Paper 21 NHS Ayrshire & Arran
Meeting: NHS Board
Meeting date: Monday 29 March 2021
Title: Performance Report
Responsible Director: Kirstin Dickson
Report Author(s): Donna Mikolajczak (Performance Manager), Paul Dunlop (Senior Performance Officer), Steven Fowler (Senior Performance Officer)
1. Purpose
This is presented to the NHS Board members for: • Discussion
This paper relates to: • Government policy/Directive
This aligns to the following NHS Scotland quality ambitions: • Safe • Effective • Person Centred
2. Report summary
2.1 Situation
The health and social care system as a whole across Ayrshire and Arran has been continuously adapting throughout the COVID-19 pandemic to effectively and safely respond to the ongoing challenges and presence of COVID-19. Re-mobilisation commenced in the summer months to restart as many of its normal services as possible, and as safely as possible. However, the resurgence of COVID-19 in the autumn and winter months placed considerable pressure on services and resulted in a decision to again pause the majority of planned care.
This report provides an overview of Unscheduled Care (2.3.1) and Planned Care (2.3.2) performance to ensure that NHS Board members are sighted on the corresponding impact of COVID-19 across the system as a whole. All NHS Boards across Scotland are required to develop the next iteration of their Re-mobilisation Plans, to cover the period from April 2021 to March 2022. This will be considered as our Re-mobilisation Plan 3 (RMP3), a one year plan setting out key priorities and actions for 2021/22. Whilst being clear about our plans in the next year, RMP3 will continue to be adapted and modified as we move forward through 2021/22.
1 of 38 The first draft of RMP3 was submitted to Scottish Government at the end of February 2021. Once this has been finalised and approved by the Scottish Government, this Performance Report will report on progress against the RMP3.
2.2 Background
Emergency Departments (EDs) at both University Hospital Ayr (UHA) and University Hospital Crosshouse (UHC) initially experienced a significant reduction in attendances following the lockdown restrictions at the end of March 2020. Attendances then steadily increased month on month, and by August 2020 had returned to levels similar to that experienced in the pre- COVID-19 period. However from September 2020 onwards, attendances have again been reducing. The new Redesigning Urgent Care (RUC) pathway was launched on 3 November 2020, with the aim of routing all unscheduled care attendances via NHS24 to be triaged and directed to the most appropriate care service, which in many cases would be alternatives to attending the Emergency Department. Although we have seen a decrease in both ED attendances and emergency admissions, rising COVID-19 positive patients in hospital over the winter months presented a significant challenge in terms of Unscheduled Care.
A re-mobilisation process over the summer months supported the re-introduction of some planned care patient activity and prioritised this on the basis of clinical urgency rather than length of wait. However, the increasing prevalence of COVID-19 during the autumn months resulted in a decision to again pause the majority of acute planned care. Cancellation of appointments was a necessary step to ensure the safety of the population, therefore on this basis compliance against key National Waiting Times Service Access targets remains at a lower level. This means that current performance is not truly comparable to system performance prior to the start of the period of the COVID-19 pandemic.
Some measures have remained stable or indeed improved throughout the initial response and through into the recovery stages. These include services that have largely been able to be delivered remotely through telephone and NearMe technology such as Child and Adolescent Mental Health Services (CAMHS), Psychological Therapies, Drug and Alcohol Treatment and Musculoskeletal Services.
We continue to monitor the effect of the pandemic across all areas of Performance routinely reported to Board members.
2.3 Performance
Sections 2.3.1 and 2.3.2 include the most up to date data using local management information in relation to unscheduled and planned care. A separate Appendix (1) includes trends in performance; Appendix (2) compares NHS Ayrshire & Arran to NHS Scotland performance; and to provide additional context, Appendix (3) highlights trends in the number of COVID-19 positive patients in our hospitals.
2.3.1 Unscheduled Care
NHS Ayrshire & Arran was an Early Implementer Test of Change Board for the National Redesign of Urgent Care (RUC) Programme. The new Redesigning Urgent Care (RUC) pathway was launched locally on 3 November 2020, with the aim of routing all unscheduled care attendances via NHS24 to be triaged and directed to the most appropriate care service, which in many cases would be via alternatives to attending the Emergency Department. The Programme was further rolled out nationally from 1 December 2020. The Redesign of
2 of 38 Urgent Care National programme aims to reduce ED attendances and prevent overcrowding in ED waiting rooms.
