enable these multi-disciplinary teams to provide individualised patient centred care. Where it makes sense flexible co-location and/or technology is essential for professionals to help them manage individuals who have complex and multiple needs. The principle is one of a “one stop shop” for individuals whereby services and professionals are wrapped around an individual rather than the individual having to make several trips to different care professionals.

When an individual does need urgent care, responsive local services will be put in place to care for that individual where appropriate. If urgent care is needed at the hospital, there will be an Urgent Care Centre as well as A&E services to appropriately manage those individuals.

17 2.4.2 Maldon District Council – LDP

Maldon District Council is currently consulting on the Draft Maldon District Local Development Plan (LDP).

The LDP will provide the framework to meet the District's growth requirements over the next 15 years. The objective is to achieve a balance in meeting needs for development - homes, employment, shopping and community facilities - with the need to protect and enhance the District's character and much valued features such as open spaces, landscape and heritage and to ensure that development takes place in the most appropriate places.

The proposals in the Draft LDP take into account consultation on the LDP Preferred Options which took place in Summer 2012. The plan sets out a strategy for sustainable development to meet the District's objectively assessed needs for new housing and employment including:

• Provision for 4,410 new dwellings until 2029 • 8.4 hectares of new employment land • Infrastructure to support the proposed new development (such as transport schemes, schools, health and open space)

The detail on how this provision is proposed to be spread across the district will be developed in the next stage Outline Business Case and will include future section 106 allocations that may support projects financial case noting that no such allocations have yet been identified

3.0 Current Provision in Maldon

The current model of care in the Maldon District is typical of that found within semi-rural Districts with a community or ‘cottage’ hospital. Whilst this model has served the district well for decades there is now universal acknowledgment both nationally and locally that these traditional models of care will need to evolve at pace to meet the changing demands of a growing elderly population.

The CCG currently commission a range of outpatient services, diagnostics, and therapy services from the St. Peters site. St. Peters is also home to a number of community hospital beds, specialist stroke beds and maternity services. St. Peters also provides the base for a number of our community based services such as district nursing, community matrons, Integrated Care Teams and community therapies.

The Table below details the services currently provided from the St. Peters site:

Service Description Hours Current Provider

Inpatient intermediate 16 inpatient intermediate care 24 hours PROVIDE

18 care beds beds supported by local GPs

Stroke rehabilitation 10 specialist rehabilitative beds 24 hours PROVIDE beds for stroke care

Early Suppported Specialist outreach service Working hours PROVIDE Discharge Team supporting rehabilitation of Mon-Fri suitable stroke patients within their own homes

In Patient Therapies A range of physiotherapy, Working hours PROVIDE occupational therapy, speech Mon-Fri and language therapy etc. supporting the in-patient beds.

Domicillary Therapies Local base for community based Working hours PROVIDE physiotherapy and occupational Mon-Fri therapy supporting integrated care

District Nursing Local base for district nursing Extended hours PROVIDE services for the local area

Outpatient Therapies Outpatient Physiotherapy and 7.30am – 7pm Mon PROVIDE Occupational therapy with – Fri referrals sourced from local GPs and Consultants

Outpatients 7 outpatient clinic rooms 10 sessions per MEHT supporting a range of outpatient week per room appointments (Standard working hours Mon-Fri)

Imaging Plain film X-Ray and Standard working MEHT Ultrasonography hours Mon-Fri

Phlebotomy Walk-in service – 4 bays Standard working MEHT hours Mon-Fri

Assessment and 4 room model assessing Standard working PROVIDE Rehabilitation Unit predominantly elderly patients hours Mon-Fri with sub-acute medical complaints

Anti-coagulation services for

19 significant proportion of Maldon District

Tissue Viability and Specialist nurse led tissue Standard working PROVIDE Lymphoedema viability service and hours Mon-Fri Services lymphoedema service.

Current space and privacy issues with service

Maternity Midwife led service with 2 24 hours MEHT labour rooms and 6 post-natal beds; day assessment service, midwife run antenatal clinics, consultant led clinics and parentcraft classes

Mental Health NEPFT

Out of Hours GP Base for local GP out-of-hours Out of working Primecare service based in ARU service hours

The following additional healthcare services are provided from other facilities within the district:

The Burnham Clinic is an old (1937) building with flat roof extensions, it is in good condition and has recently been refurbished. Situated in the heart of Burnham with adequate on road parking it currently operates from 9.00-16.30 Monday to Friday with sexual health clinics one evening and smoking cessation services another. There are 6 consulting rooms which provide a variety of outreach services including physiotherapy, phlebotomy, podiatry, voluntary sector services, IAPT and Drug and Alcohol rehabilitation, school nursing and speech and language therapy. Burnham clinic also provides a base for health visitors and evening district nursing.

The South Woodham Ferrers Clinic is a relatively new (c. 1980) building that has been recently refurbished. Situated in the heart of South Woodham Ferrers it has a good amount of dedicated car parking. It currently operates from 9.00-16.30 Monday to Friday, with 9 multipurpose consulting rooms and a large health education room providing a range of services including; phlebotomy, Physiotherapy, Sexual health, Opthalmology/optometry, Podiatry, Children’s diabetes, outpatient clinics, speech and language therapy and it provides a base for health visitors and district nurses.

Outpatient mental health services are currently provided from the Cherry Trees site (co-located with St. Peters Hospital). This site is owned and operated by the North Essex Partnership Foundation Trust (NEPFT) and see patients from across MidEssex.

In addition, NEPFT provide memory assessment service from multiple locations within the district.

20 Improving Access to Psychological Therapies (IAPT) services are interventions approved by the National Institute of Health and Clinical Excellence (NICE) for treating people with depression and anxiety disorders. These services (delivered via talking therapies) are delivered from a number of sites across the District including GP surgeries and the St. Peters site.

4.2 Primary Care

Within the Maldon district there are eight GP Practices (with some providing additional branch practices). There are an additional six GP Practices on the border of the Maldon district, two in Danbury and four in South Woodham Ferrers.

The table below identifies the primary care premises in Maldon and the populations that they currently serve;

Maldon District

PRACTICE NAME CODE Total Dispensing Numbers

Longfield Medical Centre F81022 14,323 Yes 3,105

Tollesbury Surgery F81076 3,904 Yes 1,314

Blackwater Medical Centre F81099 14,211 Yes 2,780

Burnham Surgery F81126 9,307 Yes 1,274

William Fisher Medical Centre F81130 5,941 Yes 1,682

Tillingham MC F81183 2,703 Yes 2,457

Maylandsea Medical Centre F81717 1,729 Yes 287

The Trinity Medical Practice F81751 3,132 Yes 901

55,250 13,800

Chelmsford District

PRACTICE NAME CODE Total Dispensing Numbers

Danbury Medical Practice F81100 11,115 Yes 4,879

Kingsway Surgery F81170 4,241

21 The Practice South Woodham Ferrers F81185 4,872

Wyncroft Surgery F81674 2,250 Yes 1,617

Brickfields Surgery F81721 5,971

Greenwood Surgery Y00589 4,301

32,750 6,496

These surgeries provide traditional GP delivered services along with more enhanced Primary Care services such as cervical screening, contraceptive services, vaccines and immunisations, childhood vaccines and immunisation, child health surveillance services, maternity medical services and minor surgery.

4.0 Future Provision 4.1 New Vision for Maldon

Whilst the current model of clinical services for the Maldon district has served people well for many years the outcomes of the recent Strategic Needs Assessment make it clear that the Maldon District requires a new, innovative model of health and well-being to meet the future needs of the population. With a 37% rise in those aged 65 and over within the next 10 years, and 50% rise in those aged 85 and over in the same time frame, the Maldon model needs radical change to meet these challenges. Increasing numbers of patients with long-term conditions, dementia, frailty and lifestyle related illness drive the need for change.

The new model of care proposed for the Maldon District is a key component of delivering the CCGs vision. The model challenges the concept of what constitutes a ‘local hospital’ and promotes improving the health of individuals and their communities through the promotion of well-being. The model of care focuses not only on those who are unwell but on partnering people to make healthy lifestyle choices, and helping people with long-term illnesses to manage their own conditions within a supportive framework of integrated community-based care,

22 The schematic below illustrates the proposed model of care.

Schematic of proposed hub and spoke model

The model is based on a hub and spoke concept and is suited to the dispersed nature of communities in Maldon and District, especially those in the Dengie. Hub and spoke models provide a more geographical spread of services into communities; a range of integrated care can be provided from a central point over a defined geographical area to people within the surrounding community. It can also help to link-in voluntary organisations, building and sustaining a network of health and social care resources for patients. For service providers, it can offer a foundation not previously available and a network of partner-agencies all working in the community with the benefits of local knowledge.

A number of key health and well-being services (including community-beds) will be provided from a central hub with additional services provided closer to patients in community based spokes. The hub will be based within the Maldon town (presently St. Peters) with spoke services being provided within patients homes, in existing community health facilities.

23 The CCG envisages the central hub being much more than a conventional community hospital. The traditional community hospital model of care cannot flex sufficiently to meet the changing demands of the population. Traditional reactive, acute centric, referral based care delivery will not allow MECCG to deliver its vision for health care. In order to truly transform health provision, MECCG needs a model of care that will maximise the health, well-being and independence of the population.

An integrated model of care

The diagram above illustrates the type of integration required to deliver the CCG vision for health and wellbeing. With genuine collaboration with District Councils, Local Authorities, Social Care, and Voluntary Sector a genuine, sustainable model of care is achievable.

In order to deliver an innovative model of care the CCG envisage GP services forming the heart of any new central hub within the Maldon District. This central core of primary care services provides the backbone of the model but is supported by wider health services within the hub and those additional non-health services described previously (See diagram below).

The exact distribution of services between a central hub and spokes will depend on numerous factors including (but not exclusively) the availability of community based estate, the critical mass of demand generated from rural communities, and the cost-effectiveness of spoke based provision versus centralised services.

4.2 Services

It is recognised that in order to deliver the model of care outlined above new estate will inevitably be required to replace the current St Peters Hospital at some stage in the future. The services that will need to be commissioned to deliver this model are detailed in the table below. Any future estate development will need to be designed to deliver maximum flexibility to adapt as the transformation of services progresses.

15/16 Demand 20/21 25/26 predicted predicted Commissioned Service Descriptor demand demand

Outpatient new appointment – standard Consultant and Nurse lead outpatient consultations across a wide range of specialties (see 2091 across all specialties 2354 2728 below)

(Outpatient specialty profile below)

The CCG is endorsing 8am til 8pm services 7 days per week where possible.

Outpatient Follow-up appointment – standard Consultant and Nurse lead follow-up consultations 4904 across all specialties 5522 6399

The CCG is endorsing 8am til 8pm services 7 days per week where possible.

Outpatient Procedures – These are minor medical procedures (such as intra-articular joint injections) that can be performed within 2132 outpatient procedures across multiple specialties 2450 2857 and outpatient setting.

Audiology 1114 audiology consultations in central hub 1281 1493

SWF/Burnham to be quantified

Maternity Services (Births) – Babies delivered via midwife led unit split community hospital / home birth 400 births 418 430

Maternity Services (Midwifery Episodes) – Maternity consultation between mother and midwife 1108 1157 1188

Community Therapy Service – base for 5 day community/domicillary therapy service including Physiotherapy and Occupational Administrative base only Therapy. Should ultimately co-locate with out of hospital team CCG transformation plans envisage this service becoming part of a larger 7 day 24/7 out of hospital team (Staffing mix required)

In Patient Beds – In patient community beds staffed to facilitate step-up (admission avoidance) and step-down (rapid acute discharge) 16 beds 16 beds 20 beds

Beds predominantly nurse supported with medical support from local GPs and Geriatrician

Stroke Beds – Specialist stroke care community beds. Beds are supported by a dedicated team of nursing and therapy staff with 10 (+2) beds 10 (+2) beds 12 (+2) beds rehabilitation facilities on location. Additional beds can flex from In Patient bed base at times of high demand

Early Supported Discharge – Base required for ESD team of therapists providing domiciliary rehabilitation for 200 patients post stroke 200 patients per annum 230 260

Outpatient Physiotherapy and Occupational Therapy. Predominantly outpatient based activity with Gym based rehabilitation and Provision for 12000 outpatient therapy appointments 12540 12864 group work with Gym / Rehabilitation space

The CCG is endorsing 8am til 8pm services 7 days per week where possible.

Diagnostic imaging – Plain X-Ray 9724 plain film x-ray 11270 13069

Diagnostic imaging - ultrasonography 1450 Obstetric US 1514 1554

533 General US

Phlebotomy Walk-in phlebotomy service

The CCG is endorsing 8am til 8pm services 7 days per week where possible. Numbers to be quantified

Out of Hospital / Admission avoidance services

District Nursing / Community Matron base – Early Supported Discharge Admission Avoidance and Rehabilitation services administrative base Space requirements to be quantfied ESDAAR / Out of Hospital service may require consultation capacity for community / domiciliary interface

The CCG is endorsing 7 days per week where possible.

Primary Care capacity – A number of Maldon District surgeries have indicated interest in utilising additional capacity to develop GP 4-6 clinical rooms supported primary care services. This would encompass traditional GP services, support services for in-patient facilities and innovative services for management of frail elderly patients and those with long term conditions delivered alongside consultant colleagues

Voluntary sector services – MECCG envisage voluntary sector services continuing to provide significant services alongside NHS Current capacity to be determined healthcare providers. Presently, numerous voluntary sector organisations carry out valuable NHS work within various facilities across the District. MECCG see co-location and integration of these services with traditional health services as key to the success of the model. Organisations include (not exclusively), age concern, stroke association, parkinsons society, demtia UK, Action for Family carers, Red Cross, MacMillan, Dengie Project Trust and others.

Non- Health Services MDC/ECC services. MECCG envisage a model of integrated service provision. ECC/MDC commissioned services that could benefit from co-location include CAB, housing etc…

Social Care – MECCG envisage co-location and integration of social care and reablement services along with traditional health services as integral to the success of this model. We would recommend identification of appropriate services and capacity requirements as a priority to progress this work.

Health and Well Being – MECCG envisage co-location of a range of health and well-being services including, LTC support groups, health promotional services etc. We would also see a central hub as a base for a social prescribing service forming a ‘Healthy Living Centre’.

Healthy Communities – MECCG envisage a central hub with space for developing healthy communities. Space should be available for group meetings, support networks, volunteer groups etc.

Health visiting services will be located throughout the District. Services will be split between a central hub and community based spokes.

29 Outpatient specialty splits

By analysing the historic utilisation data of the Maldon District we can define the utilisation rates of outpatient services by specialty. We are then able to define those outpatient services that are clinically appropriate to locate within a community facility given current medical best practice e.g. Clinical genetics not reasonable to relocate. This allows us to predict likely required numbers within each specialty based on need rather than historic service configuration and is demonstrated below:

Outpatient Specialty Profile 25.00%

20.00%

15.00%

10.00%

5.00%

0.00% Total TIA ENT Urology Obstetrics Neurology Cardiology Paediatrics Gynaecology Dermatology Opthalmology Rheumatology Plastic Surgery Gastroenterology General Medicine Diabetic Medicine Pain Management Pain Geriatric Medicine Respiratory Medicine

Trauma and Orthopaedics and Trauma

Profile of outpatient specialty requirements

4.3 Estate requirements

The new estates will need to be designed to deliver:

• Affordability with tenants taking full commercial risk • Functional, fit for purpose accommodation for current service provision • Maximum flexibility to adapt to change of model of service delivery • Leasing structure with flexibility to cover any changes of providers of services • Ability to expand should additional future need be identified • Flexibility on change of use should there be a reduced future need • Well designed to maximise sharing of common facilities

30 5.0 Conclusion

TO BE COMPLETED

6.0 Next Steps

TO BE COMPLETED

Appendices

Appendix 1 – Maldon District JSNA

Maldon HNA June2013_FinalVersion.pdf

31 MID ESSEX CLINICAL COMMISSIONING GROUP (CCG) Public Board Meeting Thursday, 29 January 2015 Hall 5, Spring Lodge, Powers Hall End, Witham, Essex, CM8 2HE PART ONE MINUTES

PRESENT: Dr Caroline Dollery – (CD) Chair Caroline Rassell – (CR) Accountable Officer Bryan Spencer – (BS) Vice Chair (Clinical) Caroline Anderson – (CA) Director of Nursing and Quality Dan Doherty – (DDo) – Director of Clinical Commissioning Anne-Marie Garrigan (AMG) – Lay Member (PPE & Quality) Alan Hubbard – (AH) Lay Member (Commercial) Dr Donald McGeachy - (DMc) Medical Director James Bullion (JB) – Director of Integrated Commissioning, Essex County Council (ECC) Dr Ahmed Mayet – (AM) GP Board Member Krishna Ramkhelawon – (KR) Public Health Consultant, ECC Viv Barnes (VB) – Director of Corporate Services and Board Secretary Rob Chivas (RC) – Head of Accounting (for Dee Davey, Chief Finance Officer)

IN ATTENDANCE:

Jane Hanvey (JH), Interim Project Director Rachel Harkes (RH), Head of Communications and Engagement

APOLOGIES:

Keith Andrews (KA) – Deputy Chair Cllr Dick Madden- (DM) Cabinet Holder for Families and Children at ECC

MINUTE TAKER:

Sara O’Connor, Head of Corporate Governance

Item No Item 1. Apologies and Introductions:

CD welcomed all members to the Board meeting. Apologies were noted as recorded as above. Questions from the Public:

Tom Kelly asked the following three questions:-

• The Board papers referred to underfunding of £1,060 per patient in mid Essex. What was the healthcare allocation for the Maldon District? • What was the CCG doing to alleviate shortages of nursing and specialist staff, which was having a knock-on effect on service provision? • In the light of recent media coverage about ambulance turnaround times in A&E, which it was understood were partly caused by delays in the provision of social care packages, was there any possibility of discharging medically fit patients into alternative accommodation with appropriate care support?

32 Item No Item

In response to the first question, CR advised that although the 2015/2016 funding allocation has been increased, this would still leave the CCG with a funding shortfall of 3% below target. CR explained that funding targets were calculated for the whole CCG area based on population, need, age and other demographics, so it was not possible to say whether Maldon was correctly funded.

In response to the second question, CA advised that the CCG is working closely with Health Education England to look at training and education needs. A new Certificate in Care would be implemented next year which every new Health Care Assistant would undertake. This qualification would provide a launch into shortened training forRegistered Nurse training. CA also advised that efforts are being made to encourage former staff back to the NHS and to retain existing staff in the Mid Essex area. In addition, the Deanery is encouraging medical students to train as General Practitioners (GPs). The CCG is also working with Mid Essex Hospital Trust (MEHT) to ensure efficient use of staff on the wards.

DMc commented that Anglia Ruskin University would be offering a Physician’s Assistant course. This type of post would provide an opportunity to enable Doctors and senior Nurses to provide more specialist care.

In response to the third question, CA advised that providers are collaborating to address the issue of delayed discharges. However, the current regulations governing the environment in which patients can be cared for reduced the ability to come up with creative solutions. The regulation responsibility sits with the CQC and nationally questions are being raised in relation to how regulations can support innovative solutions for delayed discharge.

Mr Kelly commented that the Ambulance service had been heavily criticised in relation to poor turnaround times, although the reasons were very often not their fault. CR acknowledged this and advised that the CCG was clear that this was a whole system problem. CR informed Mr Kelly that she received daily updates from both the Chief Executive of MEHT and the Ambulance Service. CR also advised that Social Services had been very responsive and there were very few delays in arranging care provision for patients awaiting discharge from MEHT.

CA advised that the hospital was focusing on early discharge and this should be a quicker solution to address the situation, rather than waiting for a change in the regulations.

CD invited further public questions.

Janet Cloke advised that she was aware that MEHT staff were working very hard to deal with the situation.

CA advised that whenever there is a particulardrop in A&E performance, CCG staff make unannounced inspections of the emergency floor to seek assurance in relation to patient safety and quality and ascertain action being taken to address performance .

Maureen Hennes referred to item 12 and complimented the Communications and Engagement Team on their report. Mrs Hennes suggested that to improve

33 Item No Item communication with the local population, the CCG should hold twice yearly information meetings open to the general public in each of the three areas. She suggested the agenda should include a brief reminder of the main points in the Five Year Strategic Plan, achievements, work in progress, and an opportunity for the public to ask questions and receive answers. Mrs Hennes commented that if the general public are well informed they are more likely to be supportive each time a consultation is required.

CD confirmed that the Communications and Engagement team were looking at new ways of engaging with the public and welcomed the suggestion of holding periodic wider public meetings.

Peter Mitchell, Regional Official from the British Medical Association, enquired whether a proposal for an Essex acute pathway reconfiguration review had been or was due to be considered by the CCG Board.

DMc confirmed that Essex Medical Directors had looked at several iterations of these proposals and that currently it was intended to reviewing a small number of specialties, e.g. radiology and gastroenterology, to see if there were opportunities to achieve quick gains in these areas.

CR confirmed that the CCG’s governance arrangements did not require Board level approval to commence the review, however the proposals had been discussed at the CCG’s Financial Recovery, Innovation and Transformation (FRIT) Committee meetings and by the Essex CCG Accountable Officers as a whole. VB clarified that agreement was only being sought to start looking at these options and that, if any recommendations were made, these would be submitted to the Board for decision.

Questions from the public were then closed. 3. Declarations of Interest: Presented by Dr Caroline Dollery.

AMG advised that she was now a member of the group assessing bids for Integrated Care and Commissioning grant funding.

[Action: VB – Updated declaration from AMG to be incorporated in Register of Interests.] 4. Minutes of the Last Meeting: Presented by Dr Caroline Dollery.

Amendments to the minutes were noted as follows:-

• Page 7: Beecham House should be Beauchamp House. • Page 8: DDo advised that “2 day breaches” should be “62 day breaches”. • Page 9 –The comment relating to stroke services should be attributed to KR, not KA. • Page 13 – Comments attributed to AMG regarding the Walk-in Centre were made by AM. The words “she” and “her” should be amended to “he” and “his” respectively. 5. Action Log from Previous Meetings:

The Action Log was received and progress updates noted. CA advised that the Board to Board meeting with MEHT would take place towards the end of March/early April. VB commented that the meeting had been deferred in order to focus on the Care Quality Commission (CQC) report due to be published

34 Item No Item around that time.

DDo advised that it had proved difficult to determine if there was a link between a reduction in Transient Ischemic Attack (TIA) diagnostic rates and the complexity of the computerised booking system.

[Action: DDo and AM to discuss TIA diagnostic rates in more detail to determine any action required].

6, Matters Arising from Last Meeting

CR advised that weekly meetings of the FRIT Committee (AO’s Update, page 7 of minutes) had now been reinstated.

7. Chair’s Update: Presented by Dr Caroline Dollery.

CD provided a verbal update of meetings attended and other key developments as follows:-

• CD had attended the launch of a Children and Young People leadership event organised by Essex County Council (ECC). The CCG would be working with Healthwatch to look at an integrated commissioning approach based on need. There were direct links to the national Children and Young People Mental Health Task Force which would provide an opportunity to apply for funding for innovative work.

• Waiting times for Improving Access to Psychological Therapy (IAPT) were much improved and new ideas were being developed to work with patients with mental health problems within the community.

• KR was involved in work taking place at a national level regarding Joint Strategic Needs Assessments (JSNAs).

• The Communications and Engagement team had been working on the provision of information about the 111 service and the range of alternative urgent care treatment options available to patients.

• A good relationship was being developed with the local GP federation (Chelmer Healthcare) and discussions were taking place about the standardisation of care across all mid Essex practices.

• CD had visited various locality meetings and had received positive feedback from the Chelmsford 1 locality about GPs working within A&E.

• A recent meeting with a number of Patient Reference Groups (PRGs) had been very positive. CD was keen to identify how carers of all ages could be better supported.

• Elections for GP Board members would take place in February and an information session was being held for prospective applicants. . 8. Accountable Officer’s Update: Presented by Caroline Rassell.

• CR advised that whilst the CCG had been focusing in particular upon the 4

35 Item No Item hour A&E target in recent weeks, it was important to ensure that any new arrangements to meet A&E and Referral to Treatment (RTT) targets were sustainable. Contact between system leaders had increased from monthly meetings to daily telephone updates and a lot of work was taking place to improve patient flows. A challenging target had been set to have no more than 40 people deemed medically fit remaining in hospital by the week commencing 16 February 2015. A joint programme office had been set up, led by Melanie Crass as the Programme Director for Urgent Care, with responsibility for ensuring that plans and targets were delivered.

• CR advised that the CCG had recently received guidance on how to bid for additional funding via the Prime Minister’s Challenge fund and would be submitting bids in relation to integrated out-of-hospital care and care homes.

• A commissioning strategy for Maldon would be brought to the March Board meeting. Margaret Hathaway had been engaging with PPGs, the District Council and other stakeholders to develop the strategy. CR advised that Margaret would be leaving the CCG to take up a position at Castle Point and Rochford CCG and thanked her for the valuable work she had carried out to date.