The intention of the redesign of urgent care services across Ayrshire and Arran has been to provide safe, person centred urgent care over a 24/7 period to support General Practice and Primary Care out of hours services as well as our Emergency Department and Combined Assessment Units (CAUs). As part of this programme, NHS Ayrshire & Arran introduced a Flow Navigation Centre that offers rapid access to a senior clinical decision maker who has the ability to advise self-care, and direct patients to available local services such as:
• Primary care (in and out of hours) • Mental Health Teams • Minor Injury Units • Same Day Emergency Care (Acute)
If a face to face consultation is required, this will be a scheduled appointment with the right person, at the right time in the right place based on clinical need and to ensure the safety of patients and staff.
Overall attendances at our ED departments fell to the 2nd lowest level ever recorded in January 2021. It is likely that the new pathway, combined with Tier 4 restrictions implemented in November 2020 and continued throughout December 2020 and January 2021, have contributed to the reduction in ED attendances.
Although overall attendances at our ED departments reduced in January 2021, the numbers of COVID-19 confirmed cases in hospital started to increase from a baseline of near zero in early October 2020, accelerating rapidly towards the end of December 2020, and by 25 January 2021 had reached 240 (Appendix 3). This placed considerable pressure on our services and presented a significant challenge in terms of appropriate space for these patients to be reviewed within the ED and CAU. Ward and room closures due to COVID-19 infected patients also had a significant impact on patient flow through both acute hospitals. COVID-19 positive cases in hospital peaked on 1 February 2021 and have been steadily decreasing since.
3 of 38 Emergency Department
NHS Ayrshire & Number of ED Number of ED ED Compliance Arran Attendances 12 Hour (%) Breaches Jan-20 8,820 514 77.4% Feb-20 8,006 447 77.0% Mar-20 6,915 191 86.7% Apr-20 5,314 0 96.3% May-20 7,213 0 96.1% Jun-20 7,717 0 96.4% Jul-20 8,397 2 95.4% Aug-20 8,805 3 93.5% Sep-20 7,866 88 90.5% Oct-20 7,143 110 85.6% Nov-20 6,248 117 82.0% Dec-20 6,136 274 79.2% Jan-21 5,624 312 79.1%
Difference (Jan- 20 and -3,196 -202 +1.7 Jan- 21) Source: Local monthly management reports, Information Team
ED Attendances across NHS Ayrshire & Arran decreased to a low of 5,314 in April 2020 following the outbreak of COVID-19, before returning to pre-COVID levels by the summer. Attendances have since reduced each month from August 2020, falling to 5,624 in January 2021 (a decrease of 36% compared to January 2020).
The numbers of ED 12 Hour Breaches at Board level have been increasing significantly, rising from 0 in June 2020 to 312 by January 2021. Despite this, numbers remain lower than for the same period of the previous year.
The ED 4-Hour Wait compliance at NHS Board level reduced to 79.1% in January 2021, falling below the 95% target for the sixth consecutive month having previously exceeded the target in each of the calendar months between April 2020 and July 2020.
Throughout January 2021, the pandemic continued to severely impact on waiting times in our EDs, both for 4 hour and 12 hour waits. Long waits in ED due to bed shortages were driven by the steep increase in COVID-19 positive inpatients in December 2020 and January 2021. Bed occupancy within Medical specialities was at 100% at times, with high acuity reported within the clinical areas. This meant that there were challenges with flow moving patients to downstream beds. Ward and room closures due to COVID-19 infected patients also had a significant impact on patient flow through both hospitals and this in turn has meant the 4 hour standard has been more difficult to achieve.
A comparison of ED attendances, 12 hour breaches and compliance against the 4 hour ED standard for both UHA and UHC is outlined in the infographic below.
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Comparing January 2021 against January 2020, there were 1,046 fewer ED attendances at UHA, representing a 34.4% decrease. Similarly at UHC, there were 2,150 fewer ED attendances in January 2021 than in January 2020, representing a decrease of 37.2%. The decrease at both sites was predominantly in relation to Flow 1 (Minor Injury) and Flow 2 (Acute Assessment, including Major Injury) attendances.
The ED 4-Hour Wait compliance at UHA in January 2021 was 84.5%, an increase of 20.2 percentage points when compared to the previous year, and is an increase from the 76.1% recorded the previous month (Dec 2020). At UHC, compliance was 76.2% for January 2021, a decrease of 8.1 percentage points from the previous year, and a fall from the 80.7% reported in December 2020.
There were 312 12-hour breaches at both UHA and UHC in January 2021; 38 at UHA and 274 at UHC. Numbers have decreased at UHA when compared with the previous month (December 2020: 53) and are significantly lower than for the same period last year (January 2020: 249). Numbers of 12-hour breaches at UHC reached a high of 274 in January 2021, an increase when compared with the previous month (December 2020: 221) and with the same month last year (January 2020: 265).
5 of 38 Combined Assessment Units and Emergency Admissions
NHS Ayrshire & Number of CAU Number of Emergency Arran Presentations Admissions
Jan-20 3,331 2,135 Feb-20 2,962 1,998 Mar-20 2,402 1,709 Apr-20 2,259 1,692 May-20 2,662 1,992 Jun-20 2,811 2,123 Jul-20 3,165 2,298 Aug-20 2,998 2,170 Sep-20 2,916 2,020 Oct-20 3,070 2,028 Nov-20 2,816 1,756 Dec-20 2,724 1,594 Jan-21 2,667 1,501
Difference (Jan- -664 -634 20 and Jan- 21) Source: Local monthly management reports, Information Team
CAU Presentations initially experienced a significant reduction following the outbreak of COVID-19 and subsequent lockdown in Quarter 1 of 2020/21. Numbers started to increase in the summer months but have fallen again throughout the winter period. There were 2,667 presentations in January 2021 across both UHA and UHC CAUs, down by 664 when compared with the previous year. Although the number of CAU presentations is lower in January 2021, the high number of suspected COVID-19 patients on the red pathway in our CAUs awaiting results, created a challenge due to lack of single rooms on site, and therefore impacted on the ability to safely transfer the patients ahead of test results being known.
Emergency Admission numbers also experienced a substantial decrease following the initial outbreak of COVID-19 before then rising again to pre-COVID-19 levels by July 2020. Numbers have since decreased again, dropping to their lowest ever levels in January 2021 with 1,501 emergency admissions, 634 fewer than in the same month of the previous year. However, throughout January 2021, bed capacity reduced at both sites due to ward closures imposed by infection control as a result of patient COVID-19 infections. This impacted on patient flow and Length of Stay (LOS).
A comparison of CAU attendances and emergency admissions for both UHA and UHC is outlined in the infographic below.
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* Inpatient Admissions from the ED admitted directly into Medical or Surgical ward (excluding CAU) and Inpatient admissions from the CAU admitted to CAU (regardless of source) who are transferred to a medical or surgical ward (excluding discharges directly from the CAU)
CAU Presentations reduced at both sites, with 294 fewer presentations at UHA in January 2021 compared to January 2020, a decrease of 18.0%, and 370 fewer presentations at UHC in January 2021 compared with the same month of the previous year, a decrease of 21.8%.
In terms of sources of referral, the decrease at both sites is in relation to ED and GP referrals. At UHA, ED referrals reduced by 18.3% and GP referrals reduced by 20.3% when comparing January 2021 with January 2020. At UHC, ED referrals reduced by 19.3% and GP referrals by 29.9%. Referrals from ‘Other’ sources increased at both sites (UHA: +6.2%, UHC, +63.8%).
Note: ‘Other’ referral sources include referrals from Outpatient clinics, Radiology patients requiring immediate assessment, and Cancer patients referred via the national cancer helpline, however do not include elective return patients, who are instead recorded separately as outpatient attendances at the Acute Clinic.
The numbers of Medical and Surgical Inpatient Admissions from ED and CAU have similarly experienced significant reduction at both sites, with 96 fewer admissions at UHA in January 2021 when compared to the previous year and 538 fewer admissions at UHC. These figures represent general Acute admissions, and so do not include admissions to intensive care or high dependency wards, which may be reasonably expected to have experienced significant increase during the current crisis. Maternity and Paediatric admissions are also not included within this data.
Unscheduled Care – Improvement Actions
A significant initial focus for the RUC pathway has been patients self-presenting at Emergency Departments or presenting through NHS24, and providing options in enhanced pathways for patients accessing the system through General Practice to benefit both patients and support safe sustainability of General Practice. We are also ambitious in working towards the inclusion of other primary care contractors, community pharmacy, optometry and dental services. Work is progressing across the Ayrshire Urgent Care Service to establish this as a standalone service between Primary Care and Acute Services supporting patients, services and other partners to ensure a seamless approach to access the right care in the right place. It is noted that this requires to align with the Strategic Plans of our IJBs and Directions from them to the NHS Board and Councils.