• Following a Board decision not to renew the contract for the Walk-in Centre, the Out-of-Hours Service has been relocated to MEHT. DMc had been working in A&E to provide GP input. Provision of primary care services in A&E would be tested by triaging and educating patients about treatment alternatives in an attempt to reduce admissions. Learning from the GP trial was currently being collated and analysed and information being developed for the public on alternative treatment options. CA would be attending the Health Overview and Scrutiny Committee (HOSC) to update them on immediate care changes.

In response to a query from Mr Kelly, DMc explained the meaning of the term ‘medical outlier’ and the consequences of not having patients accommodated within the correct ward.

BS stated that it was important to consider the role of primary care when looking at system resilience and commented that, if successful, the Prime Minister’s Challenge funding might help to address this.

AH stressed the importance of drawing upon the learning from previous projects of a similar nature and asked about other bids to the Prime Ministers Challenge Fund. CR advised that Chelmer Healthcare was considering ways to provide seven day working to increase patient access.

[Action: DDo to bring the commissioning strategy for Maldon to the March Board meeting]

9. Patient Story: Presented by Jane Hanvey (JH), Interim Project Director

JH provided an overview of the “100 Day Challenge” to share with the Board how Mid Essex CCG is working with all system partners to cope with rising demand, in particular from the frail and elderly. JH advised that new ways of working were being developed by providers rather than mandated by the CCG,

36 Item No Item which had fostered greater ownership by them. This model was being used to progress other areas of work to provide patient-centred care.

A short video presentation was then shown highlighting the benefits experienced by one patient during the piloting of these new arrangements for improved multi-disciplinary team working.

CD commented that those involved should be very proud of the work that was being done to provide wrap-around care for vulnerable patients and asked that thanks to BS, Carol Bladen and Liz Towers be noted. STANDING ITEMS 10. Performance Overview

10.1 Quality Report: Presented by Carol Anderson.

CA highlighted the following key issues:-

• C.difficile Infections – the annual target of 56 had been breached with 58 cases at mid-January. However, from a national benchmarking perspective performance was still extremely good. CA explained that the postcode of the patients GP was used to attribute infection rates for each area, which could give rise to anomalies, for example when patients were treated in hospitals outside Essex the breach remains attributed to Mid Essex.

• Venous Thromboembolism (VTE) – an action plan was being implemented to address issues identified following an independent audit at Colchester Hospital University NHS Foundation Trust (CHUFT). The audit highlighted there were specific issues in 2 wards and this is being addressed.

• Safeguarding of Children and Adults – CA referred to the two Section 11 audits contained within the papers. She advised that she was of the view that the audits gave an honest assessment of the current position and asked the Board to approve them for submission to the Local Safeguarding Children and Adult Boards.

• Integrated Care Team (ICT) – Staffing Report (Appendix D) – CA confirmed she was happy to take questions on this report. DDo queried whether the planned shifts for October and November were correct as they were identical. CA explained that the IT system used for rostering does not recognise weekends and bank holidays, which may explain this apparent anomaly.

In response to a query from AM regarding sickness absence, CA confirmed that relevant cases are being appropriately managed. AM also commented on the adverse impact on GP practices when community matrons are redirected to other pilot schemes. CA advised that certain projects are being tested by using the most appropriate staff available, but agreed that a longer term solution would be needed if the pilots were to be mainstreamed.

In response to a query from AH, CA confirmed that recruitment figures for UK nurses at MEHT were not included in the report but would be included in the next report to the Board.

AH also requested an update on CHUFT quality improvements. CA advised

37 Item No Item that CHUFT had carried out a thorough internal review. North East Essex CCG had shared Monitor’s report with the CCG and steps had been taken to ensure stability within the senior management team. CA commented that there appeared to be recognition that CHUFT now required an opportunity to implement the recommendations identified in all previous reviews/inspections. CHUFT had therefore been paired-up with two other Trusts to support them to do this. A number of improvements had already been made, including recruitment of Junior Doctors, reconfiguration of wards and reducing bed numbers in recognition of current staff shortages.

BS asked how the CCG received information on mental health quality and performance. CA advised that this information was provided to NECCG who managed the contract but she would arrange for this to be provided to the Board. CA stated that the number of unexpected deaths and suicides in North East Partnership Foundation Trust (NEPFT) had continued to rise and she had asked for additional information. This will be included in a future Patient Safety and Quality report. DDo queried what action was being taken by MEHT to address a number of wrong-site surgerynever events. DMc explained that a number of these incidents involved skin surgery and action has been taken, e.g. photographing the lesion at the time of diagnosis to aid identification during surgery. DMc had written to MEHT requesting further assurance on action taken.

CA advised that within CHUFT there had been approximately ten incidents reported relating to wrong-site surgery/retained objects during the past year, including retrospective incidents. CA explained that there were slight differences in the way that CHUFT and MEHT reported serious incidents/never events, but confirmed that the CCG was working with NECCG to obtain assurance that appropriate preventative action was being taken by CHUFT.

Resolved: The Board noted the Safety and Quality Scorecard, approved the Section 11 Audit for Children and Adults for submission to the Local Safeguarding Boards and noted the action plans for children and adult safeguarding.

[Action: CA to include Mental Health services in future Quality reports.]

10.2 Performance Report: Presented by Dan Doherty.

MEHT was still maintaining the RTT 18 week target, but pressures were increasing due to capacity issues. If necessary, the CCG would consider commissioning care with alternative providers. Work was in progress to meet the 31/62 day cancer targets, which remained challenging. DDo would provide a further update at the next Board meeting.

DDo stated that the IAPT waiting times were improving, but the CCG had raised a formal notice with the service provider regarding achievement of access targets. A detailed action plan was being followed with improvements now identified.

With regard to the ERS Medical contract, DDo advised there had been data quality issues affecting the CCG’s ability to analyse contract performance, but this was now improving. However, the number of delays had increased, particularly for planned appointments due to non-elective demand taking precedence.

38 Item No Item

DDo agreed to clarify the different cancer targets for the CCG and MEHT in future reports.

AH queried GP referrals in December on page 58 of the Board papers as the number of work hours seem to be exceptional in terms of demand. AM and DDo agreed to review these figures.

In response to a query from AM regarding figures for delayed transfers of care (DTOCs) on page 53, CR advised that the national definition of “delay” is used in the report. The optimum number of DTOCs should be 3% of the bed base. Therefore, 16 people would be the number expected to be delayed at MEHT, whereas there were currently 30. CR explained the medically fit were a different cohort of patients who should not be in hospital as they do not need acute medical care.

Resolved: The Board noted the content of the Performance Report and that appropriate action is being taken to address performance where there are risks.

[Action: DDo to clarify cancer targets in future Performance Reports].

[Action: AM and DDo to review GP referral figures on page 58 to check accuracy]. 10.3 Finance Recovery Report: Presented by Caroline Rassell.

CR advised that the report set out how the CCG was performing against the Financial Recovery Plan (FRP). Weekly FRIT meetings were taking place at which each Project Director was held to account for their performance against targets in the FRP. CR advised there were three projects still in the development phase and provided a verbal update on these:-

CR stated there were no indications that the £6M target saving would not be met, but confirmed savings were currently significantly under trajectory, mainly due to Mental Health Trust expenditure.

Resolved: The Board noted the content of the report and supported the continued development of savings plans and implementation of actions required to deliver the savings identified in the FRP.

10.4 2014/2015 Finance Report: Presented by Rob Chivas.

RC advised that expenditure during February and March was traditionally difficult to predict, however to date use of financial reserves had not been required. RC provided a verbal update on the following issues:-

• The CCG anticipated receiving additional funding to meet the RTT 18 week target, but would need to evidence how it was spent. • The System Resilience Group was monitoring winter monies expenditure. • The CCG would be able to decrease the forecast deficit due to a reassessment of its contribution for Continuing Health Care costs which had been reduced by £946K for 2014/15.

Following a query from AH, CR reiterated it was currently anticipated the target

39 Item No Item savings would be achieved.

BS asked for assurance that the CCG had the capacity to deliver these targets. CR confirmed that capacity was not an issue in the current financial year but it would become more challenging in 2015/16.

CR advised that the CCG was currently reporting a £15.7M deficit, but was expecting this to reduce to £14.8M by the next meeting, assuming the contingency was not spent.

Resolved: The board noted the financial position and risks to delivery of the FRP,as outlined in the report, approved the virements set out in Appendix B, and noted that CCG is incurring expenditure in excess of its statutory powers and the importance of containing the deficit for 2014/15 at a maximum of £15.7M.

10.5 Local Authority Performance Report and Scorecard, including Integrated Reablement Service Performance Report: Presented by James Bullion and Krishna Ramkhelawon.

JB highlighted the following points within the LA Performance report:

• Data suggested a general slow-down in referrals to the hospital Social Work team, although there has been an increase during December/January.

• There was a need for a comprehensive review of how Social Services assessment processes were working at the hospital, with the focus being on patients who were medically fit, but not yet delayed.

• There had been an increase in the number of people being referred to Reablement from the community, e.g. GPs and Social Workers, as opposed to the hospital, which was to be encouraged.

• Social Services was in the process of reorganising and recruiting new staff, with an additional 200 Social Worker posts across the ECC area, 40 in the CCG. This should significantly improve the Council’s performance and ability to code with multi-disciplinary teams.

CA advised that 4 medical wards at MEHT were piloting the use of named Social Workers on the ward to capture patients before the need for a S2/S5 referral arose.

JB agreed to review the figures relating to children affected by domestic abuse for the current year (page 116) to confirm their accuracy and advise CA in due course.

CD commented that it was critical that the Board was assured on all Safeguarding issues.

KR advised that a pilot scheme to provide support to a GP practice in Halstead to identify people who are smokers and refer them to the Smoking Cessation Service had proved very successful. It was planned to roll this out in other practices. Discrepancies had been identified in figures for smoking cessation

40 Item No Item to pregnant women as there seemed to be very few referrals. Work was ongoing with the Midwifery service to address this. Arrangements to increase the number of patients undergoing health checks were also being put in place, with the use of mobile units being considered.

KR stated there had been an increase in the number of pregnant women and children accessing the flu immunisation programme and advised that the final report on the programme was awaited.

BS asked whether there had been any feedback on the children’s influenza vaccination programme. KR agreed to check this with NHS England and advise BS.

In response to a query from AM regarding flu immunisation figures, KR advised that validated figures for at risk groups over 65 had not yet been received.

Resolved: The Board noted the content of the report.

[Action: JB to review figures for children affected by domestic abuse and revert to CA].

[Action: KR to check with NHS England regarding feedback on the children’s influenza vaccination programme and advise BS]. 11. Reporting from Committees Presented by Dr Caroline Dollery

11.1 Audit Chair Report

Board Members noted the issues highlighted in the Audit Chair’s report. 11.2 Quality & Governance Committee Action Notes

Board Members noted the action points from the Quality & Governance Committee held on 13 November 2014. 11.3 Finance & Performance Committee Action Notes

Board members noted the action points from the Finance & Performance Committee meeting on 6 January 2015. 11.4 Financial Recovery, Innovation & Transformation (FRIT) Committee Action Notes

Board members noted the action points from the FRIT Committee meetings held on 11 November 2014, 25 November 2014 and 9 December 2014. 12. Patient and Public Engagement (PPE) Report Presented by Anne-Marie Garrigan

AMG thanked RH for producing the new format of the report, which was noted and welcomed by the Board. RH provided a verbal update on PPE in the Maldon area, advising that she would be liaising with Peter Blackman of the South Woodham Ferrers Healthcare 2000 Group to welcome their participation. Representatives from the Dengie area had also been contacted.

BS and AM commented that patients, including young people and those harder to reach, must be engaged and involved in the design of services. CA referred to a project to improve communication with Looked After Children via new technology and CD advised that Healthwatch had been involving young people.

41 Item No Item

AMG confirmed that the intention was to involve patients earlier and more often. 13. Policies Update: Presented by Carol Anderson.

CA asked the Board to adopt the policies previously ratified by the CCG’s Quality and Governance Committee.

Resolved: The Board agreed to adopt the following policies:-

• Risk Management Policy • Media Relations Policy • Health and Safety Policy • Safeguarding Children and Adults at Risk Policy • Managing Allegations Against Staff in Relation to Safeguarding Children and Adults at Risk • Safeguarding Children and Adults Domestic Abuse Policy

NON-STANDING ITEMS 14. Better Care Fund (BCF) Section 75 Agreement: Presented by James Bullion.

JB explained that the CCG was required to re-submit its BCF submission and outlined the reasons for this. Sheila Norris, ECC, led on the revised BCF submission, which was largely the same as before. It had now been indicated to the CCG that the latest submission would be accepted and approved via the national process. The report provided to the Board explained the governance arrangements for the BCF and Section 75 Grant Agreement to the ECC.

BS suggested that a monitoring report on the performance of the BCF should become a standing item. CR advised that it might be difficult to extrapolate financial information but it was important to ensure that better outcomes were achieved. JB was of the view there would be county-wide reporting on the BCF across all CCGs to measure progress and outcomes.

In response to a query from AH regarding the focus of the fund and how the Board could be assured it would be targeted appropriately, JB advised that the BCF monies would be directed at integration of health and social care, including frailty work, admission avoidance, discharge and support for carers. He confirmed there would need to be robust governance arrangements in place to support the S75 Grant Agreement and evidence how good outcomes were being achieved.

Resolved: The Board noted the arrangements for approval of the BDF Plan and drafting of the S75 Grant agreement, agreed the governance and risk share proposals, agreed the nominated officers with voting powers for the Partnership Management Board, and approved the Accountable Officer signing the S75 Agreement on behalf of CCG.

15. 2015/2016 Budget and Medium Term Financial Plan: Presented by Caroline Rassell

CR advised that that the 2015/16 funding allocation increase was significantly higher than had been assumed in the FRP, but irrespective of this, the CCG

42 Item No Item still had to achieve £11.6M savings in 2015/16. These savings could not be achieved by using the additional allocation as there were strict stipulations how this resource had to be used by the CCG, including the possibility of new targets around parity of esteem and mental health.

CR advised that NHS England had advised that the CCG was now expected to achieve financial balance next at the end of 2015/16 and this requirement would be reflected in a report to be submitted at the next Board meeting. CR advised that this would be extremely challenging for the organisation, but confirmed appropriate action would be taken to achieve this by continuing with the CCG’s transformation programme, but cautioned this would inevitably create pressure on the CCG and its providers. Communication with providers, public, staff and other stakeholders would be vital to highlight the need to achieve financial balance.

CR stated the decision to bring certain services formerly provided by the CSU in-house had enabled the CCG to achieve a required 10% reduction in its management costs for 2015/16.

In response to a query from AH whether there was any negotiation on the requirement to achieve financial balance, CR advised that there did not seem to be any other option available.

Resolved: The Board noted the 2015/2016 financial planning position as outlined in the report and the requirement to submit a balanced budget for 2015/16. 16. Risk Assurance Report: Presented by Viv Barnes.

VB advised that a new strategic risk (risk S6a) has been identified in relation to the CCG’s capability to deliver its transformation plans.

VB stated that the risk profile has decreased across most areas as there was now greater clarity regarding finance and activity outcomes. VB also advised that the risk register had been mapped against an Internal Audit report on risks faced by CCGs across the country, to identify any new/emerging risks and this would be used to inform a review of the risk registers in early 2015/16. AH confirmed that risks had been considered in detail at the Audit Committee meeting on 19 January 2015. 17. CCG Constitution Amendments: Presented by Viv Barnes.

VB highlighted the reasons for requesting an amendment to the CCG Constitution to reduce the number of elected GP roles from eight to four. This proposal would not affect the composition of the Board, but would create greater flexibility to enable clinical input in the CCG’s day-to-day work. VB confirmed that the proposed changes had been discussed with GP members, via the GP newsletter, Primary Care Forum and GP summit and had also been reviewed and endorsed by the Audit Committee.

CR advised that she felt that the Board voting rights needed to be revisited and requested that this be undertaken at the next meeting.

Resolved: The Board approved the proposed changes to paragraph 6.1.1 (Composition of the Clinical Commissioning Group Board) of the CCG Constitution.

43 Item No Item [Action: Voting rights to be reviewed at next Board meeting.] 18. Any Other Business:

18.1 Appointment of James Bullion as Director of Adult Operations at ECC

CD asked that thanks be noted to JB for his role on the Board and congratulated him on his appointment as Director of Operations for Adult Social Services. CD also welcomed Sheila Norris who would replace JB as ECC’s representative on the Board.

CD also asked that thanks be noted to Michela McCabe for having provided administrative support to the Board.

Finally, DDo asked that thanks also be noted to Margaret Hathaway and Dawn Scrafield, both of whom were leaving to take up new posts, for their support to the CCG. 19. Date and Time of Next Meeting

Board Meeting in Public: 1:30pm Thursday, 26 March 2015. Maldon Town Hall, Market Hill, Maldon, Essex, CM9 4RL

44 Mid Essex Clinical Commissioning Group Board Action Log – Part 1

Meeting Agenda Action Lead Deadline for Outcome/Update Date Item Completion

25/9/14 10.1 Quality Report: Board update to be James Bullion February 2015 ECC and CCGs have developed a provided following completion of ECC joint service specification for Care review of quality in Care Homes Homes which is currently out for consultation. .As part of the consultation we are developing a set of key performance indicators for quality markers. Quality in care home is a priority and we will be working in partnership on developing a step change programme. 25/9/14 10.5 LA Performance Report: ECC James Bullion January 2015 Report on reablement came to Jan Reablement Strategy to be shared Board meeting. ECC working with with CCG Board for discussion CCGs on new service specification

27/11/14 5 Board Action Log: Board-to-Board Viv Barnes March 2015 Arranged for 17 March 2015 between ME CCG and MEHT to be arranged for March 2015 27/11/14 10.2 Performance Report: DDo and AM to Dan Doherty ASAP Analysis underway with MEHT. and discuss TIA diagnostic rates in more Update to be provided in future 29/01/2015 detail to determine any action required performance report. 27/11/14 13 Mid Essex CCG JSNA: Action plan Krishna 29 January 2015 Deferred until May Board meeting for implementing JSNA Ramkhelawon pending further input from Executive recommendations - including work team into action plan already underway, action leads and timescales - to be brought to next Board meeting. 29/01/15 3 Register of Interests: Updated Viv Barnes 26 March 2015 On agenda 45 Meeting Agenda Action Lead Deadline for Outcome/Update Date Item Completion

declaration from AMG to be incorporated in Register of Interests 29/01/15 8 Accountable Officer’s Update: D Doherty 26 March 2015 On agenda Commissioning Strategy for Maldon to be brought to March Board meeting. 29/01/15 10.1 Quality Report: Mental Health C Anderson 26 March 2015 20/02/2015 The new Director of services to be included in future Nursing for North Essex Mental Quality reports. Health Trust will commence at the end of March, a meeting has been requested to agree future staffing reports. 29/01/15 10.2 Performance Report: Cancer D Doherty 26 March 2015 Now included in performance reports. Targets for CCG and MEHT to be clarified in future Performance Reports. 29/01/15 10.2 Performance Report: GP Referral D Doherty/ ASAP Update included in performance figures on page 58 of Board papers of Dr Mayet report. 29 January 2015 to be reviewed. 29/01/15 10.5 LA Performance Report & J Bullion ASAP Data is correct. The trend of Scorecard: Figures for children decreases in ‘Incidents in which affected by domestic abuse to be children are affected’ reflects a reviewed and confirmed to Director of change in approach to recording Nursing & Quality. standard risk incidents in children’s social care.

Meeting Agenda Action Lead Deadline for Outcome/Update Date Item Completion

29/01/15 10.5 LA performance Report & K Ramkhelawon 26 March 2015 Information provided by NHSE – Scorecard: NHS England to be contacted to request feedback on (1) 45.1% immunised in mid Essex for children’s influenza vaccination children aged 2-4yrs (Essex programme. 43.9%; England 37.6%) Pilot in primary schools – data only available at Essex County level – 59.6% immunised, with one school opting out in Mid Essex (no rationale provided). Plans are afoot to deliver this programme for winter 2015-16. 29/01/15 17 MECCG Constitution Amendments: C Rassell ASAP Completed – on agenda 26/3/15 Voting rights to be discussed between Accountable Officer and MECCG Chair to determine if further amendments to Constitution are required.

MID ESSEX CLINICAL COMMISSIONING GROUP

Report to Mid Essex Formal Board Meeting

Meeting Date: 26 March 2015

Agenda No: 8

: Chair’s Update Report Title

: Caroline Dollery Written By

Purpose of Report : To update the Board on key issues

Previous Agenda : N/A Reference

Approval Route : N/A

Clinical Implication(s) : N/A

Financial Implication(s) : N/A

Workforce : N/A Implication(s)

Legal Implication(s) : N/A

Have the details of this paper been assessed for all of the protected characteristics under the Equality Act 2010? Yes (√) No (√)  If No, please outline why : N/A

: Equality & Diversity

If Yes, please provide details of the outcome of the assessment, including how any adverse effects will be monitored:

Is the equality analysis on the CCG website? Yes (√) No (√)

48 : N/A (covered elsewhere on the agenda) Risk(s) Identified

Significance to Key : N/A (covered elsewhere on the agenda) Target(s)

Patient & Public : N/A Involvement

Does this item go against rights or pledges of NHS Constitution? If yes, please outline how and reasons why this Constitution : is necessary:

Yes (√) No (√) 

Sustainability : N/A

Recommendation(s) : The Board is asked to note the contents of the report

49 CHAIR’S UPDATE

Submitted by: Dr Caroline Dollery, Chair Status: For Noting

1. PURPOSE

To update the Board on key areas and activities since the last Board meeting.

2. BOARD DEVELOPMENT

We have changed the format and approach to supporting the Board in addressing key strategic areas, building in a session each month devoted to such areas as how we address risk as a Board; our statutory duties; how we utilise our strengths to best effect; and addressing key challenges in our system.

This approach has given the Board more protected time to collectively think about key issues, and to introduce new members to the team.

We also ran a facilitated session for potential new Board members and clinical leads, to make sure everyone has a shared understanding of the political and organisational systems and challenges going forward, as well as making sure we are well placed to take advantage of opportunities.

3. LAY MEMBER APPOINTMENTS

The appointments of the three Lay members on the Board are all due to expire at the end of March 2015. Under their terms and conditions of office, Lay members are eligible to be considered for reappointment for a further term subject to satisfactory performance and the continued operation of the CCG. At the end of the second term of any reappointment, the Lay member roles must then be subject to a competitive selection process within which existing office holders may participate if they so wish.

I am delighted to confirm that Keith Andrew, Anne-Marie Garrigan and Alan Hubbard have all indicated their willingness to be reappointed for a second term of office. Discussions are taking place about staggering the length of their terms of office to avoid these roles all coming up for renewal at the same time in the future and I should be able to provide a verbal update on this at the Board meeting.

4. ACCOUNTABILITY AGREEMENT

We are in the process of reviewing the wording of the Accountability Agreement between the CCG and member practices to ensure that it remains fit for purpose and will be sharing any proposed changes with our Primary Care Forum. We will also be

50 considering how to ensure that the incentive funding associated with the Accountability Agreement is best used to promote member practice engagement, encourage greater participation in and understanding of the CCG’s work, and ensure that the limited funds at our disposal are used to the greatest effect.

5. TOBACCO CONTROL LAUNCH

I attended the all parliamentary launch of tobacco control, held at the Houses of Parliament, with Simon Stevens as key note speaker. Mid Essex CCG is a signatory to this campaign. Key statistics include the fact that, although starting smoking as a teenager has dropped in affluent areas, to an uptake of 18%, in deprived areas, and in particular in those with mental health problems, the uptake is 56%; one of the prime reasons people with mental health problems die 20 to 30 years younger than other people. Public health is supporting the CCG in focusing on this key area, and it is to be hoped more organisations work towards becoming smoke-free.

6. PRIME MINISTERS CHALLENGE FUND AND FORWARD VIEW

The CCG, together with Chelmer Healthcare and other key stakeholders, bid for the Challenge Fund, to allow investment in primary care, support for new ways of working and improved access, including links to the new urgent care centre. We also applied to be a Vanguard site based on our work in frailty. We are awaiting the outcome of the Challenge Fund; and came close to being a Vanguard site but we are included in a cohort who will be part of a learning set and may well be in the next phase. It is important we continue to apply these national initiatives to support our transformation programmes.

7. MENTAL HEALTH UPDATE

I have been asked to work with the Northern Strategic Clinical Network to lead the support for implementation of the Taskforce recommendations of Children and Young People’s Mental Health. This is a great privilege, and will also give us opportunities with Essex County Council to take advantage of developing early intervention and prevention strategies, as well as much improved access to evidence based treatment.

As I write, we are awaiting news of new funding to support this work, and we will work hard to make sure we involve children and young people, families and cares in taking this work forward. In addition, on the agenda today, we are discussing the action plans for the urgent care concordat, which covers all ages, and includes a wide range of organisations, including police, fire brigade and ambulance services. We have already seen a significant impact in reductions of Section 136 events as a result of having street triage in place, where police are supported by mental health nurses on patrol. This means less children and adults end up in police cells, when in fact they have a mental health problem.

51 I was also asked to the launch of the All Parliamentary Party Group report on mental health going forward post-election. The focus will be on access standards to evidence based care in the key areas of early intervention in psychosis; eating disorders; liaison psychiatry and 18 week waits for talking treatments. I am one of the regional leads on this work. Announcements about funding are imminent.

9. FRAILTY PROGRAMME

We continue to see impressive results from our frailty programme, and we have a new tranche of surgeries participating, We are working closely with Provide, NEPFT and MEHT, so we can work as quickly as feasible to get this rolled out across Mid Essex. We are also investigating new information systems which will allow shared information across health and social care. I attended a workshop with Essex County Council, where there is a real focus on improving this.

10. RECOMMENDATION

Members of the CCG Board are asked to note the report.

MID ESSEX CLINICAL COMMISSIONING GROUP

Report to Mid Essex Formal Board Meeting

Meeting Date: 26 March 2015

Agenda No: 9

: Accountable Officer Update Report Title

: Caroline Rassell Written By

Purpose of Report : To update the Board on key issues

Previous Agenda : N/A Reference

Approval Route : N/A

Clinical Implication(s) : N/A

Financial Implication(s) : N/A

Workforce : N/A Implication(s)

Legal Implication(s) : N/A

Have the details of this paper been assessed for all of the protected characteristics under the Equality Act 2010? Yes (√) No (√)  If No, please outline why : N/A

: Equality & Diversity

If Yes, please provide details of the outcome of the assessment, including how any adverse effects will be monitored:

Is the equality analysis on the CCG website? Yes (√) No (√)

53 : N/A (covered elsewhere on the agenda) Risk(s) Identified

Significance to Key : N/A (covered elsewhere on the agenda) Target(s)

Patient & Public : N/A Involvement

Does this item go against rights or pledges of NHS Constitution? If yes, please outline how and reasons why this Constitution : is necessary:

Yes (√) No (√) 

Sustainability : N/A

Recommendation(s) : The Board is asked to note the contents of the report

54 ACCOUNTABLE OFFICER’S UPDATE

Submitted by: Caroline Rassell, Accountable Officer Status: For Noting ______

1. INTRODUCTION

This report provides the Accountable Officer’s update which covers the following:

• GP Board Member Appointments • System Resilience • Easter Planning • Board to Board with Mid Essex Hospital Trust • HOSC • Prime Ministers Challenge Fund and Multi-Speciality Community Provider Bid • Recent Meetings Attended

2. GP BOARD MEMBER APPOINTMENTS

Members will recollect that at the January Board meeting it was agreed to reduce the elected GP membership from 8 to 4 to reflect the actual composition of the Board. The terms of office of the current elected GP Members expire on 31 March 2015 and so an appointment process for the four GP Board member roles, coordinated by the North Essex Local Medical Committee (LMC), commenced in January. As there were more suitable applicants than the number of vacancies, an election also had to be arranged to allow member practices to vote for their preferred candidates. The outcome of the election will be confirmed by the LMC on 20 March 2015 and a verbal update will be provided at the Board meeting.

Once the election results are known, the successful applicants will be asked to nominate the Chair and Vice Chair (Clinical) from amongst their number. These nominations will be reported at the Board meeting for members’ endorsement.

3. SYSTEM RESILIENCE

The System Resilience Group (SRG) continues to be a key meeting for the whole system in Mid Essex and since the last Board meeting has been meeting weekly specifically to focus on the A&E 4 hour wait target and the longer term transformation of immediate care. The position has not improved since the last Board meeting despite A&E attendances reducing since December and the number of medically fit in hospital reducing by one half – from 80 to 40. The system remains on weekly reporting to the Cabinet Committee about medically fit and overall system performance. An escalation meeting between the system and

55 the Regional Regulators (Trust Development Agency [TDA] and NHS England Area Team) has been set for 27th March.

The CCG leads the SRG and has put in place a system wide PMO to report and monitor on the plans which have been scrutinised by the regulators and deemed acceptable. The capacity to consistently and permanently implement the plans (which cover business as usual activity as well as new initiatives) is the challenge which the whole system has flagged. It is clear however that the expectation is that the system will be compliant and accountable for moving rapidly back to target.

The CCG has taken all the contractual routes open to it to follow process and hold to account the Trust for performance and in addition I have written to the NHS England Area Team, as head of the Quality Surveillance Group, to raise a number of issues with them and ask for their help and support. Of particular concern to the CCG are the quality issues that inevitably are arising due to the long waits.

The CCG has spent time reviewing all of the areas within its control in terms of the performance against the A&E target. All of the demand management systems that have been put in place are being reviewed to look at effectiveness and impact. Of note is that last year the CCG was the 14th lowest (out of 211 CCGs) in terms of attendances at A&E, this year the demand has increased by 8% but the CCG is now the 13th lowest in terms of attendances at A&E. This does reflect the overall national increase that has been witnessed. The CCG continues to look at better and more ways of managing demand and will introduce, for a 10 week period in April, a HIT team to target the top 10 care homes in Mid Essex who call the ambulance service. This team will consist of a therapist; nurse; pharmacist and mental health specialist. A further update will be given at the next Board. The CCG has also reviewed its support for hospital discharge, particularly with the fast track discharges and Continuing Healthcare, to monitor itself against the national Gold Standard but also look at improvements since last year.

Alongside the operational issues which cause considerable concern and resource to manage, the whole system continues with its work of transforming immediate care services. The current crisis that we are experiencing does demonstrate that a longer term and more permanent solution is needed in the system.

The Out of Hours (OOH) Service was relocated to Broomfield back in December and since January there has been a GP in the Emergency Department (ED). In February a nurse streamer also started to ensure that the GP was being triaged the right cohort of patients. The OOH service has also offered support to the ED taking patients during the day at weekends to ease any capacity problems. One of the key issues with the GP in ED pilot has been the continuity of staff working the shifts. The general feeling from those close to the service has been that the quality and consistency of the service would be much enhanced if a longer contract for the service could be given. The Area Team and the TDA have strongly supported this so the CCG has decided to put out a 6 month contract to extend the pilot. During the first 2 weeks in March, a “gold service” was put in

56 place where initial results showed that this service could take a significant number of minors, allowing the ED to focus on those patients who need an ED level of care. The plan is that this service will be ramped up from April to mitigate any possible flow of patients following the closure of the Walk in Centre. The key issue which is still being worked through between the Trust and the CCG is the physical capacity to permanently locate this service.

A significant amount of work has been undertaken with respect to the closure of the Walk in Centre. It is of note that the numbers using the working Walk In Centre have, even prior to the closure being announced, reduced significantly (by 40%). Analysis has been undertaken to understand flow and to also look at which practices in Mid Essex the patients have come from. The practice with the largest number of patients attending the Walk in Centre would see an increase of a 3 patients a day if all of those attending the Walk in Centre decided to return to general practice. We are working with all our local GPs to see how we can provide support and help to deliver any potential extra capacity.

The CCG has also focused on a communications drive with leaflets going out to practices, pharmacies, schools, community locations alerting people to the closure of the Walk in Centre and the alternative services available alongside the information about the Chose Well campaign. Over the coming weeks there will also be articles in all the local papers.

The Board should note that the contract for the GP practice registered list at the North Springfield premises previously shared with the Out of Hours service and the Walk in Centre has been awarded and from 1st April will be run by one our practices from Halstead. The North Chelmsford practice will open from 8.00am to 8.00pm Monday to Friday and provide limited sessions on Saturday and Sunday; patients wishing to gain access to extended opening hours will be able to re- register with this practice if they live within its catchment area.

4. EASTER PLANNING

NHS England are working with the system to ensure that there are robust plans in place for the Easter weekend period. We are working together to encourage a number of practices to open for a 2 hour period on Easter Saturday to mitigate pressures. There will be a “gold command” run across the system, led by the hospital, with a view to seeking to discharge as many patients as possible in the run up to Easter to assist the ED with flow through the hospital during this period.

NHS England have also written to all system partners and strongly advised that all System Resilience schemes put into place during 2014/2015 must continue during April.

57 5. BOARD TO BOARD WITH MID ESSEX HOSPITAL TRUST

A Board to Board meeting between the CCG and Mid Essex Hospital Trust is due to take place on Tuesday 17th March. This meeting will focus on quality and governance issues. A verbal report will be provided at this Board meeting. It is planned that these meetings become a more regular occurrence to ensure that our longer term visions about care in Mid Essex are aligned.

6. HEALTH OVERVIEW & SCRUTINY COMMITTEE AND MEETINGS WITH MPS

Carol Anderson attended the Essex Health Overview and Scrutiny Committee meeting on 4th March to discuss progress on the closure of the Walk in Centre, our plans for consulting on our CHC policy and a general update.

Myself, Caroline Dollery and Donald McGeachy met with 3 of our local MPs on 6th March. We provided a briefing on the major issues the CCG is facing. The key issues raised by the MPs were funding and GP provision.

7. PRIME MINISTERS CHALLENGE FUND AND MULTI-SPECIALITY COMMUNITY PROVIDER BID

As Board Members will be aware, a bid was made by Chelmer Healthcare supported by the CCG for the PM Challenge Fund. The announcement of the successful bids was supposed to be in February but at the time of writing this report nothing has yet been heard. Any further update will be provided at the Board.

The CCG also supported a bid by Chelmer Healthcare and Provide for resources to support the new models of care in the 5 Year Forward Vision. The bid was for a Multi-Speciality Community Provider, supporting the integration of out of hospital services. This bid, however, was not successful.

8. MEETINGS ATTENDED

I continue to attend the Health and Well Being Programme Board for the CCG which has focused largely on the approval of the Better Care Fund rather than integration. A proposal has recently been received from the County about how this can be restructured to meet the needs of the Health and Social Care at officer level.

In early March I attended a meeting at the House of Lords looking at the policies for health moving forward and the opportunities and challenges that these might pose.

58 The Chief Executive of Provide, the Hospital and myself continue to meet daily via a conference call to discuss and seek to resolve system wide issues.

9. RECOMMENDATION

Members of the Board are invited to note the report.

MID ESSEX CLINICAL COMMISSIONING GROUP

Report to Mid Essex CCG Board Meeting

Meeting Date: 26 March 2015

Agenda No: 11.1

: Patient Safety and Quality Report Title

: Carol Anderson, Director of Nursing Written By

Purpose & : Recommendation To provide assurance to the Board in relation to Patient Safety and Quality

Previous Agenda : Standing Item on Board Agenda Reference

Approval Route : Clinical Quality and Governance Committee

Clinical : Implication(s) Detailed within the Paper

Financial : N/A Implication(s)

Workforce : N/A Implication(s)

N/A Legal Implication(s) :

Have the details of this paper been assessed for all of the protected characteristics under the Equality Act 2010?

√ √ Yes ( ) No ( )

If No, please outline why : Equality & : Diversity If Yes, please provide details of the outcome of the assessment, including how any adverse effects will be monitored:

Is the equality analysis on the CCG website?

Yes (√) No (√)

: Detailed within the paper Risk(s) Identified

Significance to Key National and Local Targets : Target(s) Strategic Objectives

Patient & Public : Detailed within the paper Involvement

Does this item go against rights or pledges of NHS Constitution? If yes, please outline how and reasons why this is necessary: Constitution : Yes (√) No (√) √

Sustainability :

The Board are asked to:

• Note the Safety and Quality Scorecard (Appendix A) • Approve the Quality Improvement Plan (Appendix B) Recommendation(s) : • Note the HCAI performance • Note the Never Event performance • Note the update on Winterbourne • Note the upcoming CQC quality summit • Note the Quarter 3 Serious Incident and Never Event report

61 PATIENT SAFETY & QUALITY REPORT

Submitted by: Carol Anderson, Director of Nursing & Quality Status: For Noting ______

1. PURPOSE

This report provides assurance to the Mid Essex Clinical Commissioning Group Board in relation to patient safety and quality.

The report this month includes the patient safety and quality scorecard which highlights continued reporting in a number of quality indicators and is set in the CQC Domains.

The report also provides the Board with an update and assurance in relation to the wider quality and safety agenda.

2. QUALITY AND SAFETY SCORECARD

The Quality and Safety Scorecard is attached as Appendix A. The Board is asked to note the following:

Infection Control

As of mid-March there have been 66 cases of C difficile for Mid Essex CCG against a year-end ceiling of 56. Ceilings for 2015-16 have now been published and show an increase for Mid Essex CCG to 71. MEHT have been given a ceiling of 13, which is no change from the 2014-15 ceiling.

Although it is of note that MEHT have breached their 2014-15 ceiling with reported cases, the Board will be pleased to note that 3 have been appealed successfully at the HCAI Scrutiny panel and will be removed from trajectory for contractual penalty considerations. The CHUFT breach of ceiling may also be affected by appeals at the April panel meeting. Processes for investigating cases of C difficile across North Essex are being revised to reflect updated national guidance. Further detail on this will be reported to the Board in May 2015.

There were 2 cases of MRSA bacteraemia in December and 1 in January for Mid Essex CCG; with a further MRSA bacteraemia case reported from MEHT from a sample taken in February. The patient had been in the hospital for up to 4 weeks so the case is provisionally assigned to the Trust. The post infection review meeting is arranged for later in March and the outcome of this will be provided to the Board in May 2015.

The NHS Standard Contract 2015-16 and the Quality Premium requirements for improved Antimicrobial Stewardship, which will add a reduction in primary care prescribing of antibiotics, is expected imminently. The North Essex Antimicrobial

62 Stewardship group are revising Terms of Reference and preparing a Strategy with an accompanying action plan. Board will be kept appraised of developments in this area.

Serious Incidents and Never Events

Following the previous report to Board in January, Mid Essex Hospitals NHS Trust has reported a further Never Event in January 2015. The Board will recall from earlier reporting this now totals a fifth Never Event in a 4 month period. Four of these Never Events relate to wrong site surgery and the CCG have been working with the Trust to gain assurances of actions moving forward, to prevent reoccurrence and ensure lessons are learnt.

The CCG Medical Director has written to Mid Essex Hospitals to express concern around the 4 wrong site surgery events, especially in light of the repetitive nature of these incidents. In response the Trust have been reviewing the process and procedures in place and are ensuring the WHO (World Health Organisation) Surgical Safety Checklists are in place across all departments where procedures are undertaken. In addition the Trust has issued instant cameras to outpatient settings for photographs of the site to be removed to be taken to supplement the current information detailed within the patient record.

Mid Essex Hospitals recognise further work is required in relation to culture and are undertaking further work in relation to Human Factors. The quality team continue to monitor progress in this area during quality assurance visits and the Clinical Quality Review Group (CQRG).

The quarter 3 report for serious incidents and never events is attached at Appendix C

PALS and Complaints

The CCG has received the following contacts, complaints and compliments since the last report to Board.

NHS MID ESSEX Complaints PALS Compliments Total 1st January 2015 to 12th March 10 151 1 162 2015 Compared to 1st January 2014 to 6 187 5 198 12th March 2014

PALS Within the top ten concerns, eligibility for transport criteria is number one, followed closely by information about different commissioning decisions. Together these account for over half of all calls to the PALs service.

A patient who is a member of the Breath easy group complimented us on our PALS service and has asked for a representative from the CCG to attend their next meeting.

63 Complaints 10 complaints have been received, 7 are closed, the remaining 3 are in the process of being responded to and will be closed by the end of March.

ID Closed First received Specialty admitted

5414 22/01/2015 20/01/2015 Continuing Health Care 5419 11/03/2015 Continuing Health Care 5416 18/03/2015 05/02/2015 Exceptional Case Panel 5417 19/02/2015 05/02/2015 Exceptional Case Panel 5421 12/03/2015 IVF - query 5420 11/03/2015 IVF - query 5418 26/02/2015 20/02/2015 Continuing Health Care - Children 5415 23/01/2015 20/01/2015 Treatment decisions 5412 18/02/2015 21/01/2015 Medicines Management 5413 16/02/2015 08/01/2015 Community Services

Safeguarding Children and Adults

Safeguarding Children Themes and lessons learnt from NHS investigations into matters relating to Jimmy Savile – the recently released report highlight’s concerns how a famous, flamboyantly eccentric, narcissistic and manipulative television personality, using his celebrity profile and his much-publicised volunteering and fundraising roles to gain access, influence and power in certain NHS hospitals. He used the opportunities that access, influence and power gave him to commit sexual abuses on a grand scale. However features of the story have everyday implications and relevance for the NHS today. These matters are considered in Kate Lampard’s report. In light of other recent sex abuse scandals and allegations, the lessons learnt from the Savile case must form part of a wider public conversation about how all professionals and public bodies identify abuse and act to tackle it. The report makes 14 recommendations, mainly for acute trusts, for which the CCG will request assurances on through the Safeguarding Forums and CQRG. Board will be kept abreast of progress against the recommendations in future reporting.

The Southend, Essex and Thurrock (SET) Safeguarding and Child Protection Procedures 2015 have just been launched by the three Local Safeguarding Children Boards (LSCBs). All providers have been involved in the consultation process over the past year and thus aware of the updated procedures. The Essex Safeguarding Children Board (ESCB) is due to publish a summary detailing the main changes imminently and once this is available it will be disseminated to Board.

Safeguarding Adults Basic standards of care remain a concern in relation to some care home provision within Mid Essex. The Quality and Safety team continue to work collaboratively with Essex County Council to improve standards within the homes.

There continues to be three care home suspensions to admissions in Mid Essex:

Elmcroft Care Home – Tolleshunt Major The Board will recall that Mid Essex CCG had been working hard to transfer all CHC residents from this home, following concerns around the quality of care provided. However there is currently 1 Mid Essex CCG CHC funded resident remaining in the home, as the resident was assessed as funded nursing care (FNC), but an appeal was made therefore keeping the CHC funding in place. A panel review, to fully assess funding arrangements is set to convene in March 2015, whereby agreement on future placements of the resident will be ascertained. The Board will be continued to be updated on progress.

The home continues to be closely monitored and remains suspended to admissions.

Broomfield Grange - Chelmsford Admissions to this care home remain suspended.

The Old Deanery Admissions to this care home remain suspended.

Care home visits and inspections continue by the safeguarding team, incorporating a systematic approach to respond to serious concerns. The Quality Trigger Tool which RAG rates homes linked to numbers of safeguarding alerts, serious incidents raised, and confirmed outbreaks, is being used to support and inform the priority and schedule of visits. In February 2015 it triggered 4 clinical site visits, resulting in action taken against 1 home by Mid Essex CCG, in relation to withholding of monies, whilst an investigation into care provision and fraud was underway. Additionally visits to all BUPA homes continue presently to ensure quality of care provision within these settings.

Winterbourne There has been considerable frustration nationally about the lack of progress in discharging people with learning disabilities from in-patient services following the publication of “Transforming Care – A national response to Winterbourne View Hospital” in December 2012. The ambition of Transforming Care was that all people who no longer needed care in a hospital based setting would be discharged by June 2014. The recent report “Winterbourne view – Time for Change” published in November 2014 found little progress in reducing the overall numbers of people with learning disabilities in hospital based services.

In response to the lack of progress the Department for Health has mandated that all people placed in hospital based services should have an Independent Care and Treatment Review to establish whether they still need to be detained. Care and Treatment Reviews have been completed for all people that were in placed in hospital based services prior to 1st April 2014.

65 Mid Essex presently has identified 10 people in placements in Secure Services currently funded by NHS England; patients in Locked Rehabilitation Units funded by the CCG via either the Individual Placement Team or s75 agreement with Essex County Council; and patients that have been admitted for assessment and treatment in local services. The people that still remain in hospital are some of the most complex people that we support. They often exhibit behaviours that make it very difficult to support them in community based settings without the restrictions that can be applied through the Mental Health Act. Some of these behaviours may be attributable to the person’s mental health or learning disability, but many are environmental and have evolved through years (and sometimes decades) of institutional living. To find suitable accommodation and a competent care provider that can support people with this complexity of need in the community can take up to 12 months.

There are good joint working arrangements between the Individual Placement Team working on behalf of the CCGs and social workers and commissioners at Essex County Council to support the discharge of these people. For those that need to be discharged to community based services there is a parallel process underway with social workers exploring potential placements within the existing market whilst a more strategic procurement process is underway to develop solutions for the longer term should no suitable placements be available. A specialist housing provider has been identified and social workers are in the process of specifying the accommodation requirements for each person.

The Board will be updated on progress in May 2015.

Francis Action Plan (Learning from Mid Staffordshire) The new Mid Essex CCG Quality Improvement Framework updates actions from the second report from the public inquiry into the events at Mid Staffordshire hospital carried out by Robert Francis Q.C including Hard Truths from the Governments final response, also those raised by, A Promise to Learn – a Commitment to Act, Don Berwick’s review into patient safety and Professor Sir Bruce Keogh’s review of 14 hospitals that were mortality outliers. It includes the main recommendations from the reports which have significance for Mid Essex CCG. It details the updated action plan (initial plan 2013) the CCG is presently working on to ensure that all recommendations are fully considered and responded to at board level.

Key Issues & Recommendations: Reports following the public inquiry into Mid Staffordshire NHS Foundation Trust published in February 2013 and November 2013 build on the first independent inquiry and provide detailed and systematic analysis of what contributed to the failings in care at the Trust. Identifying how the extensive regulatory and oversight infrastructure failed to detect and act effectively to address the Trust’s problem and it is structured around:

• Warning signs that existed and could have revealed the issues earlier • Governance and culture • Roles of different organisations and agencies present and future

66 The report concludes that a fundamental change in culture is required to prevent a system failure from happening again and many of the changes can be implemented within current systems. The report makes 290 recommendations, which focus primarily on securing a greater cohesion and culture across the system; however no single recommendation should be regarded as the solution to the many concerns identified:

• Ensuring implementation of the inquiry’s recommendations sets out requirements for oversight and accountability to ensure implementation of its proposals. • Creating the right culture, which aspires to prevent harm to patients and provide excellent care and a common culture of caring, commitment and compassion. • The importance of making patients the main priority in all that the healthcare system does. • It proposes significant changes to the current division of regulatory responsibilities and proposes regulating the healthcare systems governance. • Commissioning for standards contains 21 recommendations specifically for commissioning organisations, with six of these specifically around the role of commissioners in performance management and oversight of quality. • There are also other recommendations which though not specific to commissioning, impact on the CCG’s role.

• Abandon blame as a tool and trust the goodwill and good intentions of the staff. • Recognise that incorrect priorities do damage; quantitative targets should not replace the goal of better care, the central focus must always be on patients. • Warning signals especially the voices of patients and carers must be listened too. • Transparency is essential expect and insist on it.

Professor Sir Bruce Keogh’s report, “Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report, investigated fourteen acute trusts which were persistent mortality outliers using the HSMR (Hospital Standardised Mortality Ratio). The investigations consisted of; analysis of data including patient and staff feedback, announced and unannounced visits by experienced clinicians, patients, managers and regulators and consideration of evidence gained to make judgements about the quality of care being provided and agree actions. Some examples of good care were found, but none of the trusts provided consistently high quality care. Issues identified include; professional and geographic isolation, failure to act on information that showed cause for concern, absence of a culture of openness and willingness to learn from mistakes, ineffective governance and assurance processes and concerns over staffing levels including difficulty recruiting staff. In many cases Trust Boards were previously unaware of problems discovered by the review teams.

Conclusions of the review include:

67 • Emphasis on the importance of boards making better use of data to identify potential problems. • The importance of monitoring bed management and patient flow, so as to decrease the risks that come with low staff to in-patient ratios. • Trusts need to work to better understand patients’ views.

The Inquiry triggered investigations into 14 other NHS organisations that had been persistent outliers on mortality indicators, the model was adopted by the CQC for inspection of acute providers.

Key Recommendations for CCGs: • Commissioners have a responsibility for monitoring the delivery of standards and quality on behalf of and in partnership with patients. • Commissioners should agree a method for measuring compliance and redress for noncompliance of standards and when selecting indicators and the means for measuring compliance, commissioners must closely engage with patients to ensure their expectations and concerns are addressed. • Commissioners must have the capacity to monitor the performance of every commissioning contract on a continuing basis and must require the providers to provide quality information. • Commissioners must have the capacity to undertake their own or Independent audits, inspections and investigations and should be entitled to intervene in the management of a complaint on behalf of a patient where it appears it is not being managed satisfactorily. • Commissioners should be accountable to the public for the scope and quality of the services they commission and fully involve and engage the public in their work. • Commissioners should have powers of intervention when substandard or unsafe services are being provided.

Due to the current challenges facing the Mid Essex Health Economy it is vital that the CCG has a robust action plan in place to ensure that it can fulfil its role in monitoring the services which it commissions. It is also important that the organisation reviews its systems and processes for utilising intelligence from all sources. This will not only ensure safety but to drive up quality.

The action plan has been updated and developed from the initial 2013 plan to address the recommendations of the reports and aims to build on the quality and safety agenda already identified within the CCG and has the following RAG rating on the 28 recommendations.