A key factor to successful implementation of the RUC pathway has been the stabilisation of the medical workforce across the Ayrshire Urgent Care Service throughout 2020 and even with the introduction of new pathways maintains good cover provision. Like most systems across Scotland, this is built on a sessional volunteer rota. The service is working towards introducing a core multi-disciplinary team led by a senior
7 of 38 clinical decision maker to support the various pathways in place with the appropriate management and clinical leadership.
A number of actions will be taken forward as a consequence of the learning captured and aligning to Phase 2 of the National RUC programme. These include:
• Developing a Professional to Professional model between primary and secondary care services
Acute clinicians within our Combined Assessment Units will support GP Practices decision making and identify where patients may be able to attend in a more planned way utilising the ambulatory care pathways. Revised pathways and referral routes have also been put in place for primary care clinicians who will be able to seek specialist advice to support patients longer at home, avoiding potential admission or referral to outpatients where possible.
• Scottish Ambulance Service
An area highlighted during the focussed work with urgent care is the use of ambulances to support patients to attend hospital safely when they have no transport whether via the Ayrshire Urgent Care Service, GP Practices or other care providers. The good working relationship and engagement with the Scottish Ambulance Service has identified that they would benefit from additional support for paramedics to review cases remotely or in a patients home with access to a senior clinical decision maker either through the Ayrshire Urgent Care Service or Emergency Department to avoid patients being conveyed to hospital where safe and appropriate. This enhanced model was launched gradually from 25 January 2021, refining and developing the model day to day taking the learning of approach from the RUC programme. The aim is to have this fully implemented by March 2021.
• Interface with other Pathways
There has been close working with the Re-design of Frailty Programme locally and RUC to identify arrangements that can be put in place through the urgent care pathway. Supporting care homes and general practice has been a key area identified from this work. These actions will be progressed through the frailty programme using data and intelligence from the RUC to inform pathways also linking closely with wider arrangements within Acute Services and HSCPs. Working closely with community nursing teams has supported patients being assessed in their own homes where appropriate.
Further work is required to understand how a mental health pathway through the Ayrshire Urgent Service 24/7 could be best utilised to support patients and GP Practices. This will be explored further under the newly commissioned group led by the Associate Medical Director for Primary Care and Associate Medical Director for Mental Health Services with updates provided through the Primary and Urgent Care Programme Board to connect the models.
8 of 38 Delayed Discharges
The number of patients whose discharge from hospital was delayed by 2 weeks or more for non-clinical reasons (excluding complex code 9 delays) is outlined below.
East North South Delayed Ayrshire Ayrshire Ayrshire Total Discharges HSCP HSCP HSCP Jan-20 0 47 37 84 Feb-20 0 38 32 70 Mar-20 0 21 18 39 Apr-20 0 5 13 18 May-20 0 2 7 9 Jun-20 0 1 6 7 Jul-20 0 0 8 8 Aug-20 0 5 5 10 Sep-20 0 5 6 11 Oct-20 0 4 10 14 Nov-20 0 9 21 30 Dec-20 0 8 11 19 Jan-21 0 6 10 16
Difference (Jan- 20 0 -41 -27 -68 and Jan- 21) Source: Public Health Scotland
The numbers of Delayed Discharges over 2 weeks (excluding complex code 9 delays) have reduced significantly over the past 12 months, down from 84 in total in January 2020 to 16 in January 2021. Numbers reached a low in June 2020 before gradually increasing to a high in November 2020, however have fallen again since.
Delayed Discharges >2 Weeks (excluding complex code 9 delays) have reduced from 19 in December 2020 to 16 in January 2021. There were 6 delays over 2 weeks for North Ayrshire HSCP residents at the end of January 2021, down from 8 the previous month and down from 47 in the same month of the previous year. For South Ayrshire HSCP residents there were 10 delays over 2 weeks at the end of January 2021, compared to 11 the previous month and a decrease from 37 recorded the previous year. Performance in East Ayrshire HSCP has continued to meet the target of zero delays over 2 weeks.
9 of 38 Delayed Discharge Occupied Bed Days (OBDs) for all delay reasons have decreased in January 2021, down by 221 bed days to a total of 2,948 when compared to the previous month (December 2020: 3,169; January 2021: 2,948), and have decreased by 2,037 when compared with the previous year (January 2020: 4,985).