Number of Red Amber Green Recommendations 28 1 4 23

It is important that the CCG develops and monitors not only this action plan but the action plans of providers, which will completed through the CQRG functions. Within the health economy the CCG will be responsible for providing a system wide update to the Mid Essex CCG Quality and Governance Committee and Board. The Quality Improvement Plan is attached for approval in Appendix B.

Nurse Staffing Update

The national policy driver of “How to ensure the right people with the right skills, in the right place at the right time” from the National Quality Board in 2013 requires Provider Trust Boards to receive monthly reports of the planned and actual staffing levels on a shift by shift basis and to be advised of the actions being taken to address any gaps and protect patients. It is the responsibility of Commissioning Boards to seek assurance that Provider staffing data has been validated.

Within Mid Essex CCG staffing data is reported monthly by MEHT and bi-monthly by Provide to quality contract meetings, in addition validity is sought as part of the quality walk rounds within each of the Providers.

MEHT MEHT have collected data which is publically available via NHS Choices. For December 2014 MEHT have revised their report to CQRG, reflecting their staffing escalation policy whereby 6 wards reported staffing fill rates below 80% and for January 2015 3 wards with rates below 80%

During December 2014 25 incidents were raised regarding staffing levels and fill rates within the inpatient and emergency areas, of these, 5 were identified as red flag events, as classified by NICE (July 2014) however no harm was recorded.

Likewise, January 2015 saw 11 incidents raised regarding staffing levels and fill rates within the inpatient and emergency areas, with 3 identified as red flag, again no harm was sustained although it was noted that IV medication, medication rounds and care rounding were delayed on one ward.

Recruitment continues with 34 overseas nurses recruited in December and January, with a further 33 registered nurses and 23 HCAs. The Trust also held a Recruitment Open Day on 14th February 2015. Latest estimate from MEHT highlights the need for an additional 40 nurses, to the estimates previously provided to Board.

PROVIDE December and January data will be provided to Board in May 2015, as it is not due to be reported to the CCG until April 2015. It will detail when available, the number of times that shifts fell below the agreed staffing levels and any incidents of harm pertaining to such shortfalls. The report will also detail the initial work that is being undertaken in relation to staffing levels and acuity in the integrated care teams. It is noted that there have been episodes of black capacity in the teams throughout the winter period secondary to staffing numbers.

Care Quality Commission (CQC)

MEHT had an announced visit in November 2014 and presently await the CQC report. There is a Quality Summit set for the end of March 2014 with the CQC to discuss

69 findings and any actions relating to this inspection. Further to this Mid Essex CCG are aware of an unannounced visit to the Emergency Assessment Unit in February 2015. Full details on these 2 inspections will be available to the Board in May 2015. If further information is made available prior to the Board in March and the completion of this report – a verbal update will be provided by the Director of Nursing.

4. RECOMMENDATION/S

The Board are asked to:

• Note the Safety and Quality Scorecard (Appendix A) • Approve the Quality Improvement Framework plan (Appendix B) • Note the Saville report update • Note the C difficile and MRSA bacteraemia performance • Note the Never Events performance • Note the position on Winterbourne • Note the forthcoming CQC Quality Summit • Note the Quarter 3 Serious Incident and Never event report

5. ASSOCIATED PAPERS

Appendix A - Quality and Safety Dashboard Appendix B - Mid Essex CCG Quality Improvement Framework Appendix C - Quarter 3 Serious Incident and Never Event report

70 Mid Essex Quality & Safety Dashboard Assurance criteria Detail Threshold(s) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Comments Operational Standards Clinically unjustified breaches (MEHT) Nil 0 0 0 0 0 0 0 0 0 0 0 Eliminating Mixed Sex Accommodation Clinically unjustified breaches (Provide) Nil 0 0 0 0 0 0 0 0 0 0 0 (EMSA) (National indicator) Clinically unjustified breaches (CHUFT) Nil 0 0 0 0 0 0 0 0 0 0 0 National Quality Requirements Annual = 0 MRSA Bacteraemia (MEHT) 1* 0 0 0 1* 0 0 0 0 0 2 Monthly = 0 Annual = 0 MRSA Bacteraemia (CHUFT) 0 0 0 0 0 0 0 0 0 0 0 Monthly = <0 Annual = 0 December and January cases deemed third party assignment Healthcare Associated Infections (HCAI) MRSA Bacteraemia (CCG) 1* 0 0 0 1* 0 0 0 2 1 5 Monthly = 0 by regional NHSE. Thus not assigned to CCG or MEHT Investigations has not highlighted evidence of patient to patient (National indicators) Clostridium Difficile infections (MEHT) Annual = 13 0 0 1 2 1 1 1 2 6 1 15 transmission Investigations has not highlighted evidence of patient to patient Clostridium Difficile infections (CHUFT) Annual = 20 1 2 0 1 2 2 2 3 3 9 25 transmission The ceiling breach position of the CCG is mirrored across many other EoE CCGs. North Essex HCAI Scrutiny Panel consider Mid Essex Clostridium Difficile infections (CCG) Annual = 56 1 7 6 10 9 11 4 3 4 5 60 cases individually and collectively to identify any commonalities and learning. Analysis will be presented in the Annual IPC Report in May Local Quality Requirements Each failure to notify the Relevant Person of a suspected or actual Reportable Patient Incident 0 breaches 0 0 0 0 0 0 0 0 0 0 0 (MEHT) Duty of Candour Each failure to notify the Relevant Person of a suspected or actual Reportable Patient 0 breaches 0 0 0 0 0 0 0 0 0 0 0 Incident(Provide) Domain 1 - Preventing people dying prematurely

Summary Hospital-level Mortality Indicator (SHMI) - HSCIC Data available up to March 2014 see comments Mortality SHMI < 100 105 April 2013 - March 2014 (published Oct 2014) Summary Hospital-level Mortality Indicator (SHMI) - Quarterly SHMI < 100 Data available up to March 2014 see comments 105.6 April 2013 - March 2014 (published Oct 2014) Figure CHUFT (rolling average) Domain 2 - Enhancing the quality of life of people with long-term conditions Domain 3 Helping people to recover from episodes of ill health or following injury Domain 4 - Ensuring that people have a positive experience of care PALS Contacts Numbers received by CCG No target 66 120 105 83 70 49 43 53 54 68 711 Compliments Number received by CCG No target 2 3 2 1 2 2 0 2 1 1 16 Please see patient experience report for detail Complaints Number received by CCG No target 4 11 8 7 8 2 5 3 4 4 56 FFT - Provide (Inpatients) Monthly Score 59 54 78 FFT - MEHT (Inpatients) Monthly Score 69 67 74 67 65 66 94% 94% 94% FFT - MEHT (A&E) Monthly Score 31 41 40 33 38 30 80% 84% 80% From October 2014 scores are no longer readily available, FFT - CHUFT (Inpatients) Monthly Score 74 75 70 70 71 73 96% 97% 94% therefore percentage recommended (Extremely Likely & Likely) will be recorded here in line with data shown on NHS Choices FFT - CHUFT (A&E) Monthly Score 44 45 40 27 37 39 77% 74% 76%

FFT - MEHT Staff (Work) Quarterly % recommended 70% 71% N/A Q3 Results not yet available

FFT - MEHT Staff (Care) Quarterly % recommended 82% 83% N/A Q3 Results not yet available

FFT - CHUFT Staff (Work) Quarterly % recommended 52% 88% N/A Q3 Results not yet available

FFT -CHUFT Staff (Care) Quarterly % recommended 67% 88% N/A Q3 Results not yet available Domain 5 - Treating and caring for people in a safe environment and protecting them from avoidable harm % of adult inpatients with VTE risk assessment on admission 95% 97.5% 97.1% 97.0% 97.6% 98.1% 97.7% 98.3% 99.1% 98.6% to hospital (MEHT) % of all adult inpatients with appropriate prophylaxis 95% 96.0% 96.0% 98.0% 97.0% 96.0% 90.1% 96.0% 95.0% 96.0% prescribed (MEHT) Percentage of all adult inpatients who have had an RCA Percentage of case notes examined. completed following a hospital acquired VTE (exceptions 100% 91.67% 98.85% Quarter 1 - 2 Avoidable HAT, apply) MEHT Quarter 2 - 1 Avoidable HAT % of adult inpatients with VTE risk assessment on admission 98% 97.0% 97.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.0% Query raised with PROVIDE as May previously scored as 93%. to hospital (Provide) Venous Thrombo-embolism (VTE) % of all adult inpatients with appropriate prophylaxis 95% 100% 100% 100% 100% 100% 100.0% 100.0% 100.0% 100.0% prescribed (Provide) (National Indicators) No of all adult inpatients who have had an RCA completed 100% 0 0 0 0 0 0 0 0 0 following a hospital acquired VTE (exceptions apply) Provide % of adult inpatients with VTE risk assessment on admission 95% 94.50% 93.70% 94.70% 93.80% 93.1% 93.9% 93.8% 94.4% 88.1% VTE is an area of Quality Action to hospital (CHUFT) % of all adult inpatients with appropriate prophylaxis 100% - quarterly 97.50% 99.20% 97.10% 98.80% 98.30% 98.8% 98.8% 97.5% prescribed (CHUFT) No of all adult inpatients who have had an RCA completed Query raised with Trust - awaiting outcome following a hospital acquired VTE (exceptions apply) CHUFT 71 Mid Essex Quality & Safety Dashboard Assurance criteria Detail Threshold(s) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Comments 4 X Wrong site surgery Number reported (all Mid providers) Nil 0 0 0 0 0 0 1 1 2 1 5 1 X Wrongly prepared high risk injectable medication Confirmed as: Never Events 3 x retained foreign object Number reported (CHUFT) Nil 0 1 0 0 2 0 1 0 1 0 5 1 x Wrong site surgery 1 x Wrong impant No. Open Serious Incidents (non pressure ulcer) 39 57 70 77 72 57 53 65 61 67 No. Open Serious Incidents that are inactive (non PU) 3 4 4 3 4 5 5 5 3 4 Serious Incidents (SI) No. Open Serious incidents (pressure ulcer) 21 15 13 22 24 16 16 11 15 25 No. new SIs (non pressure ulcer) in month 7 21 23 16 15 10 14 25 16 23 170 Adjusted to allow for 3 voided SIs in January No. new SIs (pressure ulcer) in month 18 6 7 11 9 5 13 5 16 10 100 MATERNITY PERFORMANCE - MID ESSEX HOSPITAL SERVICES NHS TRUST Births Total Number of Births 4700-4800 371 372 394 404 393 412 366 382 397 372 3,863 C Section Total Rate Planned + Emergency 24% 27.49% 26.88% 26.40% 31.19% 32.32% 32.04% 25.41% 29.84% 30.23% 27.96% Total MW/Birth Ratio 1:32 01:32 01:32 01:32 01:32 01:32 01:32 01:32 01:32 01:32 01:32 Staffing Levels Total Supervisor to MW Ratio 1:15 01:17 01:17 01:17 01:17 01:17 01:12 01:12 01:12 01:12 01:12 Total Eclampsia <3 1 0 1 1 0 0 0 0 1 0 Maternity Morbidity Total Unplanned Admission to ITU <3 1 0 0 1 2 1 0 0 0 0 Total Postpartum Hysterectomies ≤2 0 0 0 0 0 0 0 0 0 0 Total No. of Serious Incidents 1 0 4 8 1 1 2 2 3 1 1 Risk Management Total Failed Instrumental Delivery <2% 0.00% 0.27% 0.25% 0.00% 0.00% 0.00% 0.27% 0.00% 0.25% 0.00% Total Shoulder Dystocia <1% 0.54% 0.27% 0.76% 0.25% 0.76% 0.49% 0.82% 1.05% 0.50% 1.34% Complaints Total Number of Complaints (formal) <5/month 1 4 2 5 5 1 4 6 4 1 Smoking Total At Time of Delivery <11% 8.17% 5.68% 8.72% 7.56% 7.60% 5.09% 5.25% 6.81% 7.20% 6.22% Women who are Breastfeeding Total At 10 Days >75% 54.8% 59.2% 64.0% 66.0% 56.8% 62.2% 63.0% 64.9% 66.4% 72% INNOVATION

CQUIN PROVIDE Achievements as per CQUIN Scheme Requirements Met Only undertaking relevant mandatory CQUINS

Quarter 1 - 1 indicator not met within Medicines Optimisation and therefore not paid. Achievements as per CQUIN Scheme Requirements Met CQUIN MEHT Quarter 2 - Queries remain for 3 indicators (Frailty, Sepsis and Medicines Optimisation)

CQUIN CHUFT Achievements as per CQUIN Scheme Requirements Met

Key Report not due in month Report not received Area of concern - considerably outside threshold/trajectory Area of concern - slightly outside of threshold/trajectory No concern - within threshold/trajectory

Mid Essex CCG – Quality Improvement Framework

Mid Essex updated response to the reports of the Mid Staffordshire NHS Foundation Trust public inquiry, ‘Patients First and Foremost’ and the initial Government response; A Promise to Learn – a Commitment to Act; complimented with additions from the Berwick Report and Keogh review into the quality of care and treatment at 14 hospital Trusts.

73 Executive Summary: This report provides a summary of the main issues raised in the second report from the public inquiry into the events at Mid Staffordshire hospital carried out by Robert Francis Q.C including Hard Truths from the Governments final response, also those raised by, A Promise to Learn – a Commitment to Act, Don Berwick’s review into patient safety and Professor Sir Bruce Keogh’s review of 14 hospitals that were mortality outliers. It includes the main recommendations from the report which have significance for Mid Essex CCG. It details the updated action plan (initial plan 2013) the CCG is presently working on to ensure that all recommendations are fully considered and responded to at board level.

The report concludes that a fundamental change in culture is required to prevent a system failure from happening again and many of the changes can be implemented within the current system. The report makes 290 recommendations, which focus primarily on securing a greater cohesion and culture across the system; however no single recommendation should be regarded as the solution to the many concerns identified: • Ensuring implementation of the inquiry’s recommendations sets out requirements for oversight and accountability to ensure implementation of its proposals. • Creating the right culture, which aspires to prevent harm to patients and provide excellent care and a common culture of caring, commitment and compassion. • The importance of making patients the main priority in all that the healthcare system does. • It proposes significant changes to the current division of regulatory responsibilities and proposes regulating the healthcare systems governance. • Commissioning for standards contains 21 recommendations specifically for commissioning organisations, with six of these specifically around the role of commissioners in performance management and oversight of quality.

74 • There are also other recommendations which though not specific to commissioning, impact on the CCG’s role.

Don Berwick’s review of patient safety, corrected the ambition to be the ‘continual reduction’ of harm. It concluded that rules and regulations have a role in making care safer, but they pale into insignificance when compared to the power of constant learning. The report found that the NHS should: • Abandon blame as a tool and trust the goodwill and good intentions of the staff. • Recognise that incorrect priorities do damage; quantitative targets should not replace the goal of better care, the central focus must always be on patients. • Warning signals especially the voices of patients and carers must be listened too. • Transparency is essential expect and insist on it.

The Inquiry triggered investigations into 14 other NHS organisations that had been persistent outliers on mortality indicators, the model was adopted by the CQC for inspection of acute providers.

75 Key Recommendations for CCGs: • Commissioners have a responsibility for monitoring the delivery of standards and quality on behalf of and in partnership with patients. • Commissioners should agree a method for measuring compliance and redress for non-compliance of standards and when selecting indicators and the means for measuring compliance, commissioners must closely engage with patients to ensure their expectations and concerns are addressed. • Commissioners must have the capacity to monitor the performance of every commissioning contract on a continuing basis and must require the providers to provide quality information. • Commissioners must have the capacity to undertake their own or Independent audits, inspections and investigations and should be entitled to intervene in the management of a complaint on behalf of a patient where it appears it is not being managed satisfactorily. • Commissioners should be accountable to the public for the scope and quality of the services they commission and fully involve and engage the public in their work. • Commissioners should have powers of intervention when substandard or unsafe services are being provided.

The following action plan has been updated and developed from the initial 2013 plan to address the recommendations of the reports and aims to build on the quality and safety agenda already identified within the CCG.

It will also be important that the CCG develops and monitors not only this action plan but the action plans of providers. Within the health economy the CCG will be responsible for providing a system wide update to the Mid Essex CCG Quality and Governance Committee and Board.

Mid Essex CCG Commitments An open culture (transparency, openness and candour) Quality and Safety first (getting the basics right) Patient feedback on the services that we commission will be routinely We will ensure that the services we commission will demonstrate how collected and published. We will use this data to act like a smoke alarm to safety issues such as infection control, management of serious untoward detect service failures. We will also highlight patients who receive good incidents, treatment interventions and the prevention of pressure ulcers care as well as bad. are addressed. We will use this feedback to address issues of concern with any of our The minimum standards set by the Care Quality Commission (CQC) providers. should not be the standard for contracting services. As the CCG our aim As a CCG we will welcome complaints, be open in acknowledging service will always be to contract for best practice standards. difficulties, and encourage providers to do the same. The care that we commission needs to be of the highest standard and We will make comparable information freely available at hospitals, clinically effective and take into account National Institute of Clinical surgeries and care homes and we will help patients to make judgments Excellence (NICE) quality standards and new innovations in clinical care based on objective data about standards and outcomes. and service delivery. Feedback from GPs and Practice Nurses will be collected through an The CCG is committed to ensuring that children and vulnerable adults are electronic system and processed by our Lead Nurse and Lead GP for not at risk from being abused or neglected and receive the care they Quality. require. Safeguarding is an important function through commissioning and We will have active and on-going engagements with patients, the public through the delivery of care from those contracted by us. and all interested stakeholders. We will use their feedback and patient stories to both challenge and improve clinical services.

Ensuring robust accountability Contracts that work for patients and clinicians We will scrutinise and ensure we have the capacity to undertake audits, We will make it clear the standard of services that we expect to be inspections and investigations of individual/ group cases and clinical delivered by all of our providers. services. We will ensure that enhanced quality standards are embedded in our We will ensure our Clinical Leaders will be at the heart of our Quality and contracts and that we incentivise providers to constantly improve and safety surveillance. deliver the highest possible care. Clinicians from the CCG will be visible on provider sites. The CCG will not We will ensure that quality standards are agreed by the doctors and be a distant ivory tower organisation passing judgement from on high but nurses who deliver the service. will work in partnership with the hospitals and community services The contract standards will be monitored and both the sanctions and providing care to patients. incentives will be understandable and acceptable to clinical leaders and We will at all times be accountable for the scope and quality of all the patients who receive clinical services. services that we commission. We will ensure clinical leadership is in place in all of our providers services.

77 Summary of Recommendation as at February 2015

Number of Recommendations Red Amber Green 28 1 4 23

No Theme Recommendation CCG Position CCG Actions 2013 Evidence February Owner RAG presented in 2013 2015 F2 Adoption and A common set of core CCG core values System Leadership Staff Handbook AO Amber B2 demonstration of values and standards identified and shared Group to lead by As maturing K8 shared culture shared throughout the with partners. example. Away day organisation and values system; working on Staff away day to Request Providers Board agreed level of embedding Leadership at all levels from explore values to submit risk willing to take process and ward to the top of the completed and reported organisational procedure Department of Health, back values to the CCG Appraisal system committed to and capable of to ensure sharing embedded involving all staff with those Strategy focussed throughout the values and standards; appraisal system system Leadership academy developed to ensure courses made A system which recognises staff understand the available to all staff and applies the values of organisations values through appraisals / transparency, honesty and are reflected in staff PDP’s candour attitudes and behaviours. Constitution updated Freely available, useful, and approved at reliable and full information New appraisal system Board. on attainment of the values implemented. and standards Working on OD strategy for A tool or methodology such dissemination across as a cultural barometer to organisation measure the cultural health of all parts of the system 360o with all stakeholders

Staff Engagement Group

78 No Theme Recommendation CCG Position CCG Actions 2013 Evidence February Owner RAG presented in 2013 2015

F7 Change All NHS staff should be Staff away day re Contracts to be Remains Work in DCS Red contracts of required to enter into an values and vision. reviewed, including Progress employment to express commitment to a commitment to include an abide by the NHS values MECCG constitution abide by NHS express and the Constitution, both of completed values and commitment to which should be constitution in line abide by the incorporated into the with CCG NHS values and contracts of employment. constitution. the Constitution To consult with staff around change to JD to support CCG values.

F17 Involvement in The NHS Commissioning CCG has been working Continued Regular reports and DON Green the design of Board together with Clinical closely with NHS collaboration with attendance to QSG by AO new quality Commissioning Groups England to enhance NHS England to AO and DON DCC standards in should devise enhanced quality across Mid develop new collaboration quality standards designed Essex – Quality quality standards. Within MECCG with the NHSCB to drive improvement in the Surveillance Groups in Inclusion of commissioned health service. place, whereby the monitoring of services Failure to comply with such CCG has membership. compliance with the contractual standards should be a these standards to monthly/quarterly matter for performance The 2013/14 contracts be prominent within Clinical Quality Review management by provide contract levers the performance Group meetings with commissioners rather than enabling effective management providers monitor KPIs the regulator, although the performance framework. To and CQUIN schemes latter should be charged management to be in include audit, within their contract. with enforcing the provision place. reviews and by providers of accurate potential contract Escalations to SPRG information about penalties. compliance to the public. Pre Risk Summit MEHT F18 Involvement of It is essential that GPs and Director of Develop links with Board comprises of a DON Green clinicians in the professional bodies in which Nursing have professional bodies clinical majority formulation of doctors and nurses have developed standards once systems and the standards confidence are fully involved and inform workforce processes have Medical Director 79 No Theme Recommendation CCG Position CCG Actions 2013 Evidence February Owner RAG presented in 2013 2015 and means of in the formulation of redesign. been agreed Director of Clinical measuring standards and in the means commissioning compliance of measuring compliance. requires clinical qualification

F38 Ensure The Care Quality CCG system in place to Ensure complaints Quarterly Patient DON Green complaints Commission should ensure link complaints with monitoring experience report monitoring to as a matter of urgency that other sources of incorporates detailing numbers of incorporate it has reliable access to all intelligence. analysis of formal complaints and analysis of the useful complaints narrative as well as PALs contacts, narrative as well information relevant to Use information from numbers themes and as numbers assessment of compliance ‘friends and family test’, Quality reports escalations of with fundamental standards, CQUIN and intelligence from Trusts should concern. and should actively seek gathered from walk clearly this information out, around and informal demonstrate any Quality Surveillance probably via its local sources to inform problems with Group agendas and relationship managers. Any monitoring. compliance papers bureaucratic or legal standards obstacles to this should be Regular CQC meetings Quality and removed. with CCG in place to Governance share intelligence Committee papers and agendas F120 Learning From Commissioners should 2013/14 contract Patient stories to MECCG Board has DON Green B6 Complaints require access to all requires providers to be taken to Board. had patient stories to complaints information as submit regular Board since 2014 and when complaints are complaint activity Providers to made and should receive information. Providers demonstrate Provider reports complaints and their continue to report into changes in practice reviewed at CQRG on outcomes as near to real the Clinical Quality following learning a quarterly basis, time basis as possible. This Review Groups. from complaints. including means commissioners demonstration of should be required by the CCG able to changes following NHS Commissioning Board performance manage complaints and PALs to undertake the support complaints using the contacts and oversight of GP’s in this NHS Complaints Policy area and be given the as a framework of best resources to do so. practice

80 No Theme Recommendation CCG Position CCG Actions 2013 Evidence February Owner RAG presented in 2013 2015 F123 Responsibility GPs need to undertake a The contractual Establish fully GP’s on Board MD Green B5 for monitoring monitoring role on behalf of monthly Clinical Quality functioning delivery of their patients who receive Review Group information system Primary care forum standards and acute hospital and other meetings attended by for quality represented by GP’s quality specialist services. They CCG GP with providers monitoring across from each locality should be an independent, monitor KPIs and GP network professionally qualified CQUIN schemes within GP Newsletter check on the quality of the contract. This is service, in particular in also a forum for raising GP representation at relation to an assessment of other quality issues, as CQRG’s outcomes. They need to raised by GPs and have internal systems other services. GP Briefings enabling them to be aware of patterns of concern, so Quality Team that they do not merely treat strengthened and CCG each case on its individual based to progress merits. They have a quality agenda. responsibility to all their Identified GP lead for patients to keep themselves quality & safety in informed of the standard of place. service available at various Informal clinical providers in order to make meeting between CCG patients’ choice reality. A GP’s and Trust GP’s duty to a patient does Clinicians. not end on referral to Hosted joint learning Hospital, but is a continuing events by EQUIP. relationship. They will need to take this continuing partnership with their patients seriously if they are to be successful commissioners.

F124 Duty to require The commissioner is Provider organisations Review information Triangulation of quality DON Green and monitor entitled to and are required to be from quality at providers occurs delivery of should, wherever it is registered and systems to inform through the Quality fundamental possible to do compliant with CQC CQUIN targets and and Governance standards so, apply a fundamental minimum standards. future KPIs to Committee and Quality safety and incentivise quality. Surveillance Group. 81 No Theme Recommendation CCG Position CCG Actions 2013 Evidence February Owner RAG presented in 2013 2015 quality standard in respect Contracts include Strengthen use of of each item of service it is schedules of quality local incentive MECCG able to commissioning. In relation and performance section of contract. evidence to each such standard, it standards, information commissioning should agree a method of requirements and intentions and measuring Compliance and CQUIN schemes contracting priorities redress for noncompliance. (where standards are from quality are born Commissioners should often higher than CQC from quality concerns consider whether it would minimum standards). and areas requiring incentivise compliance by CQUIN schemes, in strengthening for each requiring redress for particular, provide an individual provider. individual patients who have incentive for providers received substandard to improve quality. Examples- discharge service to be offered by the CQUINs 2015/16, provider. These must be National contract local never event consistent with fundamental provides redress for hospital acquired standards enforceable by patients in certain grade 4 avoidable the Care Quality circumstances pressure ulcers Commission. 2015/16 North Essex Harm Free Care Collaborative in place – involving all providers.

F125 Responsibility In addition to their duties Provider organisations Ensure soft MECCG able to DCC Green for requiring with regard to the are required to be intelligence and evidence and monitoring fundamental standards, registered and hard data are used commissioning delivery of commissioners should be compliant with CQC to inform the intentions and enhanced enabled to promote minimum standards. contracts process. contracting priorities standards improvement by requiring from quality are born compliance with enhanced Contracts include from quality concerns standards or development schedules of quality and areas requiring towards higher standards. and performance, strengthening for each information individual provider. requirements, CQUIN schemes which are all Examples- discharge reviewed and re- CQUINs 2015/16, negotiated on an local never event annual basis. hospital acquired 82 No Theme Recommendation CCG Position CCG Actions 2013 Evidence February Owner RAG presented in 2013 2015 grade 4 avoidable pressure ulcers 2015/16 F126 Preserving The NHS Commissioning Adherence to the Quality transition DON Green corporate Board and local National Quality handover document memory commissioners should Board’s guidance on written (PCT to CCG) develop and oversee a code Maintaining of practice for managing Quality during the Preserved corporate organisational transitions, to transition. memory ensure the information conveyed is both candid Review of policies to and comprehensive. This ensure safe transition. code should cover both transitions between Quality hand over commissioners and document produced to guidance for commissioners support transition. on what they should expect Hand over document to see in any organisational presented to CCG transitions amongst their Board. providers. F127 Resources for The NHS Commissioning Quality management MECCG Structure AO Green Scrutiny Board and local function provided within Charts commissioners must be the CCG’s overall provided with the running cost allowance. 2014/15 & 2015/16 infrastructure and the Contracts inc. support necessary to enable KPIs/CQUINS/ a proper scrutiny of its Reporting providers’ services, based requirements on sound commissioning contracts, while ensuring Provider CQRGs providers remain responsible and Provider Quality accountable for the services Accounts they provide.

F128 Expert Support Commissioners must have Management support Continue to pursue From October 2014:- DCC access to the wide range of provided through collaborative, Adult CHC Green experience and resources combination of CCG mutually enhancing Children’s Continuing necessary to undertake a employed staff and relationships Health 83 No Theme Recommendation CCG Position CCG Actions 2013 Evidence February Owner RAG presented in 2013 2015 highly complex and contract with CSU. Contracting technical task, including Collaborative CCG HR specialist clinical advice and working across North Individual Funding procurement expertise. Essex in place Request/Exceptional When groups are too small Clinical Expertise in Cases to acquire such support, Governing Body Procurement they should collaborate with A register of clinical expertise in house others to do so. expertise is available to since demise of the organisation. CECSU. Where economical shared on hosting arrangement e.g. Information Governance Essex wide F129 Ensuring In selecting indicators and The monthly contract Within MECCG DON Green Assessment and means of measuring Clinical Quality Review CQRGs for all commissioned enforcement of compliance, the principal Group monitors quality providers services fundamental focus of commissioners KPIs and CQUIN the contractual standards should be on what is schemes and is a Quality Committee monthly/quarterly through reasonably necessary to forum for raising other Clinical Quality Review contracts safeguard patients and to quality issues. Contract Group meetings with ensure that at least performance providers monitor KPIs fundamental safety and management in place and CQUIN schemes quality standards are as required within their contract. maintained. This requires close engagement with System that links Escalations to SPRG patients, past, present and complaints to quality potential, to ensure that information being Agenda and papers to their expectations and developed to ensure Quality and concerns are addressed. trends are identified. Governance Committee and Board Friends and Family Test, Focussed Patient Experience date collection in CQUIN targets for all Trusts.

CCG staff intelligence 84 No Theme Recommendation CCG Position CCG Actions 2013 Evidence February Owner RAG presented in 2013 2015 system. F130 Relative Commissioners – not Clear outcomes in CCG Workshop to Commissioning DCS Green position of providers – should decide integrated plan. gather local intentions 2015/16 commissioner what they want to be Monthly meeting with expertise to agree and provider provided. They need to take each provider. commissioning JSNA review DON into account what can be intentions for provided, and for that CCG currently sets out 2014/15 Discharge workshop purpose will have to consult commissioning for CQUIN 2015/16 clinicians both from intentions annually with CQUIN workshop potential providers and local providers. for 2014/15 Contractual meeting elsewhere, and to be willing Commissioning based CQUINS organised minutes 2015/16 to receive proposals, but in on health needs of Oct 2013 the end it is the population through a commissioner whose locality approach. decision must prevail. Local clinicians are engaged with Lead GP’s in the development of service models through strategic forums

F131 Development of Commissioners need, Continue to engage in Continue to work Regular reports and AO Green alternative wherever possible, to Quality collaboratively with attendance to QSG by sources of identify and make available Surveillance Groups other CCG’s. AO and DON provision alternative sources of and risk summits to provision. This may mean share intelligence and Pre risk summit – that commissioning has to performance and MEHT November be undertaken on behalf of quality issues on those 2014 consortia of commissioning specialist providers with groups to provide the whom we commission System Review Group negotiating weight collaboratively. necessary to achieve a Collaborative Collaborative negotiating balance of commissioning commissioning: power with providers. agreements in place Mental heath with other CCGs LD Ambulance Ramsay Health F132 Monitoring Tools Commissioners must have Monthly contract Quality intelligence Walk rounds schedule ALL EXEC Amber the Clinical Quality system to be and reports DIRECTO 85 No Theme Recommendation CCG Position CCG Actions 2013 Evidence February Owner RAG presented in 2013 2015 capacity to monitor the Review Group monitors developed to utilise RS performance of Performance/quality all information and Independent reviews every commissioning KPIs and CQUIN escalate when necessary contract on a schemes and is a appropriately. continuing basis during the forum for raising other Contract audit contract quality issues, utilising Design mechanism period. up to date quality and for smaller performance contractual review Such monitoring may information. include requiring quality Design an information generated by Announced and enhanced review the provider. unannounced walk system for around schedule in commissioned Commissioners must also place services have the capacity to CCG Quality team is undertake their own (or established with the independent) audits, prime focus on inspections, and delivering these investigations. outcomes.

The possession of accurate, Quality collaborative relevant, and useable agreed leads for information from which the specialist areas safety and quality of a service can be ascertained is the vital key to effective commissioning, as it is to effective regulation.

Monitoring needs to embrace both compliance with the fundamental standards and with any enhanced standards adopted.

F133 Role of Commissioners should be Proactive PALS and Updating PALS Complaints Policy in DON Green Commissioners entitled to intervene in the complaints team with leaflets and place in Complaints management of an posters and leaflets posters. 86 No Theme Recommendation CCG Position CCG Actions 2013 Evidence February Owner RAG presented in 2013 2015 individual complaint on across all GP surgeries Quarterly Patient behalf of the patient where it and a number of public experience report appears to them it is not places. detailing numbers of being dealt with NHS Complaints Policy formal complaints and satisfactorily, while in place for CCG and PALs contacts, respecting the principle that all Providers. themes and it is the provider who has escalations of primary responsibility to Complaints, themes concern. process and respond to and trends etc. complaints about its monitored at CQRG Quality Surveillance services. and Quality & Group agendas and Governance papers Committee. Quality and Governance Committee papers and agendas F134 Role of Consideration should be CCG PALs Team This is currently not Advocacy contract in DON Green commissioners given to whether currently supports widely publicised place via ECC utilised in provision of commissioners should be complainants. and will form part by CCG for use of support for given responsibility for of the new PALs NHS Patients complainants commissioning patients’ Team members both leaflets and advocates and support had advocate training. posters. services for complaints against providers. CCG able to sign post independent advocacy for patients not wishing to use PALs.

F135 Public Commissioners should be Three lay members on New proposed DCS Amber B3, 7 accountability accountable to their public the Board each with engagement model to of for the scope and quality of dedicated portfolios, Board commissioners services they commission. one Lay member is the and public Acting on behalf of the lead for patient & public Consultations on engagement public requires their full engagement with an Immediate care involvement and additional GP who also services engagement. undertakes quasi lay Service restriction incl member role. IVF There should be a There is a Mid Essex CCG 5 year strategy 87 No Theme Recommendation CCG Position CCG Actions 2013 Evidence February Owner RAG presented in 2013 2015 membership system Patient Reference CCG 2 year plan whereby eligible members Groups with Tier 3 obesity of the public can be membership groups in involved in and contribute to each locality supported Public meetings twice the work of the by Executive Director a year commissioners. and PPE Champions. There should be lay members of the Board held in public at commissioner’s board. each meeting with locality of Board Commissioners should meeting shared across create and consult with Mid Essex. patient forums and local representative groups. Annual General Individual members of the Meeting date being public (whether or not agreed in members) must have September/October. access to a consultative process so their views can Governance processes be taken into account. in place to ensure transparency of There should be regular decision making which surveys of patients and the audited by internal public more generally. audit.

Decision-making processes A number of focus should be transparent: groups have been held decision making bodies across the locality to should hold public familiarise the meetings. community with the CCG. Commissioners need to create and maintain a A PPE Strategy refresh recognisable identity, which is underway and a becomes a familiar point of detailed PPE action reference for the plan being developed community. Work is planned to integrate better with PPGs and other 88 No Theme Recommendation CCG Position CCG Actions 2013 Evidence February Owner RAG presented in 2013 2015 provider PPE work across Mid Essex.

F136 Public Commissioners need to be CCG’s established as MECCG Authorised as DCS Amber B7 Accountability recognisable public bodies, statutory bodies on 1st assured with support visibly acting on behalf of April 2013. the public they serve and Nurses in uniform with a sufficient Patient public infrastructure of technical involvement explicit in Corporate identity support. Effective local CCG action plan. commissioning can only Communications team work with effective local Locality commissioning in place monitoring, and that cannot system in place. be done without Public events prior Evolving knowledgeable and skilled CCG becoming a communications local personnel engaging statutory body. strategy with an informed public. Training in PPE being planned for all commissioners and clinical leads as a part of the PPE action plan so that PPE will become an integral part of the commissioning process and cycle for all service commissioning.

F139 The need to put The first priority for any Current contracts have Current contractual Within MECCG DON Green B3 patients first at organisation charged with quality standards arrangements commissioned all times responsibility for including CQUIN. services performance management the contractual of a healthcare provider Quality Systems have monthly/quarterly should be ensuring that been designed to Clinical Quality Review fundamental patient safety address these issues. Group meetings with and quality standards are providers monitor KPIs being met. Such an Quality and safety walk and CQUIN schemes organisation must require arounds are patient within their contract. 89 No Theme Recommendation CCG Position CCG Actions 2013 Evidence February Owner RAG presented in 2013 2015 convincing evidence to be focused. available before accepting Compassion in that such standards are Providers share PPE Practice reports being complied with. work plans as part of quality contractual Escalations to SPRG monitoring. and Contractual Route

Providers demonstrate Commissioner Serious achievements in quality Incident and Never accounts. Event scrutiny via North Essex SINE It is planned for the panel CCG to work more closely in the PRG Quality Assurance through the PPE work Visits – schedules and plan with key providers reports to around their PPE CQRG/Quality and structures. Governance Committee F140 Performance Where concerns are raised The CCG participates Further Regular reports and DON Green managers that such standards are not in the Essex Quality development work attendance to QSG by working being complied with, a Surveillance Group required to AO and DON constructively performance management where local intelligence maximise role of with regulators organisation should share, is shared with a the QSG. Pre risk summit MEHT wherever possible, all number of regulators relevant information with the and Commissioners. relevant regulator, including information about its The CCG meets judgement as to the safety regularly with the CQC of patients of the healthcare to focus on delivery of provider. local provision.

F141 Taking Any differences of The CCG participates Further Regular reports and DON Green responsibility for judgement as to immediate in the Essex Quality development work attendance to QSG by quality safety concerns between a Surveillance Group required to AO and DON performance manager and where local intelligence maximise role of a regulator should be is shared with a the QSG. discussed between them number of regulators and resolved where and Commissioners. 90 No Theme Recommendation CCG Position CCG Actions 2013 Evidence February Owner RAG presented in 2013 2015 possible, but each should recognise its retained The CCG meets individual responsibility to regularly with the CQC take whatever action within to focus on delivery of its power is necessary in the local provision. interests of patient safety.

F142 Clear lines of For an organisation to be A Monthly contract A number of flows Within MECCG DCC Green responsibility effective in performance Clinical Quality of information are commissioned DON supported management there must Review Group monitors based on person to services by good exist unambiguous lines of Performance/quality person rather than the contractual information referral and information KPIs and CQUIN process. Need to monthly/quarterly flows flows, so that the schemes and is a develop Clinical Quality Review performance manager is not forum for raising other sustainable Group meetings with in ignorance of the reality. quality issues, utilising process that is not providers monitor KPIs up to date quality and reliant on and CQUIN schemes performance individuals. within their contract. information. Escalations to SPRG Number of flows of information are based on person to person rather than process. F143 Clear Metrics on Metrics need to be Each contract has a Process DCC/ Green Quality established which substantial number of commenced to Regular reports and DON are relevant to the quality of quality key ensure all data is attendance to QSG by care and performance indicators gathered in one AO and DON patient safety across the which is based on place. service, to allow norms to national evidence Within MECCG be established so that practice. These are commissioned outliers or progression to monitored at CQRG services poor performance can be where poor the contractual identified and accepted as performance is monthly/quarterly needing to be fixed. addressed. Clinical Quality Review Group meetings with Benchmarking data is providers monitor KPIs utilised to measure and CQUIN schemes local performance e.g. within their contract. NRLS. 91 No Theme Recommendation CCG Position CCG Actions 2013 Evidence February Owner RAG presented in 2013 2015 Escalations to SPRG Use of quality surveillance meetings. Process commenced to ensure all data is gathered in one place.

F174 Candour about Where death or serious Each contract has Currently assessed Duty of Candour – DON Green B5 Harm harm has been or may have specific KPI in relation on individual basis explicit in all providers been caused to a patient by to this recommendation need to consider contracts in line with an act or omission of the with significant financial sustainable audit CQC requirements. organisation or its staff, the penalty for failure to approach. patient (or any lawfully adhere. Monitored on a entitled personal monthly basis (KPI) representative or other Monitoring of all SI and through CQRG authorised person) should StEIS reportable be informed of the incident, incidents through Duty of Candour given full disclosure of the contract. checked individually surrounding circumstances on each serious and be offered an All cases reviewed by incident submission – appropriate level of support, clinical leads. reviewed by clinical whether or not the patient or lead representative has asked for this information. Duty of Candour audit

F208 Strengthening Commissioning Currently each provider Provider Assurances received DON Green identification of arrangements should has its organisational organisations to be from providers in healthcare require provider requirements which are required to ensure CQRG via the support organisations to ensure by not influenced by the staff are clearly compassion in practice workers and means of identity labels and CCG. identifiable through work streams on easy nurses uniforms that a healthcare the contracting identification of support worker is easily process. unregisters/registered distinguishable from that of Include uniform staff. a registered nurse. guide in contract.

F253 Access to quality The information behind the Quality and safety Liaise with risk lead Ward based DON Green B7 and risk profile quality and risk profile as dashboard forms part in trusts to ensure scorecards in place in K2 well as the ratings and of the quality & safety this information is MEHT – able to methodology should be board report which is available. identify and triangulate 92 No Theme Recommendation CCG Position CCG Actions 2013 Evidence February Owner RAG presented in 2013 2015 placed in the public domain held in public. quality concerns as far as is consistent which CQUIN includes maintains legitimate element to develop Staffing boards and confidentiality of such ward based quality metrics information together with scorecards to be available on each appropriate explanations to publically displayed ward for public review enable the public to in each clinical understand this tool. area.

93 KEY

Abbreviation Position Position Held By (@ February 2015) AO Accountable Officer Caroline Rassell DON Director of Nursing and Quality Carol Anderson DCC Director of Clinical Commissioning Dan Doherty DCS Director of Corporate Services Viv Barnes MD Medical Director Donald McGeachy CFO Chief Finance Officer Dee Davey

Abbreviation F Francis Report https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/279124/0947.pdf B Berwick Report – A Promise to Learn - A Commitment to Act https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf K Keogh Review http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/outcomes/keogh-review-final-report.pdf

Berwick Recommendation Summary Keogh Ambitions Summary B1 Reduction in harm through learning K1 Demonstrable progress towards reducing avoidable deaths B2 Leadership for quality of care, patient safety in particular K2 Confident and competent use of data, accessible and easy to use B3 Patient and Public involvement K3 Patient and Public Involvement B4 Staffing levels, now and in the future K4 Confidence in CQC B5 Quality and patient safety training for all K5 No hospital to be isolated B6 The NHS should become a learning organisation K6 Nurse staffing and skill mix B7 Transparency should be complete, timely and unequivocal K7 Junior doctors and clinical leaders B8 All organisations should seek out the patient and carer voice K8 Engaged staff B9 Clear and Simple regulatory systems B10 Responsive regulation of organisations

Mid Essex Serious Incident and Never Event Report Quarter 3; October 2014 – December 2014.

This report provides a thematic overview of all Serious Incidents reported from Mid Essex in October – December 2014.

Background

In 2014-2015 all Mid Essex commissioned providers are required to report Serious Incidents in line with the North Essex CCG’s Serious Incident and Never Event Policy. The Provider, in agreement with the CCG, applies a grade of one or two to each incident depending on severity (two being the more serious). In addition providers are given the ability to report incidents with a grading of zero where there may be discrepancies as to whether an incident is serious enough for reporting through the formal process. Once an initial investigation is completed the CCG and provider jointly agree if the case is to be de-escalated or raised as a serious incident.

Serious Incidents are required to be investigated and reported within 45 working days with the process being overseen by the CCG. Serious Incidents that may indicate the need for a more in-depth, independent, investigation may require an allowance of up to 26 weeks, as negotiated between the provider and MECCG.

Never events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers. These are reportable as level 2 Serious Incidents and require high level scrutiny and monitoring.

This report has been broken down into three key sections as follows:

1. Review of non-pressure ulcer serious incidents reported during October 2014-December 2014

2. Pressure ulcer serious incidents reported during October 2014-December 2014

3. Never Events reported during October 2014-December 2014

Appendix 1. Details of each non pressure ulcer serious incident reported October 2014 - December 2014

95 1.0 Review of [Non – Pressure Ulcer] Serious Incidents reported during October 2014 - December 2014

Total Level 0 Level 1 Level 2

Oct-14 0 13 1 14

Nov-14 0 23 2 25

Dec-14 0 13 3 16

Total 0 49 6 55

There were a total of 55 non pressure ulcer serious incidents reported in Mid Essex October 2014 – December 2014. As detailed in the table above, 50 of the incidents were graded as level 1 and 5 were graded as level 2. Of the 5 level 2 incidents 3 have been categorised as never events. 5 further incidents which were raised were subsequently de-escalated after being identified as not meeting SI criteria 1.1 Breakdown by Organisation The following table provides a further breakdown of the spread of non–pressure ulcer incidents across the various sectors and localities.

Sector Provider

14 14 14

Oct Nov Dec Total Acute MEHT 12 19 13 44 Provide 0 5 1 6 Community BCH 0 1 0 1

Out of Hours Primecare 0 0 0 0 CCG Mid Essex 1 0 2 3 CSU CHC 0 0 0 0 Hospice Farleigh 0 0 0 0 Patient Transport ERS 0 0 0 0 Ramsay - Private Hospital 1 0 0 1 Springfield

14 25 16 55

The highest reporting organisation is identified as MEHT with 44 non pressure ulcer serious incidents. MEHT would be expected to be the highest reporting organisation, out of the Mid Essex CCG commissioned services, due to size of the Trust and the number of services they provide.

1.2 Categories Of the 55 serious incidents raised in the Mid Essex locality they are noted to relate to the following StEIS categories

Month

StEIS Incident Type TOTAL

MEHT PROVIDE CCG RAMSAY BCH Abscond 0 1 0 0 0 1

C diff. and Healthcare acquired infections 2 0 0 0 0 2

Confidential Information Leak 3 2 0 0 0 5

Delayed Diagnosis 4 0 0 0 0 4

Drug Incident (Chemotherapy) 1 0 0 0 0 1

Drug Incident (General) 1 0 0 0 0 1

Drug Incident (Insulin) 1 2 0 0 0 3

Failure to act upon test results 1 0 0 0 0 1

Failure to obtain consent 0 1 0 0 0 1

Infected Healthcare Worker 1 0 0 0 0 1

Maternity Services – Unexpected 1 0 0 0 0 1 admission to NICU

Maternity Services - Unexpected 1 0 0 0 0 1 admission to ITU

Maternity Services – Unexpected 1 0 0 0 0 1 neonatal death

MRSA Bacteraemia 0 0 2 0 0 2

Other 4 0 0 0 1 5

Safeguarding Vulnerable Child 1 0 0 0 0 1

Screening Issues 1 0 0 0 0 1

Slips / Trips / Falls 10 0 1 0 0 11

Sub-optimal care of the deteriorating 4 0 0 0 0 4 patient

Transfusion Incident 1 0 0 0 0 1

Surgical Error 1 0 0 1 0 2

Unexpected death of inpatient (not in 2 0 0 0 0 2 receipt)

Wrong Site Surgery 3 0 0 0 0 3

44 6 3 1 1 55

Appendix 1 provides details of all non-pressure ulcer serious incidents reported during quarter 3 2014/15

1.3 Themes Of the 55 non-pressure ulcer serious incidents reported across Mid Essex slips/trips/falls is the highest ranking, with 11 reported incidents (20%). This remains a high priority and concern for the CCG.

Slips/Trips/Falls There were only 12 moderate or severe harm patient falls reported in Mid Essex during 2012-13. Work was undertaken with all providers to improve the reporting of moderate and severe harm injuries following an inpatient fall, which has culminated in improved reporting. It is important to appreciate this increase in falls reporting is due to better reporting at providers and not due to an actual increase in serious incident falls. Such candid, open reporting is the first step towards understanding of the causation of falls, learning from these falls and putting in place robust fall prevention strategies. The majority of inpatient falls occurred at MEHT in the emergency and care of the elderly settings. MEHT now utilise a bespoke falls RCA which has enabled the trust to look at each individual fall and understand contributory factors and possible causations. RCAs undertaken have identified concerns with completion of risk assessments for high risk patients, placement of high risk patients in the ward (side rooms) and care of the acutely confused patient/dementia patient as common themes. Each fall is also reviewed by a falls panel, which determines if the fall is avoidable and owns the overarching action plan for falls. This action plan is presented to CQRG on a quarterly basis. In the September CQRG MEHT presented their action plan alongside a Trust Falls Delivery Plan, which introduced the identified changes required to minimise the likelihood of falls resulting in significant harm, improve care provided to patients post fall, including minimising the risk of falls reoccurring whilst an inpatient at MEHT and ultimately improve patient safety and experience. The plan was accepted by the CCG and the key outcome measure was to reduce falls by a minimum of 20% was noted. The CCG have considered the concerns with falls during 2014/15 when contracting for quality in 2015/16. There are specifically built KPIs being negotiated presently to improve work around the prevention of falls in the inpatient setting. The CCG are also working with a Specialist Public Health trainee who is auditing falls at MEHT for Q1 & 2 presently. We anticipate results to be available in Q1 2015/16.

1.4 Level 2 Serious Incidents

Month Incident Provider Reference Description Level Report- date ed

MEHT STEIS Delayed diagnosis resulting in septic shock 02/May/2014 2 Nov 14 2014/37296 and arm amputation.

MEHT STEIS Wrong site surgery – ultrasound guided 30/Sep/2014 Never Oct 14 2014/32854 injection carried out on incorrect hip. Event

MEHT STEIS Wrong Site Surgery – biopsy taken on the 30/Oct/2014 Never Nov 14 2014/36441 lower part of his ear instead of the upper Event part.