In North Ayrshire, there were 283 fewer OBDs in January 2021 when compared with the previous month (December 2020: 1,048; January 2021: 765), in East Ayrshire, there were 9 fewer OBDs (December 2020: 389; January 2021: 380), and in South Ayrshire there were 71 additional OBDs (December 2020: 1,732; January 2021: 1,803).
Delayed Discharges – Improvement Actions
East Ayrshire HSCP continues to actively manage transfers of care where hospital- based treatment is no longer clinically required and people can be more appropriately supported in another setting. The HSCP Hospital Team liaises daily with colleagues in Hospital Services to identify East Ayrshire residents and to allocate immediately to facilitate timely care and support planning for individuals.
Recently, there has been a notable increase in the levels of complexity of support that the Hospital Team has been managing and some challenges in securing specialist facilities for long-term care to meet those needs. Short delays can occur when Care Homes cannot accept immediate admissions while following COVID-19 guidance. Any such delays are kept to a minimum with close liaison with person delayed and their family.
Community teams have continued to play a central role in the response to COVID-19, with East Ayrshire Community Hospital (EACH), the Care at Home and District Nursing services in East Ayrshire having supported a number of people with suspected or confirmed COVID-19.
North Ayrshire HSCP continues to prioritise delayed discharges with specific focus on waiting times. Regular scrutiny and review of performance remains in place with daily assurance around the position and actions required.
A new Team Manager for the HSCP hospital team has started within UHC and is developing positive and effective working relationships with the acute team. The Team Manager will remain on site with a clear role around discharge to assess, prompting a home first model and effecting timely activity around discharge arrangements with a view to reducing delayed discharges.
The HSCP have also re-configured the Anam Cara dementia respite service by converting 9 beds for interim placement for individuals awaiting care at home services to reduce delayed discharges, whilst maintaining 5 respite beds to ensure support is available where required.
The HSCP have also commissioned 10 care home beds in Irvine for a period of three months. This will allow discharge to an interim placement for patients identified as requiring long term residential or nursing care but where their care home of choice is not available. In addition, it will allow the Social Work team to discharge and complete assessment out-with the acute setting. Placements are only possible with patient/ family /representative agreement and subject to negative COVID tests as per Scottish Government guidance.
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The partnership has also effectively reviewed and stabilised the position around community waiting lists for admission to Care Homes and there are now no delays in terms of assessment or funding to access a Care Home placement within Community Care services in North Ayrshire.
The reduction in demand for care home placements has seen demand and referrals for Care at Home significantly increase. There is a comprehensive ongoing programme of recruitment within the service to ensure sufficient contingency and capacity to further reduce delayed discharges and also to ensure community waiting lists can be addressed. Those waiting lists are actively being reviewed to ensure the waiting list is a true reflection of unmet need and to ensure support can be put in place as quickly as possible.
In South Ayrshire HSCP, there has been a continued focus on delayed discharges. The senior team within South Ayrshire continue to meet weekly to focus on supporting those who have waited longest to move and to identify areas for improvement across the system. This has resulted in a reduction in the average time waited for a care home place but there remain approximately 18 people waiting long periods due to guardianship processes. The management team have implemented improved processes to manage the application arrangements for Guardianship Orders and the progress of each Guardianship is being closely monitored. The team are utilising options at community hospital sites in relation to some guardianship patients transferring from Acute hospitals.
The Head of Community Health and Care Services and Director for University Hospital Ayr have commissioned an “extreme team” to focus on process improvement in pursuit of the aim to reduce delays. Six work streams have been identified and small tests of improvement have been initiated.
Despite this work, in recent weeks, referral numbers for care at home continue to increase significantly at a time when additional ‘care at home’ capacity has become fully utilised. In order to address this, the Care at Home service has been allocated funding for a 6 month test of change post to reduce hospital delays. The post holder is working closely with private providers to arrange care packages to support people home from hospital on the day they are medically fit in line with a discharge to assess model. The current difficulty relates to the lack of capacity across internal and external Care at Home. Discussions are being held with private providers to highlight the challenges they are facing in terms of capacity and consider how the HSCP can support them. Capacity within both the Care at Home and Reablement Service is being increased through ongoing recruitment activity. The Reablement service has recently offered 31 new staff posts but require a further 30 to fully staff the service as intended.