MEHT STEIS Wrong Site Surgery - wrong area excised on 15/Oct/2014 Never Dec 14 2014/39794 anterior scalp and skin grafted. Event

MEHT STEIS Information governance - Printing of Patient 15/Nov/2014 2 Dec 14 2014/39744 Handover Sheets and Patient Test results were sent to wrong printer – off site

MEHT STEIS Wrongly prepared high risk injectable 25/Nov/2014 Never Dec 14 2014/40471 medication – error in intravenous Event chemotherapy dose required for patient

2.0 Review of Pressure Ulcers Serious Incidents reported during October 2014 - December 2014

34 grade 3 and 4 pressure ulcer serious incidents were reported for Mid Essex in quarter 3 2014/15, 32 of which were, grade 3 pressure ulcers. Only 2 grade 4 pressure ulcers were reported.

Grade 3 pressure ulcers

Oct Nov Dec Sector Provider Total 14 14 14

Acute MEHT 6 4 4 14

Provide 5 1 12 18 Community BCH 0 0 0 0

CCG Mid Essex 0 0 0 0

11 5 16 32

Grade 4 pressure ulcers

Oct Nov Dec Sector Provider Total 14 14 14

Acute MEHT 0 0 0 0

Provide 2 0 0 2 Community BCH 0 0 0 0

CCG Mid Essex 0 0 0 0

2 0 0 2

The table below highlights the present position on avoidability of all 34 ulcers reported

Pressure Ulcer avoidability for all Pressure Ulcer SI’s reported in Quarter 3

Sector Provider

Avoidable Unavoidable Under Investigation Total Acute MEHT 8 6 0 14

Provide 7 4 9 20 Community BCH 0 0 0 0

CCG Mid Essex 0 0 0 0

15 10 9 34

Pressure Ulcer avoidability for all Pressure Ulcer SI’s reported in Quarter 2

Sector Provider

dable Avoi Unavoidable Under Investigation Total Acute MEHT 9 1 0 10

Provide 4 9 0 13 Community BCH 0 0 0 0

100 CCG Mid Essex 1 1 0 2

14 11 0 25

It must be noted that pressure ulcer data is shown by number reported in month – this does not necessarily equate to the number of pressure ulcers acquired in each month.

It is important that future reporting of grade 3 and 4 pressure ulcers continues to detail pressure ulcers not only by number reported, but shown as number actually acquired within each month. This will show improvement in incidence and allow incidence to be reviewed alongside prevalence studies, such as the National Safety Thermometer.

Of the 34 pressure ulcers reported in quarter 3, 5 were acquired in quarter 1 2014/15, 11 in quarter 2 2014/15 and the remaining 18 in quarter 3 2014/15.

Any further pressure ulcers acquired in quarters 1, 2 or 3 will be reported in quarter 4 2014/15.

The CCG continues to work with providers on the reporting of grade 3 and 4 acquired pressure ulcers. As previously noted above there has been a significant improvement in the reporting by providers, however reporting is still sporadic at times.

MEHT – During 2011-12 MEHT reported 5 grade 3 and 4 pressure ulcers and it was felt that there was a significant under reporting of all hospital acquired pressure ulcers. Data for 2012-13 highlighted only 7 grade 3 and 4 pressure ulcers raised in total. Following this significant work was undertaken between the CCG quality team and MEHT, resulting in a contract query being raised in April 2013 to ensure that all MEHT acquired grade 3 and 4 pressure ulcers (avoidable or unavoidable) were raised in line with national guidance. Resulting in 60 hospital acquired grade 3 and 4 pressure ulcers being raised in 2013-14 and to date (Q1, Q2 & Q3 2014-15) 43 being raised and investigated.

The CCG have received multiple assurances from the Trust on pressure ulcer management moving into 2014-15 and are pleased with the continued improved reporting and recognition from the Trust on the importance of improving this basic care standard. Within contracting for quality 2015/15 pressure ulcers remain high on the KPI agenda with adherence to NICE guidance, reporting, completion of RCAs and avoidability panels. The local fines in place continue into 2015/16, with a new focus on grade 2 pressure ulcers. It must also be recognised that there were no grade 4 pressure ulcers reported as being acquired in MEHTs care in Q3.

PROVIDE – Provide also continue on a journey of improvement in their grade 3 and 4 pressure ulcer reporting. The inpatient ward areas continue to be good reporters of acquired pressure ulcers; reporting within the integrated care teams still remains low in Q3 and is very inconsistent across teams and Provide have been challenged to understand if identified teams are low reporters, or are providing higher standards of pressure area care.

101 3.0 Never Events

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb -15 Mar-15

Mid Essex CCG 0 0 0 0 0 0 1 1 2

“Never events” are defined as ‘serious, largely preventable patient safety Quarter 1 – No never events reported incidents that should not occur if the available preventative measures have been implemented by healthcare providers’. Quarter 2 - Although there were no never events reported in quarter 2 2014/15 for Mid Essex CCG it should be noted that one of the dental To be a “never event”, an incident must fulfil the following criteria; cases raised but subsequently transferred to NHS England as lead • The incident has clear potential for or has caused severe harm/death. commissioners was identified as meeting the never event criteria – wrong

• There is evidence of occurrence in the past (i.e. it is a known source of risk). site surgery.

• There is existing national guidance and/or national safety recommendations on how Quarter 3 – There have been 4 never events reported in quarter 3 as the event can be prevented and support for implementation. follows:

• The event is largely preventable if the guidance is implemented. • StEIS 2014/32854 – Wrong Site Surgery • StEIS 2014/36441 – Wrong Site Surgery • Occurrence can be easily defined, identified and continually measured. • StEIS 2014/39794 – Wrong Site Surgery • StEIS 2014/40471- Wrongly prepared high risk injectable medication We are now reporting Never Events based on month declared on StEIS and not by incident date. Only StEIS 2014/36441 has been fully investigated, confirmed as a never event and closed. At this point all others remain under investigation

The national schedule for Never Events is currently out for consultation. Once ratified, it will be included in the north Essex Serious Incident policy

102 Appendix 1 - Details of each non pressure ulcer serious incident reported October – December 2014

Reporting Incident Ref Description Result Reported Provider date Other - Instrument trays decontaminated STEIS BCH inappropriately in an external 08/Oct/2014 1 Nov-14 2014/36077 decontamination unit.

STEIS Fall - Care home patient fall resulting Commissioning 24/Aug/2014 1 Oct-14 2014/32074 fractured neck of femur.

STEIS MRSA Bacteraemia - Patient MRSA Commissioning 02/Dec/2014 1 Dec-14 2014/40697 positive

STEIS MRSA Bacteraemia - Patient MRSA Commissioning 17/Dec/2014 1 Dec-14 2014/41757 positive

STEIS Wrong site surgery - – ultrasound guided Never MEHT 30/Sep/2014 Oct-14 2014/32854 injection carried out on incorrect hip. Event

Infected healthcare worker - Member of staff from ward was diagnosed with TB STEIS MEHT whilst on holiday in Portugal having 01/Oct/2014 1 Oct-14 2014/33370 suffered respiratory problems since May 2014.

STEIS Fall - Patient fall - Fracture to right neck of MEHT 13/Oct/2014 1 Oct-14 2014/33501 femur confirmed

STEIS Fall - Unwitnessed fall from bed. Right MEHT 11/Oct/2014 1 Oct-14 2014/33520 fractured neck of femur confirmed on x-ray.

STEIS C diff and healthcare acquired infections - MEHT 20/Sep/2014 1 Oct-14 2014/33807 Patient identifed as C. difficile positive.

Sub-optimal care of the deteriorating STEIS MEHT patient 29/Mar/2014 1 Oct-14 2014/33817 - child

Delayed diagnosis - Failure to diagnose STEIS MEHT fracture of right wrist and subdural 13/Jul/2014 1 Oct-14 2014/34356 hematoma following fall in care home.

STEIS Medication error (general) - Incorrect dose MEHT 17/Oct/2014 1 Oct-14 2014/34378 administered

STEIS Fall - Unwitnessed patient fall resulting in MEHT 15/Oct/2014 1 Oct-14 2014/34734 fractured neck of femur

STEIS MEHT Unexpected death of inpatient 20/Oct/2014 1 Oct-14 2014/34964

Other - Patient accident outside A & E STEIS MEHT where wheelchair collided with a van 26/Oct/2014 1 Oct-14 2014/34976 causing patient injury.

103 Safeguarding Vulnerable Child - patient STEIS MEHT presented at A & E re possible overdose 06/Oct/2014 1 Oct-14 2014/35135 and allegations of sexual abuse.

STEIS MEHT Fall - Patient fall resulting in fractured foot. 01/Nov/2014 1 Nov-14 2014/35730

STEIS Fall - Patient fall resulting in fractured MEHT 24/Oct/2014 1 Nov-14 2014/36233 pelvis.

Wrong Site Surgery - Patient attended for a STEIS biopsy on the upper part of his ear. Never MEHT 30/Oct/2014 Nov-14 2014/36441 Procedure was undertaken on the lower Event part of the ear.

STEIS Other - piece of tube went missing during MEHT 08/Nov/2014 1 Nov-14 2014/36879 procedure..

Sub-optimal care of the deteriorating STEIS patient - Patient transferred to radiology for MEHT 10/Nov/2014 1 Nov-14 2014/36927 MRI without an escort as required and subsequently deteriorated

Delayed Diagnosis - Patient reviewed and discharged following road traffic accident. . STEIS MEHT X-rays re-examined next day and patient 08/Nov/2014 1 Nov-14 2014/36956 contacted to attend local hospital as fracture identified

Delayed diagnosis - Following diagnosis of STEIS tendonitis patient later admitted with septic MEHT 02/May/2014 2 Nov-14 2014/37296 shock resulting in amputation of left arm and extensive surgery on right.

STEIS Screening Issue - Essex Sickle Cell and MEHT 11/Nov/2014 1 Nov-14 2014/37397 Thalassaemia Service

Patient was sitting in chair and had an STEIS MEHT unwitnessed fall - confirmed fractured neck 15/Nov/2014 1 Nov-14 2014/37412 of femur

Fall - Patient found sitting on floor in front of STEIS MEHT chair. Patient reported pain in hip - 15/Nov/2014 1 Nov-14 2014/37414 confirmed fractured neck of femur

STEIS Information Governance - Sensitive clinical MEHT 29/Oct/2014 1 Nov-14 2014/37601 information governance breach (verbal).

Information Governance - Personal data STEIS MEHT relating to patients held on unprotected 07/Nov/2014 1 Nov-14 2014/37735 staff home computer equipment

Unexpected death - death following surgery STEIS MEHT required after inpatient fall (StEIS 17/Nov/2014 1 Nov-14 2014/37741 2014/37414)

MEHT 15/Nov/2014 1 Nov-14 STEIS Medication error (Insulin) - Missed dose of

104 2014/37905 insulin. .

STEIS Maternity Services - Unexpected neonatal MEHT 15/Nov/2014 1 Nov-14 2014/37914 death

STEIS Sub-optimal care of the deteriorating MEHT 19/Nov/2014 1 Nov-14 2014/38471 patient - patient died

STEIS Maternity Services - Unexpected admission MEHT 25/Nov/2014 1 Nov-14 2014/38814 to ITU

Transfusion incident – Readmitted following STEIS MEHT transfusion found to have pulmonary 19/Nov/2014 1 Nov-14 2014/38821 oedema.

STEIS Fall - Patient fall resulting in re-opening of MEHT 26/Nov/2014 1 Nov-14 2014/38975 surgical wound.

Delayed Diagnosis - Patient attended A&E, STEIS reviewed and discharged home. Patient MEHT 25/Jun/2014 1 Dec-14 2014/39648 returned the following day with neutropenic sepsis.

Information Governance - Patient STEIS MEHT Handover Sheets and Patient Test results 15/Nov/2014 2 Dec-14 2014/39744 were sent to incorrect external printer

STEIS Wrong Site Surgery - Wrong area excised Never MEHT 15/Oct/2014 Dec-14 2014/39794 on anterior scalp and skin grafted. Event

STEIS Failure to act upon test results - Chest x- MEHT 23/Sep/2014 1 Dec-14 2014/39818 ray.

STEIS Maternity Services - Unexpected admission MEHT 06/Dec/2014 1 Dec-14 2014/40106 to NICU

Wrongly prepared high risk injectable STEIS Never MEHT medication – error in intravenous 25/Nov/2014 Dec-14 2014/40471 Event chemotherapy dose required for patient

Surgical - Error - Nearing the end of STEIS MEHT surgery it was noted that a piece of integra 11/Dec/2014 1 Dec-14 2014/40731 mesh used for the patient was out of date.

STEIS MEHT Other - specimen incorrectly labelled. 09/Dec/2014 1 Dec-14 2014/41319

STEIS MEHT Other - Poor A & E performance. 09/Dec/2014 1 Dec-14 2014/41407

STEIS Sub-optimal care of the deteriorating MEHT 11/Dec/2014 1 Dec-14 2014/41426 patient - patient died.

STEIS C diff and healthcare acquired infection - MEHT 03/Dec/2014 1 Dec-14 2014/41653 Patient C difficile positive.

STEIS Fall - Patient fall resulting in fracture to MEHT 21/Dec/2014 1 Dec-14 2014/41802 wrist.

105 STEIS MEHT Fall - Patient fall resulting in head injury. 27/Oct/2014 1 Dec-14 2014/42588

STEIS Absconsion - Patient absconded from the Provide 01/Nov/2014 1 Nov-14 2014/36477 ward.

Medication error (Insulin) - wrong dose STEIS Provide administered on 2 separate occasions 09/Nov/2014 1 Nov-14 2014/37481 (Linked to StEIS 2014/37502)

Medication error (Insulin) - wrong dose STEIS Provide administered on 2 separate occasions 10/Nov/2014 1 Nov-14 2014/37502 (Linked to StEIS 2014/37481)

Information Governance - ASQ sent out to STEIS patient with a new birth notification relating Provide 28/Oct/2014 1 Nov-14 2014/37843 to another client inadvertently stapled to questionnaire.

Failure to obtain consent - Formal complaint by mother of patient alleging she STEIS Provide was sprayed by the consultant with liquid 24/Nov/2014 1 Nov-14 2014/38351 nitrogen without consent which caused blistering.

Information Governance - Staff member left STEIS their laptop bag with diary, laptop and some Provide 16/Dec/2014 1 Dec-14 2014/41246 staff information beside car and drove off without it.

STEIS RAMSAY Surgical error - requiring return to theatre 25/Sep/2014 1 Oct-14 2014/34493

106

MID ESSEX CLINICAL COMMISSIONING GROUP

Report to: Mid Essex CCG Board

Meeting Date: 26 March 2015

Agenda No: 11.2

Report Title : Performance Report

Written By Penny Rogers

The CCG Board to be kept informed of the CCG performance to date within data perimeters of national and local objectives

Purpose : It fits with the National Mandate 2013-2015, the NHS Constitution, Everyone Counts: Planning for Patients, the CCG Operational Plan and the CCG Strategic Plan

Previous Agenda : Reference Standing agenda item

Approval Route : Monthly reports are submitted to the CCG’s Finance and Performance Committee

Commissioning decisions have direct service impact which should affect delivery Clinical Implication(s) : of the national and local objectives.

To be financially fit to deliver national requirements. The CCG is expected to Financial Implication(s) : achieve national/local service directives within allocated financial resources.

Workforce : Implication(s) N/A

The NHS constitution sets out rights and pledges for patients and the public Legal Implication(s) : which the CCG is required to fulfil and the Duty of Quality Act 1999.

107

Have the details of this paper been assessed for all of the protected characteristics under the Equality Act 2010? Yes (√) No (√) √ If No, please outline why :

An initial equality impact assessment has been completed and this report has no equality issues. Equality & Diversity :

If Yes, please provide details of the outcome of the assessment, including how any adverse effects will be monitored:

Is the equality analysis on the CCG website? Yes (√) No (√)

The performance report will highlight any risks facing the CCG which could affect Risk(s) Identified : the achievement of the national and local directives 2013/14.

Significance to Key : Target(s) Service performance is monitored against national and local directives.

Patient & Public : Stakeholders are actively involved in many of the CCG /PCTs planning processes. Involvement

Does this item go against rights or pledges of NHS Constitution? If yes, please outline how and reasons why this is necessary: Constitution : Yes (√) No (√) 

Sustainability : N/A

The Board is asked to note the contents of this report and be assured that Recommendation : appropriate actions are being taken to address performance where there are risks.

108 Performance Report 109 March 2015

Executive summary

Further work is also ongoing to reduce NEL admissions and the main Over the past two months, since the last update to Board, the focus of this is the ESDAAR (Early Supported Discharge & Admission CCG continues to strive to improve performance to meet Avoidance) Service combined with the outputs of Practice based national standards and ensure patient care is provided with Multi Disciplinary Teams (MDT) management of frail elderly patients the best possible outcomes. identified by the CCG Risk Stratification Tool. However performance has continued to be below standard for A&E and Cancer Services. A& E has seen unprecedented 18 weeks - The Trust has consistently met aggregate compliance in demand on its services this winter and this has resulted in all three RTT standards, 95% non-admitted, 90% admitted and 92% sustained underperformance against the 95% waiting time incompletes except in august when performance dropped in the standard. A knock-on effect of this pressure is elective surgery admitted pathway as additional activity took place to reduce the cancellations with subsequent impact on 18 week backlog, number of patients on the backlog. This was a national requirement. particularly in orthopaedics as the hospital had to use the However the unprecedented urgent care demand has had an impact on RTT and the backlog has grown in the admitted pathway for ward for emergency care. Work is underway to address the ophthalmology, orthopaedics and plastics and in non -admitted backlog. dermatology. Performance at speciality level will recover and the Cancer services will not recover performance until May 2015. Trust will continue to maintain aggregate compliance of all standards. The hospital has employed a very experienced Cancer Director Funding has not been specifically allocated in planning for speciality who is working with a National Intensive Support Team to compliance and this may present an in year risk to manage capacity if review and ensure all cancer pathways are compliant and mandated. sustainable. Cancer Waits - The Trust has not met the 62 day cancer standard The CCG has been proactively working with the Trust to (85%) this year and performance will not recover until Qtr. 2 in improve performance and ensure patient safety and quality is 2015/16. The CCG is working with the Trust to improve performance maintained. and ensure sustainability so that patient quality and care is not Immediate Care - The national standard is to see and treat compromised. Additional support from the Intensive Support Team starts in March and a sustainability project is planned to start in 95% of patients within 4hrs. Due to unprecedented demand Qtr.1 onwards to include increased efficiency in MDTs, planning for the Trust has performed below standard all year. The aim is to 16/17 pathway changes, peer review and strengthening governance achieve 95% from April 2015.The CCG is working with the structures. During 14/15 there has been a significant increase in Trust to schedule and profile the QIPP plans for an Urgent urgent 2week waits >20% overall in referrals including breast and this Care Centre (UCC) and Long Term Condition work. The UCC has had an impact on diagnostic waits. The CCG has set aside will remove nearly 10,000 A&E attendances and will also have investment for diagnostics and outpatient increases to ensure a circa 800 NEL admission reduction. The UCC ‘stream and compliance. This takes account of recent national campaigns. treat’ service is currently undergoing pilot testing on the MEHT site. The CCG is seeking commitment from MEHT Executive to secure long term premises for locating a Primary 110 Care staffed UCC within the MEHT ED.

Executive summary

There is a heavy focus on the CCG achieving the targets in IAPT Services Dementia and IAPT and work continues in 14/15 to ensure we get as close to target as possible. The CCG commissioned a new Provider in 2014/15 to deliver the target of 12.5% of patients entering treatment. This is based on The national requirements for 2015/16 are still to achieve 67% diagnosis rate for dementia and 15% access to IAPT services the CCG prevalence in the national Psychiatric Morbidity Survey 2000. The Provider has failed to achieve this target mainly due to Dementia Diagnosis inheriting a backlog, capacity issues and insufficient referrals. The The CCG has developed a strong action plan working with NHSE Provider implemented a change management programme, has to support GPs to deliver this target. The CCG aims to improve cleared the backlog and is at full capacity. Following a recent the secondary care pathway and access to memory loss clinics intense communications campaign there has been an increase in working with North Essex Partnership Foundation Trust. The CCG referrals and the Provider is on track to achieve Qtr.4. and now is also closely working with ECC to ensure support networks are has the platform to meet the target of 15% for 15/16, 50% in place. recovery and the new access waiting times targets of 95% within 18 weeks and 75% first appointment within 6 weeks by Qtr.4. The national guidance has now changed the prevalence denominator for 15/16 and reduced it to just 65yrs+. This will mean 490 less to be diagnosed in 15/16. Sustaining Recovery However the LES/DES incentives for GPs are not continuing into Our 2015/16 plans reflect our ambition to continue to recover our 15/16 and this will mean extra support will be needed from the performance on these key metrics for which performance is CCG Mental Health GP leads to work closer with GP’s and currently below acceptable levels. continue to support them in 15/16. We are planning to achieve 67%.

111

NHS Constitution Targets

Target Current Target Current NHS Constitution NHS Constitution 15/16 Performance 15/16 Performance Jan-15 Ambulance clinical quality – Category Jan-15 YTD 18 week RTT - admitted % within 18 weeks 90% 75% 90.6% A (Red 1) 8 minute response time 70.1% Jan-15 Ambulance clinical quality – Category Jan-15 YTD 18 week RTT - non-admitted % within 18 weeks 95% 75% 96.7% A (Red 2) 8 minute response time 61.9% Jan-15 Ambulance clinical quality - Category A Jan-15 YTD 18 week RTT - incomplete % within 18 weeks 92% 95% 95.0% 19 minute transportation time 90.7% Jan-15 % waiting 6 weeks or more for Jan-15 Number of 52 week Referral to Treatment Pathways 0 <1% 0 diagnostic tests 1.5% Jan-15 % of patients who spent 4 hours or less YTD to 11-Mar-15 Cancer: Two Week Wait 93% 95% 95.0% in A&E (MEHT) 88.14% Trolley waits in A&E: Patients who Jan-15 have waited over 12 hours in A&E YTD to 01-Mar-15 Cancer: Breast Symptom Two Week Wait 93% 0 91.1% from decision to admit to admission 0 (MEHT) Jan-15 Cancer: 31 Day First Treatment 96% NHS Constitution Support Measures 94.2% Jan-15 Mixed Sex Accommodation (MSA) Jan-15 YTD Cancer: 31 Day Subsequent Treatment - Surgery 94% 0 100.0% Breaches 2 Jan-15 Urgent operations cancelled for a Jan-15 YTD Cancer: 31 Day Subsequent Treatment - Drug Treatments 98% 0 93.8% second time (MEHT) 2 Cancelled Operations - % of patients Jan-15 Q3 2014/15 Cancer: 31 Day Subsequent Treatment - Radiotherapy 94% not treated within 28 days of last Reduce 89.7% 3.3% minute elective cancellation (MEHT) Jan-15 Mental Health - CPA follow up within 7 Q3 2014/15 Cancer Plan: 62 Day Standard 85% 95% 66.7% days 99.3% Jan-15 Ambulance - % of patients handed YTD to Feb-15 Cancer: 62 Day Screening Standard 90% 85% 87.5% over within 15 minutes 39.8%

112

Meeting the NHS Constitution standards

The CCG will continue to commission and performance manage The Orthopaedic delays are due to MEHT having to close the contracts and apply penalties where appropriate to ensure orthopaedic ward in order to use it for emergency admissions sufficient services are delivered to deliver our population’s rights and then infection control cleansing before it could be restored under the NHS Constitution , including responsibilities relating to for the use of orthopaedic patients. service access and choice. Whilst acknowledging the achievement of the standards the A&E- % of Patients Seen & Treated in four hours: CCG continues to proactively work with the Trust to ensure 2014/15 has seen unprecedented demand on the urgent care compliance across all specialities and ensure equity of service services with more patient acuity and admissions to the hospital. delivery for all patients. The tables below show the admitted Although reflective of the national Emergency Department (ED) and non admitted specialities at risk. More detail can be found pressures this has resulted in MEHT not meeting the standard of in the scorecard attached to this report. 95% for A&E. Year on Year Variance 18 week specialty 2014/15 2013/14 Oct-14 Nov-14 Dec-14 Jan-15 Total % within Total Conversion compliance - Admitted Target Outturn Year to Date Quarter Breaches Admissions General Surgery 85.7% 91.3% 93.0% 90.9% 90.9% 86.1% Attendances 4 hours Attendances Rate Urology 93.4% 92.9% 94.9% 97.3% 97.0% 90.8% Trauma & Orthopaedics 87.8% 90.8% 93.1% 95.0% 94.1% 89.3% Q1 22,245 1,960 91.19% 8.2% 13.6% 1.1% Ear, Nose & Throat (ENT) 93.3% 92.9% 92.1% 93.6% 91.1% 91.4% Ophthalmology 94.5% 85.4% 100.0% 65.0% 59.5% 87.5% Q2 21,963 1,752 92.02% 6.6% 12.9% 1.4% Oral Surgery 95.0% 88.6% 88.7% 98.0% 92.8% 91.5% Neurosurgery Q3 22,055 2,880 86.94% 10.1% 3.0% -1.7% Plastic Surgery 92.1% 91.8% 89.4% 93.8% 87.8% 90.6% Cardiothoracic Surgery General Medicine 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Q4 (to 2nd Mar) 13,857 2,986 78.45% 5.3% 4.5% -0.2% 90% Gastroenterology 100.0% 100.0% 100.0% 100.0% 100.0% 98.7% YTD to 2nd Mar 80,120 9,578 88.05% 7.7% 8.6% 0.2% Cardiology 98.8% 100.0% 94.7% 100.0% 78.3% 96.1% Dermatology 100.0% Thoracic Medicine 100.0% 100.0% 100.0% 100.0% 100.0% Total Attendances show a 7.7% increase on 2013/14. Neurology 100.0% 90.0% 100.0% 100.0% 100.0% 99.0% Rheumatology 100.0% 100.0% 100.0% Admissions have shown a significant drop in quarter 3 which is Geriatric Medicine Gynaecology 97.6% 98.6% 100.0% 100.0% 93.2% 97.9% continuing in quarter 4 compared to Q1/Q2, but overall an 8.6% Other 93.1% 93.9% 93.5% 96.7% 96.2% 92.0% Total 92.5% 92.5% 92.4% 95.1% 90.5% 91.2% increase on 2013/14. 18 week specialty 2014/15 2013/14 Oct-14 Nov-14 Dec-14 Jan-15 compliance - Non-Adm Target Outturn Year to Date The immediate care strategy implementation, which is being General Surgery 89.5% 86.4% 96.3% 96.3% 90.3% 90.7% overseen by the System Resilience Group, addresses the need to Urology 98.4% 99.3% 100.0% 100.0% 99.6% 99.0% Trauma & Orthopaedics 95.2% 98.4% 98.8% 99.0% 96.3% 98.4% change and work together with local services to be able to flex in Ear, Nose & Throat (ENT) 97.5% 93.2% 93.1% 95.3% 94.3% 94.9% Ophthalmology 99.0% 97.5% 97.2% 99.7% 99.8% 98.7% busy times and manage demand in a more co-ordinated and Oral Surgery 98.0% 96.2% 96.2% 100.0% 95.8% 97.0% Neurosurgery 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% supportive approach to ensure patient access is improved and Plastic Surgery 97.5% 96.2% 97.2% 98.8% 94.6% 96.6% Cardiothoracic Surgery maintained. General Medicine 99.5% 99.1% 100.0% 95.4% 100.0% 98.8% 95% Gastroenterology 98.8% 97.7% 95.1% 100.0% 98.4% 98.3% Cardiology 98.9% 98.5% 99.0% 100.0% 99.3% 98.7% Dermatology 96.9% 88.8% 89.6% 81.0% 80.2% 92.2% 18 weeks Pathway: MEHT has been meeting aggregate level Thoracic Medicine 99.0% 93.9% 91.6% 86.0% 83.5% 95.2% Neurology 99.4% 97.3% 96.1% 95.0% 91.8% 96.6% but there is still some work to ensure it is achieved at speciality Rheumatology 99.7% 100.0% 100.0% 100.0% 99.2% 99.6% Geriatric Medicine 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% level, mainly Dermatology in the non-admitted pathway and Gynaecology 99.6% 97.9% 100.0% 100.0% 100.0% 99.7% Other 98.6% 98.2% 97.0% 97.1% 98.0% 98.0% Orthopaedics, Ophthalmology and Plastics in the admitted Total 98.2% 97.1% 96.9% 97.0% 96.3% 97.5% pathway. 113 Meeting the NHS constitution

Cancer standards:

MEHT - January 2015 Target Denominator Numerator Breaches %

Cancer Two Week Wait 93% 636 600 36 94.3% The Trust has not achieved the 62 day standard since October

2013 and this is mainly due to: Breast Symptom Two Week Wait 93% 163 148 15 90.8%

31 Day First Treatment 96% 127 122 5 96.1%

 An increase of 20% in Qtrs. 1-3 of 2 week referrals in 14/15 31 Day Subsequent Treatment - Surgery 94% 26 24 2 92.3%

adding pressure on diagnostic and histology, mainly in the 31 Day Subsequent Treatment - Drug Treatments 98% 42 38 4 90.5%

urology pathway

31 Day Subsequent Treatment - Radiotherapy 94% N/A N/A N/A N/A  The loss of the local Cancer Network to coordinate

Cancer Plan 62 Day Standard 85% 67.0 46.0 21.0 68.7% changes/issues around pathways resulting in delay in inter

62 Day Screening Standard 90% 4.5 3.5 1.0 77.8% provider discussions/resolutions

62 Day Upgrade Standard 5 3 2 66.7%  More complex patients on shared pathways having delays in

inter provider care.

On a positive note the Trust has reduced significantly the number The Trust has taken action and employed more management and of 100day waits to four patients clinical resource with strong leadership and support from the

National Intensive Support Team. A full review of all tumour site pathways is being undertaken with a comprehensive recovery plan and trajectories. The CCG is proactively working with the Ambulance Service Performance: Trust and will ensure patient care is not compromised and that Performance issues with East of England Ambulance Service NHS the improvements now being made to the 62 day standard will be Trust (EEAST) continue. Whilst there are good working sustainable. We are working closely with the Trust to ensure the relationships between the Ambulance Crews and handover to Trust provision of quality care and assurance that the Trust will meet staff, the handover target is still not met. This is similar for most and sustain this standard in 2015/16. Trusts in the EoE. The CCG continues to work with the CCG collaborative commissioning arrangement to support EEAST to The following table shows the January position for MEHT and the move to a more sustainable position for all national targets. Key performance has dropped ( more detail is in the scorecard issues of focus are capacity, recruitment and the ambulance service attached to this report). This is due to intensive work in relation transformation/performance recovery plans. to pathway issues being addressed and the CCG is assured patient care is not compromised.

114

Key Targets

Stroke Targets National targets- 80% (90% stay on stroke unit) MEHT has met this target in February but year end still below at 75.4% 60% TIA scanned and treated in 24hrs MEHT has met this target consistently Whilst improvements have been made in the provision of stroke care, further development is required to consistently achieve key standards, reduce overall stroke mortality and better long terms outcomes. Current performance is shown in the table below. The CCG will continue to work in collaboration with Essex County Council and local providers to ensure: • Early detection and improved management of hypertension • Ensuring high calibre specialist stroke workforce and capacity locally to ensure optimal outcome for stroke sufferers. • Ensure continued improvement in the increasing the rate of ESD. • Continued education and health promotion to promote healthier choices.

2014/15 Target Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 MEHT - Stroke Metrics YTD Stroke - discharged with AF on anticoagulants 60% 85.7% 100.0% 80.0% 100.0% 85.7% 100.0% 100.0% 75.0% 100.0% 91.5% Stroke - 4 hours direct to stroke unit 90% 62.5% 71.1% 75.8% 80.8% 67.7% 74.3% 77.1% 90.9% 80.6% 78.1% 80.0% 76.5% Stroke - 90% of time on the stroke unit 80% 76.5% 69.2% 72.2% 76.9% 62.9% 77.8% 69.6% 79.4% 87.9% 78.1% 83.3% 75.4% Stroke - 60 minutes to scan 50% 47.1% 50.0% 45.7% 55.6% 38.2% 56.8% 41.7% 55.9% 60.6% 65.6% 70.0% 52.8% Stroke - 60 minutes to scan urgent only 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Stroke - scanned with 24 hours 100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Stroke - thrombolysed within 3 hours 12% 12.9% 11.1% 6.9% 4.3% 19.4% 3.7% 7.5% 15.6% 13.3% 15.4% 8.3% 10.5% Stroke - thrombolysed No Target 12.9% 16.7% 20.7% 10.9% 19.4% 7.4% 12.5% 18.8% 13.3% 26.9% 12.5% 15.3% Stroke - discharged with JCP 85% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Stroke - discharged with ESD 40% 36.8% 36.7% 40.0% 36.4% 45.5% 47.1% 32.0% 40.9% 31.6% 35.7% 46.2% 38.5% Stroke - psychological support within 6 mths 40% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 5.9% 0.0% 0.0% 0.0% 0.0% 0.4% Stroke - six month followup 95% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% TIA - high risk, not admitted, treated within 24 60% 59.3% 63.0% 67.9% 91.7% 74.2% 55.0% 58.3% 71.4% 56.3% 63.3% 65.5% 65.4% TIA - high risk, treated within 24 hours 60% 69.4% 61.3% 72.7% 90.5% 78.6% 65.5% 62.5% 66.7% 57.1% 65.6% 65.6% 69.0% TIA - low risk, treated within 7 days from first 65% 84.4% 100.0% 84.2% 90.9% 88.6% 97.3% 87.9% 85.7% 86.8% 91.2% 92.7% 90.2% TIA - low risk, treated within 7 days from onset 65% 62.5% 80.5% 57.9% 72.7% 72.7% 81.1% 75.8% 74.3% 73.7% 58.8% 61.8% 70.0%

115 Targets at Risk and Key Actions

A&E- % of Patients Seen & Treated in four hours: • Q1- 91.19% • Q2 -92.02% Admissions via A&E 2014/15 14/15 vs 13/14 2013/14 13/14 vs 12/13 2012/13 • Q3 – 76.53% Apr 1,695 9.9%  1,543 -1.2%  1,561 Performance continues to be below the standard in February and May 1,840 11.6%  1,649 3.7%  1,590 Jun 1,774 16.1%  1,528 1.0%  1,513 at the beginning of March. The aim is till to try to achieve the Jul 1,808 16.5%  1,552 -3.0%  1,600 standard by April 2015. Aug 1,865 11.9%  1,667 6.9%  1,559

The System Resilience Group is overseeing the recovery plan and Sep 1,777 6.3%  1,672 10.1%  1,518 Oct 1,836 4.9%  1,751 15.4%  1,517 monitoring and reviewing the use and outputs of the resilience Nov 1,784 -3.3%  1,845 27.8%  1,444 monies. Dec 1,885 2.7%  1,836 16.7%  1,573 Contract penalties are applied for failing to achieve the standard Jan 1,906 4.9%  1,817 28.9%  1,410 Feb 1,560 12.7%  1,384 in Q1/Q2/Q3. A trajectory for improvement has been agreed and Mar 1,771 10.3%  1,605 is linked to financial penalties. YTD 18,170 7.8%  16,860 10.3%  15,285

The tables show performance year on year performance against the standard 95%, attendances and admissions. A&E % Seen within 4 Hours A&E Attendances 2014/15 14/15 vs 13/14 2013/14 13/14 vs 12/13 2012/13 2014/15 14/15 vs 13/14 2013/14 13/14 vs 12/13 2012/13 Apr 89.87% -5.8%  95.64% -0.7%  96.35% Apr 7,158 3.8%  6,899 7.5%  6,417 May 92.22% -3.2%  95.39% -1.5%  96.90% May 7,554 7.8%  7,010 -1.1%  7,087 Jun 91.41% -5.7%  97.11% -0.3%  97.43% Jun 7,533 13.3%  6,648 -1.6%  6,759 Jul 95.82% 0.7%  95.10% 1.3%  93.81% Jul 7,438 3.8%  7,165 1.5%  7,061 Aug 90.03% -2.9%  92.95% -3.8%  96.76% Aug 7,142 4.3%  6,848 0.9%  6,789 Sep 90.13% -7.0%  97.11% 0.1%  96.96% Sep 7,383 11.9%  6,598 -1.1%  6,669 Oct 88.48% -10.2%  98.68% 2.8%  95.85% Oct 7,388 8.6%  6,800 1.6%  6,693 Nov 90.51% -5.2%  95.72% -1.4%  97.14% Nov 7,187 9.0%  6,592 0.9%  6,532 Dec 81.99% -12.3%  94.31% 0.1%  94.17% Dec 7,480 12.6%  6,644 2.8%  6,464 Jan 78.37% -16.2%  94.57% 1.0%  93.62% Jan 6,929 5.7%  6,557 4.3%  6,284 Feb 92.54% -2.7%  95.26% Feb 6,136 -1.7%  6,244 Mar 92.48% -2.6%  95.11% Mar 7,701 9.4%  7,039 YTD 88.95% -6.7%  95.65% -0.3%  95.91% YTD 73,192 8.0%  67,761 1.5%  66,755

116

Targets at Risk and Key Actions Cancer Standard -62 day Dementia The national requirement is to achieve 67% of the prevalence. The The Trust has not been achieving the 62 day standard this year. CCG has fallen short of this target and was only at 49% from Additional management resources are in place and a draft action January data. plan and trajectories shared, and being firmed up to ensure the improvement is achievable to meet 85% and the service will then The CCG is targeting personal support to practices with the lowest be sustained. uptake and other actions are: An Access group with representation from the Trust and CCG • Reconciling data sources with existing Practice meets monthly, and closely monitors the plans and trajectories Registers. Not all practices have made the proper requests for both Cancer services and 18 weeks pathway. or downloads for this data. Weekly meetings are held in addition with the Trust and CCG to • Undertake medication searches to identify patients on monitor weekly patient waits and the operational actions being dementia drugs to identify patients who are on dementia taken to improve the service. medication but who don’t have dementia diagnosis code attached Contract penalties apply. • Review of all patient records by a Clinician (if there is no reference to a confirmed diagnosis in the records and /or The following table shows outturn 13/14 and performance in letters) to determine whether a Dementia diagnosis code is 2014/15 to January. appropriate or not, before adding the patient to the Practice register • Patients in Care Homes that may have been diagnosed with 2014/15 2013/14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Target Outturn Dementia – this is where the largest cohort of undiagnosed dementia patients may be found. All Cancer 2 week waits 93% 97.0% 96.3% 95.2% 96.0% 95.4% 94.5% 93.3% 93.9% 94.0% 93.2% 94.3% IAPT 2 week waits for Breast Symptoms 93% 97.6% 96.1% 96.2% 94.7% 94.9% 93.3% 94.7% 98.2% 95.9% 94.3% 90.8% The CCG commissioned 12.5% of prevalence population to access treatment from IAPT services. The Provider has not met the 31 Day First Treatment 96% 98.9% 95.8% 94.7% 96.8% 98.1% 100.0% 99.3% 98.1% 95.6% 97.4% 96.1% quarterly plans. The Provider has had some capacity issues but not enough 31 Day Subsequent Treatment - Surgery 94% 98.9% 81.8% 100.0% 97.2% 100.0% 93.5% 96.6% 95.5% 97.1% 95.5% 92.3% referrals has been the main problem. The Provider and the CCG have undertaken a surge in communication promotions. 31 Day Subsequent Treatment - Drug 98% 99.8% 96.3% 100.0% 96.4% 97.6% 100.0% 100.0% 100.0% 100.0% 97.4% 90.5% CCG leads have contacted practices. Leaflets , posters, flyers have been distributed. Billboards in train stations and shops . Intranet 31 Day Subsequent Treatment - Radiotherapy 94% N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A at District Councils and MEHT. The CCG has a weekly column in the Essex Chronicle and a weekly CCG newsletter goes to all 62 day Standard 85% 83.1% 78.8% 72.4% 72.2% 72.3% 76.6% 73.5% 76.2% 72.0% 67.4% 68.7% practices, and the CCG is exploring advertising on the radio. 62 day Screening Standard 90% 95.1% 81.8% 100.0% 75.0% 82.4% 100.0% 92.3% 94.1% 66.7% 93.8% 77.8% The CCG issued a contract notice and a remedial recovery plan is being monitored to ensure the prediction of achieving Q4 is met. 62 day Upgrade Standard No Target 96.3% 100.0% No patients No patients 100.0% 100.0% 50.0% 50.0% No patients 50.0% 66.7% However the current full year forecast is the service will not reach the 12.5% commissioned and will fall short to 9.6% but will meet 3.75% in Qtr.4 which moves them into the 15% commissioned in 2015/16. 117 Activity

The following table shows the current CCG position of the Monthly Activity Report data for April – January 2014/15.

Monthly Activity Report- 2012/13-2013/14 2013/14-2014/15 2014/15

Commissioner Year on Year Growth Year on Year (Apr-Jan) Against Plan (Apr-Jan) Variance to Plan Actual Plan GP Referrals -13.2%  9.7%  51,032 57,460 12.6%  Other Referrals -8.7%  5.7%  37,737 40216 6.6% 

All 1st Outpatient Attendances -12.4%  3.9%  77,972 82,386 5.7%  Elective Ordinary -4.8%  -2.5%  7,900 7,722 -2.3%  Elective Daycase 8.2%  2.5%  29,825 31,277 4.8%  Non-Elective 6.7%  5.5%  27,610 28,313 2.5% 

• GP referrals are over plan. This is due to a backlog in the CRS from 2013/14 and also a substantial rise in 2week urgent referrals, in excess of 20%, and this has had an impact on first outpatients. • Elective is down although this will increase as the Trust draw down their backlog. • Day-case is up but this is because the data includes day attenders, mainly oncology patients. • Non Elective is above plan due to the urgent care pressures and it being too early to evidence any impact from the resilience schemes.

118 CCG Plans to meet national targets 2015/16

18 Week RTT - Admitted Pathways May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Completed pathways < 18 weeks 1,403 1,337 1,692 1,688 1,403 1,692 1,487 1,487 1,345 1,274 1,345 1,416 2015/16 Total Completed Pathways 1,549 1,472 1,859 1,859 1,549 1,859 1,627 1,627 1,472 1,394 1,472 1,549 Plan % within 18 weeks 90.6% 90.8% 91.0% 90.8% 90.6% 91.0% 91.4% 91.4% 91.4% 91.4% 91.4% 91.4% Cancer 62 Day Standard Quarter 1 Quarter 2 Quarter 3 Quarter 4 Number waiting < 62 days 167 163 213 185 2015/16 Total number waiting 196 191 248 211 Plan % within 62 days 85.2% 85.3% 85.9% 87.7% MEHT A&E Quarter 1 Quarter 2 Quarter 3 Quarter 4 Number waiting > 4 hours 1,098 1,022 1,078 1,053 2015/16 Total Attendances 22,870 22,714 22,006 22,410 Plan % < 4 hours 95.2% 95.5% 95.1% 95.3% IAPT - Access Quarter 1 Quarter 2 Quarter 3 Quarter 4 The number of people who receive 1,473 1,473 1,473 1,473 psychological therapies

2015-16 The number of people who have Plan depression and/or anxiety disorders 39,263 39,263 39,263 39,263 (local estimate based on Adult Psychiatric Morbidity Survey 2000). % per quarter (e.g. 3.75%) 3.75% 3.75% 3.75% 3.75% IAPT - Recovery Quarter 1 Quarter 2 Quarter 3 Quarter 4 The number of people who finish treatement having attended at least 519 519 519 519 two treatment contacts and are moving to recovery (those who at 2015-16 The number of people who finish Plan treatement having attended at least 999 999 999 999 two treatment contacts and coded as discharged) minus (The number % Moving to Recovery 52.0% 52.0% 52.0% 52.0% IAPT - % with First Appt within 6 weeks Quarter 1 Quarter 2 Quarter 3 Quarter 4 The number of ended referrals that finish a course of treatment in the 835 835 835 835 reporting period who received their 2015-16 The number of ended referrals that Plan finish a course of treatment in the 1,113 1,113 1,113 1,113 reporting period. % within 6 weeks 75.0% 75.0% 75.0% 75.0% IAPT - % with First Appt within 18 weeks Quarter 1 Quarter 2 Quarter 3 Quarter 4 The number of ended referrals that finish a course of treatment in the 1,058 1,058 1,058 1,058 reporting period who received their 2015-16 The number of ended referrals who Plan finish a course of treatment in the 1,113 1,113 1,113 1,113 reporting period. % within 18 weeks 95.1% 95.1% 95.1% 95.1% Dementia Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Number of People diagnosed (65+) 3,230 3,230 3,254 3,254 3,254 3,278 3,302 3,302 3,302 3,326 3,350 3,374 2015-16 Estimated dementia prevalence 4,820 4,820 4,820 4,820 4,820 4,820 4,820 4,820 4,820 4,820 4,820 4,820 Plan % 67.01% 67.01% 67.51% 67.51% 67.51% 68.01% 68.51% 68.51% 68.51% 69.00% 69.50% 70.00% 119 Mid Essex CCG

High Risk Dashboard & Performance Scorecards

2014/15

Contents – • Dashboard -CHUFT • Dashboard -MEHT • Dashboard - NHS Constitution • Graphs MEHT A&E activity • Dashboards - Cancer CCG/MEHT/CHUFT • Dashboards - Stroke CCG/MEHT/CHUFT

120 CHUFT Performance Dashboard

2014/15 2013/14 Data Source Freq Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Target Outturn Year to Date Friends and Family Test Response Rate - A&E (CHUFT) 15% Unify2 M 8.1% 18.1% 17.7% 16.4% 18.1% 18.6% 17.3% 13.4% 8.4% 8.3% 16.5% 15.3% E.A.6 Friends and Family Test Response Rate - Inpatients (CHUFT) 15% Unify2 M 37.7% 35.8% 32.5% 34.1% 27.6% 23.2% 21.9% 24.0% 28.2% 19.2% 20.0% 26.9% Friends and Family Test Response Rate - A&E & Inpatients combined (CHUFT) 15% Unify2 M 20.1% 25.5% 23.5% 23.3% 21.9% 20.4% 19.1% 17.6% 15.3% 13.0% 17.9% 19.9% E.A.S.4 Healthcare acquired infection (HCAI) measure (MRSA) 0 HPA M 0 0 0 0 0 0 0 0 0 0 0 0 E.A.S.5 Healthcare acquired infection (HCAI) measure (clostridium difficile infections) 20 HPA M 17 1 2 0 1 2 2 2 3 3 9 25 E.B.1 Referral to Treatment pathways - Admitted patients treated with 18 weeks 90% Unify2 M 90.7% 80.9% 85.1% 85.7% 81.7% 81.3% 79.6% 75.5% 71.8% 80.1% E.B.2 Referral to Treatment pathways - Non-Admitted patients treated with 18 weeks 95% Unify2 M 97.6% 96.1% 96.3% 96.2% 95.5% 94.2% 92.9% 91.9% 91.0% 94.2% No submission No submission E.B.3 Referral to Treatment pathways - Incomplete - patients waiting less than 18 weeks 92% Unify2 M 95.5% 95.4% 96.7% 95.9% 94.9% 93.5% 92.3% 90.4% 89.1% E.B.S.4 Number of 52 week Referral to Treatment Pathways 0 Unify2 M 1 0 0 1 0 0 0 1 0 E.B.4 Diagnostic test waiting times <1% Unify2 M 0.3% 1.3% 0.6% 0.5% 0.4% 1.3% 0.4% 0.6% 0.7% 2.6% 2.1% E.B.5 A&E waiting time - total time in the A&E department 95% Unify2 M 94.8% 95.2% 94.9% 94.3% 90.6% 88.9% 94.4% 88.3% 89.6% 69.3% 69.0% 79.9% 87.3% E.B.S.5 Trolley waits in A&E 0 Unify2 M 0 0 0 0 0 0 0 0 0 0 6 0 6 Total A&E Attendances Unify2 M 76,476 6,579 6,951 6,945 7,187 6,888 6,626 6,961 6,026 6,204 5,785 5,370 71,522 E.B.6 All Cancer 2 week waits 93% Open Exeter M 96.2% 90.6% 94.0% 94.1% 90.8% 86.3% 91.4% 92.7% 96.2% 96.0% 94.4% 92.6% E.B.7 Cancer 2 week waits for Breast Symptoms 93% Open Exeter M 92.5% 92.9% 95.7% 96.0% 90.3% 91.0% 92.7% 95.4% 96.4% 91.0% 94.9% 93.6% E.B.8 Cancer 31 Day First Treatment 96% Open Exeter M 95.6% 90.6% 96.0% 98.4% 94.5% 96.0% 92.8% 89.9% 94.4% 96.1% 90.8% 94.0% E.B.9 Cancer 31 Day Subsequent Treatment - Surgery 94% Open Exeter M 93.1% 80.0% 80.0% 100.0% 72.0% 81.3% 66.7% 73.0% 81.8% 95.0% 82.6% 79.8% E.B.10 Cancer 31 Day Subsequent Treatment - Drug 98% Open Exeter M 99.7% 100.0% 96.7% 100.0% 100.0% 100.0% 98.1% 98.0% 98.0% 100.0% 98.4% 98.8% E.B.11 Cancer 31 Day Subsequent Treatment - Radiotherapy 94% Open Exeter M 97.1% 99.2% 100.0% 100.0% 100.0% 98.0% 94.2% 97.4% 99.1% 89.9% 92.4% 97.1% E.B.12 Cancer 62 day Standard 85% Open Exeter M 82.6% 67.8% 75.3% 78.1% 77.9% 73.1% 76.2% 70.3% 81.7% 76.7% 70.0% 74.8% E.B.13 Cancer 62 day Screening Standard 90% Open Exeter M 93.4% 92.5% 96.0% 88.0% 89.5% 88.4% 100.0% 88.9% 92.5% 96.4% 72.2% 91.1% E.B.14 Cancer 62 day Upgrade Standard No Target Open Exeter M 96.4% 90.0% No patients 83.3% 82.6% No patients 68.2% 63.6% No patients No patients 83.3% 78.0% E.B.S.1 Mixed Sex Accommodation (MSA) Breaches 0 Unify2 M 0 0 0 0 0 0 0 0 0 0 0 0 Total number of urgent operations cancelled No Target SITREP M 0 0 0 0 0 0 0 0 0 0 0 0 E.B.S.6 Urgent operations cancelled for a second time 0 SITREP M 0 0 0 0 0 0 0 0 0 0 0 0 E.B.S.7i Ambulance handover time - over 30 minutes Reduction EEAST M 13.8% 17.4% 17.0% 20.2% 12.2% 14.0% 8.3% 13.2% 8.4% 37.1% 42.1% 29.5% 19.4% E.B.S.7ii Ambulance handover time - over 1 hour Reduction EEAST M 1.3% 1.8% 1.4% 2.6% 2.4% 2.4% 1.0% 3.8% 0.6% 11.2% 16.3% 10.6% 4.7% Ambulance - % of patients handed over in 15 minutes (figures from Ambulance SITREP) 85% EEAST M 38.1% 26.7% 26.9% 28.5% 41.0% 40.0% 44.0% 40.8% 42.5% 13.9% 13.5% 18.0% 31.1% Ambulance - % of patients handed over in 30 minutes (figures from Ambulance SITREP) Improve EEAST M 86.2% 82.6% 83.0% 79.8% 87.8% 86.0% 91.7% 86.8% 91.6% 62.9% 57.9% 70.5% 80.6% % of all adult inpatients who have had a VTE risk assessment 95% Unify2 M 94.3% 94.5% 93.7% 94.8% 93.8% 93.0% 94.0% 93.9% 94.4% 88.5% 93.4% Number of Delayed Transfers of Care No Target SITREP M 8 17 17 20 19 15 19 24 26 10 12