Initial discussions have taken place with the Heads of Community Health and Care in North and East Ayrshire HSCP’s and Assistant Directors for University Hospital Ayr and University Hospital Crosshouse in relation to Home First principals and developing a systematic approach to the implementation of these across Ayrshire. Work is planned, with support from the iHub through Health Improvement Scotland, to conduct a whole system self-assessment using the 10 Home First principles as set out by the Joint Improvement Team (and any other more recent guidance). This evaluation will allow the HSCPs to establish a baseline position across the three partnerships and the two acute sites and inform a strategic Ayrshire wide approach which aligns to Caring for Ayrshire. It will also be linked to work being undertaken by Scottish Government and the iHub to improve discharge planning.
11 of 38 A small Test of Change in relation to Home First is being progressed within a single site within South Ayrshire with a view to informing Pan Ayrshire work and resource implications.
We continue to pursue a ‘Home First’ approach for everyone and although progress is at an early stage, key partners are engaged in this work. We are progressing a joined up approach across health and social care to ensure that the Home First model is the key consideration for all patients and we are reviewing our pathways in support of this ambition to undertake assessments at home within 72 hours of discharge from hospital.
2.3.2 Planned Care Inpatient/Daycases and Outpatients COVID-19 has had a significant impact on the delivery of Inpatient/Daycase and Outpatient planned care throughout the pandemic. The service has had to continuously adapt. In March 2020, all routine Inpatient/Daycase surgery ceased with planned care surgery restricted to emergency and cancer/very urgent cases only. Emergency surgery continued in all specialties, and in some specialties a small number of very urgent cases continued.
A re-mobilisation process over the summer months supported the re-introduction of some planned care. This re-mobilisation process prioritised planned care patient activity on the basis of clinical urgency rather than length of wait.
The increasing prevalence of COVID-19 during the autumn months resulted in a decision to again pause some of the planned care with the suspension of Priority 3 and Priority 4 elective surgery in week commencing 9th November (with the exception of paediatric cochlear implant in Priority 3 and cataract surgery in Priority 4 which continued). This pause was further extended to include Priority 2 surgery from 6th January 2021 in response to the extreme pressures and the inability to provide a safe COVID-free ward environment for post-operative recovery.
Inpatient/DayCases
As outlined above, there have been significant constraints in operating capacity during the pandemic. Overall elective surgical waiting lists have increased, with the biggest impact being for the patients awaiting procedures in the less clinically urgent Priority 3 and particularly the Priority 4 categories. The number of patients waiting has increased from 4,679 at December 2020 to 4,996 at January 2021. A comparison of the number of patients waiting is outlined below:
Number waiting As at 29 February As at 31 As at 31 (including 2020 (Pre-COVID-19) December 2020 January 2021 unavailable patients) Inpatients / > 12 weeks 1,103 3,172 3,448 Day cases < 12 weeks 2,913 1,507 1,548 All waits 4,016 4,679 4,996 Source: Local monthly management reports, Information Team Please note that the total numbers for New Outpatients and Inpatients/Day cases in the above table include unavailable patients. Compliance figures for National Report exclude unavailable patients.
12 of 38 The allocation of operating theatre capacity based on clinical priority has affected some surgical specialties more than others. The Number of Inpatients/Daycases by specialty waiting > 12 Weeks is outlined below:
Specialty As at 29 February As at 31 As at 31 January 2020 (Pre-COVID- December 2020 2021 19) ENT 54 287 319 General Surgery (inc 102 520 574 Vascular) Gynaecology 1 122 139 Ophthalmology 294 432 458 OMFS 62 222 222 Plastic 0 26 34 Trauma & Orthopaedics 561 1,112 1,209 Urology 28 356 391 Other 1 95 102
Total 1,103 3,172 3,448
Source: Local monthly management reports, Information Team
Inpatients/Daycases – Improvement Actions
A contingency arrangement has been put in place, allowing relocation of clinically suitable patients to either Golden Jubilee National Hospital, BMI Rosshall Hospital, Nuffield Hospital or BMI Carrick Glen Hospital where NHS Ayrshire & Arran surgeons are operating. This is supported by Scottish Government colleagues who have contracted the ‘lease’ of some private sector hospital facilities for this purpose and commenced on 18th January 2021.
The Re-mobilisation Plan 3 will focus on beginning to recover routine and planned care services. The pandemic response has provided an opportunity to expedite and benefit from new practices and approaches. The continued development and expansion of these approaches will form a key component of the routine and planned care recovery.
Throughout the pandemic, the allocation of the limited operating capacity has been driven by the relative clinical priority of each case. This has been clinically-led, and coordinated by the Theatre Re-Start Groups which have met weekly. This approach has proven to be effective and will be continued through 2021/22 to ensure that there continues to be a prioritisation which is based on each patient’s clinical urgency.