Stroke: % of people spending 90% of their time on a stroke unit 80% Stroke M 85.2% 83.0% 83.3% 89.8% 78.9% 87.5% 89.1% 85.7% 82.5% 93.0% 68.3% 84.1% Stroke - High Risk TIA: Seen and treated within 24 hours 60% Database M 73.5% 85.0% 87.5% 66.7% 70.8% 82.4% 60.0% 68.0% 76.9% 73.7% 62.5% 72.6%

2014/15 2013/14 Data Source Freq Quarter 1 Quarter 2 Quarter 3 Quarter 4 Target Outturn Cancelled Operations - % of patients not treated within 28 days of last minute elective cancellation E.B.S.2 Reduction Unify2 Q 14.3% 4.2% 11.1% 12.1% (MEHT) Acute Bed Capacity: G&A available beds No Target Unify2 Q 696 699 672 679

121 MEHT Performance Dashboard

2014/15 2013/14 Data Source Freq Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Target Outturn Year to Date Friends and Family Test Response Rate - A&E (MEHT) 15% Unify2 M 11.7% 5.2% 22.5% 26.2% 23.8% 17.8% 14.7% 11.9% 13.4% 9.3% 14.2% 16.0% E.A.6 Friends and Family Test Response Rate - Inpatients (MEHT) 15% Unify2 M 31.3% 30.3% 30.3% 29.1% 30.9% 25.6% 32.6% 36.7% 42.3% 44.5% 42.8% 34.5% Friends and Family Test Response Rate - A&E & Inpatients combined (MEHT) 15% Unify2 M 19.8% 15.1% 25.5% 27.3% 26.6% 20.7% 20.2% 21.5% 24.8% 22.6% 25.5% 23.0% E.A.S.4 Healthcare acquired infection (HCAI) measure (MRSA) 0 HPA M 3 1 0 0 0 0 0 0 0 0 0 1 E.A.S.5 Healthcare acquired infection (HCAI) measure (clostridium difficile infections) 13 HPA M 14 0 0 1 2 1 1 1 2 6 1 15 E.B.1 Referral to Treatment pathways - Admitted patients treated with 18 weeks 90% Unify2 M 92.5% 91.1% 92.0% 91.4% 89.0% 87.6% 91.9% 92.5% 92.4% 95.1% 90.5% 91.2% E.B.2 Referral to Treatment pathways - Non-Admitted patients treated with 18 weeks 95% Unify2 M 98.2% 98.4% 99.1% 98.1% 97.6% 97.3% 97.4% 97.1% 96.9% 97.0% 96.3% 97.5% E.B.3 Referral to Treatment pathways - Incomplete - patients waiting less than 18 weeks 92% Unify2 M 97.1% 97.1% 97.2% 97.4% 97.6% 98.0% 97.8% 97.1% 96.8% 96.3% 95.0% E.B.S.4 Number of 52 week Referral to Treatment Pathways 0 Unify2 M 0 0 0 0 0 0 0 0 0 0 2 E.B.4 Diagnostic test waiting times <1% Unify2 M 0.1% 0.0% 0.1% 0.1% 0.5% 0.1% 0.1% 0.4% 0.9% 2.1% 1.4% E.B.5 A&E waiting time - total time in the A&E department 95% Unify2 M 95.1% 89.9% 92.2% 91.4% 95.8% 90.0% 90.1% 88.5% 90.5% 82.0% 78.4% 79.2% 88.2% E.B.S.5 Trolley waits in A&E 0 Unify2 M 0 0 0 0 0 0 0 0 0 0 0 0 0 Total A&E Attendances Unify2 M 81,598 7,158 7,554 7,533 7,438 7,142 7,383 7,388 7,187 7,480 6,929 6,406 79,598 E.B.6 All Cancer 2 week waits 93% Open Exeter M 97.0% 96.3% 95.2% 96.0% 95.4% 94.5% 93.3% 93.9% 94.0% 93.2% 94.3% 94.6% E.B.7 Cancer 2 week waits for Breast Symptoms 93% Open Exeter M 97.6% 96.1% 96.2% 94.7% 94.9% 93.3% 94.7% 98.2% 95.9% 94.3% 90.8% 95.0% E.B.8 Cancer 31 Day First Treatment 96% Open Exeter M 98.9% 95.8% 94.7% 96.8% 98.1% 100.0% 99.3% 98.1% 95.6% 97.4% 96.1% 97.2% E.B.9 Cancer 31 Day Subsequent Treatment - Surgery 94% Open Exeter M 98.9% 81.8% 100.0% 97.2% 100.0% 93.5% 96.6% 95.5% 97.1% 95.5% 92.3% 95.2% E.B.10 Cancer 31 Day Subsequent Treatment - Drug 98% Open Exeter M 99.8% 96.3% 100.0% 96.4% 97.6% 100.0% 100.0% 100.0% 100.0% 97.4% 90.5% 97.5% E.B.11 Cancer 31 Day Subsequent Treatment - Radiotherapy 94% Open Exeter M N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A E.B.12 Cancer 62 day Standard 85% Open Exeter M 83.1% 78.8% 72.4% 72.2% 72.3% 76.6% 73.5% 76.2% 72.0% 67.4% 68.7% 73.0% E.B.13 Cancer 62 day Screening Standard 90% Open Exeter M 95.1% 81.8% 100.0% 75.0% 82.4% 100.0% 92.3% 94.1% 66.7% 93.8% 77.8% 86.5% E.B.14 Cancer 62 day Upgrade Standard No Target Open Exeter M 96.3% 100.0% No patients No patients 100.0% 100.0% 50.0% 50.0% No patients 50.0% 66.7% 67.9% E.B.S.1 Mixed Sex Accommodation (MSA) Breaches 0 Unify2 M 0 0 0 0 0 0 0 0 0 0 0 0 Total number of urgent operations cancelled No Target SITREP M 4 0 0 0 0 0 2 0 1 0 0 3 E.B.S.6 Urgent operations cancelled for a second time 0 SITREP M 0 0 0 0 0 0 1 0 1 0 0 2 E.B.S.7i Ambulance handover time - over 30 minutes Reduction EEAST M 12.4% 19.1% 12.2% 13.6% 8.4% 12.9% 19.5% 15.9% 15.6% 28.2% 30.2% 29.4% 18.4% E.B.S.7ii Ambulance handover time - over 1 hour Reduction EEAST M 2.4% 4.0% 2.3% 2.3% 1.1% 3.1% 4.4% 2.5% 2.9% 8.9% 10.9% 9.6% 4.6% Ambulance - % of patients handed over in 15 minutes (figures from Ambulance SITREP) 85% EEAST M 51.3% 40.0% 43.8% 43.7% 53.0% 44.6% 37.9% 43.0% 38.8% 31.4% 29.6% 29.6% 39.8% Ambulance - % of patients handed over in 30 minutes (figures from Ambulance SITREP) Improve EEAST M 87.6% 80.9% 87.8% 86.4% 91.6% 87.1% 80.5% 84.1% 84.4% 71.8% 69.8% 70.6% 81.6% % of all adult inpatients who have had a VTE risk assessment 95% Unify2 M 97.8% 97.5% 97.1% 97.0% 97.6% 98.1% 97.7% 98.3% 99.1% 98.6% 97.9% Number of Delayed Transfers of Care No Target SITREP M 27 25 26 27 26 29 31 19 37 32 30

Stroke: % of people spending 90% of their time on a stroke unit 80% Stroke M 74.9% 76.5% 69.2% 72.2% 76.9% 62.9% 77.8% 69.6% 79.4% 88.6% 77.4% 74.9% Stroke - High Risk TIA: Seen and treated within 24 hours 60% Database M 72.6% 59.3% 63.0% 67.9% 91.7% 74.2% 55.0% 58.3% 71.4% 56.3% 60.0% 65.0%

2014/15 2013/14 Data Source Freq Quarter 1 Quarter 2 Quarter 3 Quarter 4 Target Outturn Cancelled Operations - % of patients not treated within 28 days of last minute elective cancellation E.B.S.2 Reduction Unify2 Q 3.1% 10.7% 6.5% 3.3% (MEHT) Acute Bed Capacity: G&A available beds No Target Unify2 Q 546 546 546 564

122 Mid Essex CCG Performance against National Indicators (NHS Constitution) 2014/15

2014/15 2013/14 Year to Data Source Freq Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Comments Target Outturn Date E.A.3 IAPT Roll-Out 12.5% IAPT Provider M 9.4% 0.68% 0.51% 0.46% 0.38% 0.45% 0.53% 0.61% 0.57% 0.80% 1.1% 6.06%

Friends and Family Test Response Rate - A&E (MEHT) 15% Unify2 M 11.7% 5.2% 22.5% 26.2% 23.8% 17.8% 14.7% 11.9% 13.4% 9.3% 14.2% 16.0%

E.A.6 Friends and Family Test Response Rate - Inpatients (MEHT) 15% Unify2 M 31.3% 30.3% 30.3% 29.1% 30.9% 25.6% 32.6% 36.7% 42.3% 44.5% 42.8% 34.5%

Friends and Family Test Response Rate - A&E & Inpatients combined (MEHT) 15% Unify2 M 19.8% 15.1% 25.5% 27.3% 26.6% 20.7% 20.2% 21.5% 24.8% 22.6% 25.5% 23.0%

E.A.S.2 IAPT Recovery Rate 50% IAPT Provider M 52.0% 56.9% 54.5% 52.4% 61.9% 59.3% 52.4% 62.5% 56.2% 58.6% 53.9% 56.6%

Healthcare acquired infection (HCAI) measure (MRSA) - Responsible 0 HPA M 4 1 0 0 0 1 0 0 0 2 1 5 E.A.S.4 Healthcare acquired infection (HCAI) measure (MRSA) - Assigned 0 HPA M 2 0 0 0 0 0 0 0 0 0 0 0

E.A.S.5 Healthcare acquired infection (HCAI) measure (clostridium difficile infections) 56 HPA M 57 1 7 6 10 9 11 4 3 5 5 61

E.B.1 Referral to Treatment pathways - Admitted patients treated with 18 weeks 90% Unify2 M 93.7% 93.6% 93.3% 92.9% 90.4% 87.8% 91.8% 91.9% 91.6% 95.5% 90.6% 91.8%

E.B.2 Referral to Treatment pathways - Non-Admitted patients treated with 18 weeks 95% Unify2 M 98.3% 98.4% 98.6% 98.2% 97.6% 96.9% 96.8% 96.9% 96.6% 96.7% 96.7% 97.4%

E.B.3 Referral to Treatment pathways - Incomplete - patients waiting less than 18 weeks 92% Unify2 M 96.7% 96.6% 96.8% 96.6% 97.1% 96.7% 96.4% 95.9% 95.6% 96.1% 95.0%

E.B.S.4 Number of 52 week Referral to Treatment Pathways 0 Unify2 M 4 1 0 1 0 0 0 0 0 0 0

E.B.4 Diagnostic test waiting times <1% Unify2 M 0.2% 0.4% 0.2% 0.2% 0.5% 0.3% 0.2% 0.7% 0.9% 2.4% 1.5%

E.B.5 A&E waiting time - total time in the A&E department (MEHT) 95% Unify2 M 95.1% 89.9% 92.2% 91.4% 95.8% 90.0% 90.1% 88.5% 90.5% 82.0% 78.4% 79.2% 88.2%

E.B.S.5 Trolley waits in A&E (MEHT) 0 Unify2 M 0 0 0 0 0 0 0 0 0 0 0 0 0

E.B.6 All Cancer 2 week waits 93% Open Exeter M 97.0% 96.6% 95.3% 95.6% 95.0% 94.3% 93.9% 93.9% 94.1% 93.6% 95.0% 94.7%

E.B.7 Cancer 2 week waits for Breast Symptoms 93% Open Exeter M 96.8% 96.5% 94.9% 94.4% 93.5% 93.1% 94.7% 97.5% 96.3% 92.6% 91.1% 94.5%

E.B.8 Cancer 31 Day First Treatment 96% Open Exeter M 98.1% 96.6% 96.7% 99.2% 96.2% 100.0% 98.6% 94.5% 97.6% 98.0% 94.2% 97.1%

E.B.9 Cancer 31 Day Subsequent Treatment - Surgery 94% Open Exeter M 98.1% 86.2% 97.1% 94.4% 96.3% 90.5% 96.6% 96.7% 95.7% 95.2% 100.0% 94.8%

E.B.10 Cancer 31 Day Subsequent Treatment - Drug 98% Open Exeter M 99.8% 97.5% 100.0% 97.1% 97.9% 100.0% 97.6% 100.0% 100.0% 97.5% 93.8% 98.0%

E.B.11 Cancer 31 Day Subsequent Treatment - Radiotherapy 94% Open Exeter M 96.8% 100.0% 100.0% 100.0% 100.0% 95.5% 91.8% 97.9% 100.0% 93.2% 89.7% 96.8%

E.B.12 Cancer 62 day Standard 85% Open Exeter M 81.3% 79.7% 67.6% 71.4% 66.7% 68.1% 73.5% 76.7% 68.9% 66.7% 66.7% 70.8%

E.B.13 Cancer 62 day Screening Standard 90% Open Exeter M 97.2% 85.0% 100.0% 84.2% 90.0% 100.0% 100.0% 92.9% 88.9% 100.0% 87.5% 91.9%

E.B.14 Cancer 62 day Upgrade Standard No Target Open Exeter M 95.5% 100.0% No patients 100.0% 50.0% 100.0% 66.7% 40.0% No patients 0.0% 66.7% 66.7%

E.B.15.i Ambulance clinical quality – Category A (Red 1) 8 min response time - EoE Trust 75% M 73.6% 69.1% 66.3% 65.7% 66.3% 69.1% 71.1% 73.5% 73.6% 71.7% 73.5% 70.1%

E.B.15.ii Ambulance clinical quality – Category A (Red 2) 8 min response time - EoE Trust 75% M 69.4% 61.4% 61.0% 60.5% 59.6% 61.1% 62.6% 62.6% 64.2% 61.1% 64.9% 61.9%

E.B.16 Ambulance clinical quality - Category A 19 min transportation time - EoE Trust 95% Ambulance M 92.9% 91.0% 90.1% 90.3% 89.3% 90.3% 91.5% 90.5% 91.9% 90.3% 92.1% 90.7% E.B.15.i Ambulance clinical quality – Category A (Red 1) 8 min response time - Mid Essex CCG patients 75% Trust M 69.1% 64.7% 61.4% 65.2% 75.8% 66.2% 75.0% 64.3% 67.9% 59.8% 66.2% 66.1%

E.B.15.ii Ambulance clinical quality – Category A (Red 2) 8 min response time - Mid Essex CCG patients 75% M 66.5% 59.1% 56.8% 60.1% 58.0% 63.7% 61.5% 60.7% 61.7% 62.0% 61.6% 60.6%

E.B.16 Ambulance clinical quality - Category A 19 min transportation time - Mid Essex CCG patients 95% M 91.2% 88.9% 89.8% 89.4% 88.5% 90.8% 90.6% 87.9% 89.7% 89.8% 88.2% 89.4%

E.B.S.1 Mixed Sex Accommodation (MSA) Breaches 0 Unify2 M 5 0 0 0 0 0 0 2 0 0 0 2

E.B.S.6 Urgent operations cancelled for a second time (MEHT) 0 SITREP M 0 0 0 0 0 0 1 0 1 0 0 2

E.B.S.7i Ambulance handover time - over 30 minutes (MEHT) Reduction EEAST M 12.4% 19.1% 12.2% 13.6% 8.4% 12.9% 19.5% 15.9% 15.6% 28.2% 30.2% 29.4% 18.4%

E.B.S.7ii Ambulance handover time - over 1 hour (MEHT) Reduction EEAST M 2.4% 4.0% 2.3% 2.3% 1.1% 3.1% 4.4% 2.5% 2.9% 8.9% 10.9% 9.6% 4.6%

2014/15 2013/14 Data Source Freq Quarter 1 Quarter 2 Quarter 3 Quarter 4 Comments Target Outturn

Cancelled Operations - % of patients not treated within 28 days of last minute elective cancellation E.B.S.2 Reduction Unify2 Q 3.1% 10.7% 6.5% 3.3% (MEHT)

E.B.S.3 Mental Health Measure – Care Programme Approach (CPA) 95% Unify2 Q 97.7% 98.6% 100.0% 99.3%

123 SRG Performance Management

MEHT A&E % Seen within 4 Hours Month: 11

A&E % Seen within 4 Hours MEHT A&E % Seen within 4 Hours 2014/15 14/15 vs 13/14 2013/14 13/14 vs 12/13 2012/13 Target 100.00% Apr 89.87% -5.8%  95.64% -0.7%  96.35% 95% 98.00% May 92.22% -3.2%  95.39% -1.5%  96.90% 95%96.00% Jun 91.41% -5.7%  97.11% -0.3%  97.43% 95%94.00% Jul 95.82% 0.7%  95.10% 1.3%  93.81% 95%92.00%   90.00% Aug 90.03% -2.9% 92.95% -3.8% 96.76% 95%88.00% Sep 90.13% -7.0%  97.11% 0.1%  96.96% 95%86.00% Oct 88.48% -10.2%  98.68% 2.8%  95.85% 95%84.00% Nov 90.51% -5.2%  95.72% -1.4%  97.14% 95%82.00%   80.00% Dec 81.99% -12.3% 94.31% 0.1% 94.17% 95%78.00% Jan 78.37% -16.2%  94.57% 1.0%  93.62% 95%76.00% Feb 79.22% -13.3%  92.54% -2.7%  95.26% 95% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar  Mar 92.48% -2.6% 95.11% 95% 2014/15 2013/14 2012/13 Target YTD 88.16% -7.2%  95.39% -0.5%  95.85%

MEHT A&E Attendances

A&E Attendances MEHT A&E Attendances 2014/15 14/15 vs 13/14 2013/14 13/14 vs 12/13 2012/13 9,000 Apr 7,158 3.8%  6,899 7.5%  6,417 May 7,554 7.8%  7,010 -1.1%  7,087 8,000 Jun 7,533 13.3%  6,648 -1.6%  6,759 7,000 Jul 7,438 3.8%  7,165 1.5%  7,061 6,000 Aug 7,142 4.3%  6,848 0.9%  6,789 5,000 Sep 7,383 11.9%  6,598 -1.1%  6,669 4,000 Oct 7,388 8.6%  6,800 1.6%  6,693 3,000 Nov 7,187 9.0%  6,592 0.9%  6,532 2,000 Dec 7,480 12.6%  6,644 2.8%  6,464 1,000 Jan 6,929 5.7%  6,557 4.3%  6,284 0 Feb 6,406 4.4%  6,136 -1.7%  6,244 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar  Mar 7,701 9.4% 7,039 2014/15 2013/14 2012/13 YTD 79,598 7.7%  73,897 1.2%  72,999

MEHT A&E Breaches

A&E Breaches MEHT A&E Breaches 2014/15 14/15 vs 13/14 2013/14 13/14 vs 12/13 2012/13 Apr 725 140.9%  301 28.6%  234 1,600 May 588 82.0%  323 46.8%  220 1,400 Jun 647 237.0%  192 10.3%  174 1,200   Jul 311 -11.4% 351 -19.7% 437 1,000 Aug 712 47.4%  483 119.5%  220 800 Sep 729 281.7%  191 -5.9%  203 600 Oct 851 845.6%  90 -67.6%  278 Nov 682 141.8%  282 50.8%  187 400 Dec 1,347 256.3%  378 0.3%  377 200 Jan 1,499 321.1%  356 -11.2%  401 0 Feb 1,331 190.6%  458 54.7%  296 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Mar 579 68.3%  344 2014/15 2013/14 2012/13 YTD 9,422 176.7%  3,405 12.5%  3,027

MEHT Admissions via A&E

Admissions via A&E MEHT Admissions via A&E 2014/15 14/15 vs 13/14 2013/14 13/14 vs 12/13 2012/13 Apr 1,715 11.1%  1,543 -1.2%  1,561 2,500 May 1,848 12.1%  1,649 3.7%  1,590 2,000 Jun 1,798 17.7%  1,528 1.0%  1,513 Jul 1,837 18.4%  1,552 -3.0%  1,600 1,500 Aug 1,901 14.0%  1,667 6.9%  1,559   Sep 1,784 6.7% 1,672 10.1% 1,518 1,000 Oct 1,855 5.9%  1,751 15.4%  1,517   Nov 1,819 -1.4% 1,845 27.8% 1,444 500 Dec 1,920 4.6%  1,836 16.7%  1,573 Jan 1,945 7.0%  1,817 28.9%  1,410 0 Feb 1,591 2.0%  1,560 12.7%  1,384 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Mar 1,771 10.3%  1,605 2014/15 2013/14 2012/13 YTD 20,013 8.6%  18,420 10.5%  16,669

124 SRG Performance Management

MEHT A&E Conversion Rate

Conversion Rate MEHT A&E Conversion Rate 2014/15 14/15 vs 13/14 2013/14 13/14 vs 12/13 2012/13 30.00% Apr 23.96% 1.6%  22.37% -2.0%  24.33% May 24.46% 0.9%  23.52% 1.1%  22.44% 28.00% Jun 23.87% 0.9%  22.98% 0.6%  22.38% Jul 24.70% 3.0%  21.66% -1.0%  22.66% 26.00% Aug 26.62% 2.3%  24.34% 1.4%  22.96%   Sep 24.16% -1.2% 25.34% 2.6% 22.76% 24.00% Oct 25.11% -0.6%  25.75% 3.1%  22.67% Nov 25.31% -2.7%  27.99% 5.9%  22.11% 22.00% Dec 25.67% -2.0%  27.63% 3.3%  24.33% Jan 28.07% 0.4%  27.71% 5.3%  22.44% 20.00% Feb 24.84% -0.6%  25.42% 3.3%  22.17% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar  Mar 23.00% 0.2% 22.80% 2014/15 2013/14 2012/13 YTD 25.14% 0.2%  24.93% 2.1%  22.83%

System Measure of MEHT Non-Elective Activity

Non-Elective FFCE's MEHT Non-Elective FFCEs 2014/15 14/15 vs 13/14 2013/14 13/14 vs 12/13 2012/13 3,500 Apr 3,004 10.6%  2,716 -3.8%  2,823 May 3,221 8.3%  2,975 -3.0%  3,068 3,000 Jun 3,144 17.9%  2,666 -5.8%  2,829 2,500 Jul 3,163 12.0%  2,825 -4.9%  2,969 2,000 Aug 3,125 9.0%  2,866 2.1%  2,806 Sep 3,118 6.4%  2,931 6.7%  2,748 1,500   Oct 3,218 5.1% 3,062 12.0% 2,734 1,000 Nov 3,073 -2.0%  3,135 16.2%  2,699 Dec 3,121 -1.2%  3,160 14.0%  2,773 500 Jan 3,162 -0.9%  3,191 22.4%  2,608 0 Feb 2,827 2.0%  2,772 8.2%  2,561 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar  Mar 3,150 5.4% 2,988 2014/15 2013/14 2012/13 YTD 34,176 5.8%  32,299 5.5%  30,618

125 Cancer Performance against National Indicators 2014/15

2014/15 2013/14 Mid Essex CCG Data Source Freq Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Year to Date Target Outturn