The pandemic resulted in elective inpatient orthopaedic surgery being amalgamated onto a single operating site at UHA. This allowed the initiation and testing of a new way of working across NHS Ayrshire & Arran which will be continued and built upon through 2021/22.
13 of 38 Supporting investment will facilitate the creation of an Elective Centre of Excellence for Orthopaedic Surgery.
Collaborative working with Independent Sector hospitals was effective during the pandemic, and opportunities to continue this will be explored.
New Outpatients
The impact of social distancing requirements and the availability of staff and physical resources has had a significant impact on the new outpatient waiting list, which has increased from 21,200 at the end of February 2020 to 32,726 at the end of January 2021. It was necessary to pause some outpatient work during January 2021 to allow the appropriate consultant team to focus on the emergency COVID-19 response. This is likely to continue for a further short term period.
A comparison of the number of patients waiting is outlined below:
Number waiting As at 29th As at 31st As at 31st (including February 2020 December 2020 January 2021 unavailable (Pre-COVID-19) patients) New > 12 weeks 4,012 19,831 21,008 Outpatients < 12 weeks 17,188 12,906 11,718 All waits 21,200 32,737 32,726 Source: Local monthly management reports, Information Team Please note that the total numbers for New Outpatients and Inpatients/Day cases in the above table include unavailable patients. Compliance figures for National Report exclude unavailable patients.
Outpatients – Improvement Actions
Patient referrals continue to be prioritised in line with clinical priorities. Through the course of the pandemic, clinical teams have developed and enhanced various strategies to maximise the delivery of outpatient services whilst optimising patient and staff safety, including the use of Near Me, Active Clinical Referral Triage, Virtual Review and Patient Initiated Review.
In many specialties the expansion of non-face to face appointments has been very successful, particularly for return appointments. Moving onto 2021/22 we will be continuing this practice, and will be monitoring the ongoing use of this appointment type. Although the re-establishment of more face to face appointments in those specialties where this is required but is currently constrained will result in a proportionate drop in the percentage of non-face to face appointments compared to the peak of the pandemic, we expect to continue to deliver 20% of appointments on a non-face to face basis going forwards.
A number of services have expanded the use of Patient Initiated Review (PIR) during the pandemic, resulting in fewer patients being automatically re-appointed for follow up appointments. A joint acute and primary care working group are in the process of consolidating this work with a view to ensuring a consistent approach, and an approach which can then be rolled out to a wider range of services during 2021/22. This working group will also be considering how this new activity can be better captured and reported.
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In line with emerging guidance we will also be undertaking a piece of work to review the opportunity to safely increase the capacity of clinics and waiting areas when it is safe to do so.
National Waiting Times - Service Access Targets
The pausing of planned care has in turn impacted on the number of patients waiting and as a direct consequence affected compliance against the National Waiting Times and Service Access targets. With a reduction in planned and elective care activity and a renewed focus on ensuring timely delivery of patient care for those most urgent at need, compliance against the National Waiting Times targets will remain low.
A comparison of compliance in January 2020 and January 2021 is outlined below. Future reporting will represent a move away from measuring compliance, to measuring activity and trajectories outlined in the RMP3.
Service Access
30.9% 74.8% of patients were waiting fewer than 12 weeks for Inpatient or Jan 2021 Jan 2020 day case treatment
of patients were waiting fewer than 12 weeks for a New 35.8% 80.8% 95% Jan 2021 Jan 2020 Outpatient appointment
of patients waited fewer than 18 weeks from Referral to 74.5% 79.0% 90% Jan 2021 Jan 2020 Treatment
The formal measure of performance against the 12 weeks Treatment Time Guarantee (TTG) for Inpatients/DayCases applies to patients seen (completed waits), however the number of patients waiting for treatment at a point in time (ongoing waits) is also a key measure in assessing NHS hospitals' performance.
Local management information indicates that at the end of January 2021, 30.9% of patients who were waiting for their Inpatient/Daycase treatment, had to that date, waited less than 12 weeks (ongoing waits). This is a decrease of 1.5 percentage points, from 32.4% at December 2020. Prior to the impact of COVID-19, performance at February 2020 was 71.8%.
The Treatment Time Guarantee (TTG) states that eligible patients must start to receive treatment within 12 weeks (84 days) of the treatment being agreed (this guarantee is based on completed waits). Local management data indicates that in January 2021 , there were 380 patients admitted under this standard. Of those patients seen, 81.3% were seen within 12 weeks of referral.
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A comparison of TTG (completed waits) performance is outlined below:
TTG <= 12 > 12 % within Completed Total weeks weeks 12 weeks Waits Feb-20 1,036 3555 1,391 74.5 Mar-20 789 256 1,045 75.5 Apr-20 198 3 201 98.5 May-20 187 17 204 91.7 Jun-20 269 129 398 67.6 Jul-20 336 277 613 54.8 Aug-20 344 381 725 47.5 Sep-20 357 426 783 45.6 Oct-20 481 336 817 58.9 Nov-20 452 218 670 67.5 Dec-20 461 176 637 72.4 Jan-21 309 71 380 81.3 Source: Local monthly management reports, Information Team
Compliance in relation to completed waits has been affected by the measures put in place to effectively and safely manage the ongoing pressures of COVID-19. At the outset of the pandemic, the number of patients being admitted under this standard reduced, with only urgent or urgent cancer suspected cases, which resulted in higher levels of compliance being recorded in April and May 2020. Services started to resume in July 2020, with the re- mobilisation process prioritising planned care on the basis of clinical urgency. The number of patients admitted under the TTG increased from 398 in June 2020 to 817 in October 2020, before decreasing month on month to 380 in January 2021, after the decision to again pause some planned care. This has again resulted in higher levels compliance being recorded. Work is ongoing to ensure the quality of data for reporting and as a result, the data reported previously has been revised.
Local management information at the end of January 2021 indicates that 35.8% of patients waiting for a new outpatient appointment had been waiting 12 weeks or less. This is a decrease of 3.6%, from 39.4% at December 2020. Prior to the impact of COVID-19, performance at February 2020 was 81.1%.
18 Weeks Referral to Treatment compliance has also been affected by the measures put in place to effectively and safely manage the pressures of COVID-19, which resulted in higher than expected compliance being recorded in April and May 2020.
The target for 18 week Referral to Treatment (RTT) compliance is 90% and local management information indicates that compliance has increased by 3.4 percentage points, from 71.1% in December 2020 to 74.5% at January 2021. Prior to the impact of COVID-19, performance at February 2020 was 79.7% and had been showing an improving trend. The 18 weeks RTT measurement is based on the patients who have completed their treatment stage. At the current time, we are prioritising the reduced treatment capacity for Urgent Cancer Suspected (UCS) and Urgent patients, and less urgent patients are not being treated. Therefore the 18 weeks RTT measurement cannot be meaningfully compared to performance prior to the COVID-19 outbreak.
16 of 38 Diagnostics
Like other services, routine diagnostic services including x-rays and scans were suspended from mid-March 2020 in order to create additional capacity to support the emerging COVID- 19 demand; and also to reduce the public footfall in the hospitals with the associated risk of increased transmission of the infection. Urgent and Urgent Cancer Suspected imaging investigations have continued throughout. This has resulted in an increased backlog of patients awaiting routine imaging investigations.
The re-mobilisation process has prioritised planned care patient activity on the basis of clinical urgency rather than length of wait.
Endoscopy
Endoscopy services have been significantly impacted during the COVID-19 outbreak due to the re-designation of space to expand ICU facilities, social distancing, reduced patient throughput due to national infection control protocols, and the risk associated with aerosol generating procedures.
With the exception of November 2020, there has been a month on month increase in those waiting over 6 weeks from 735 as at the end of February 2020 to 3,083 at January 2021. A comparison of the number of patients waiting is outlined below:
Number waiting As at 29th As at 31st As at 31st (including unavailable February 2020 December 2020 January 2021 patients) Endoscopy > 6 weeks 735 3,014 3,083 <6 weeks 1,295 822 756 All waits 2,030 3,836 3,839 Source: Local monthly management reports, Information Team
Endoscopy – Improvement Actions
The Endoscopy service continues to function with capacity limited due to a combination of facility reduction (loss of recovery space at UHC to COVID-19 ICU) and infection control measures. This has been further impacted by the requirement to re-deploy a number of endoscopy nurses to support ward and ICU staffing.
The Emergency Management team did support the implementation of the Low Risk Pathway in endoscopy, which will allow increased patient throughput, however shortly after this approval, the COVID-19 prevalence increased significantly and so the decision was taken to delay the implementation of this pathway.
The reduced local capacity has been partly mitigated by ongoing use of some colonoscopy capacity at Golden Jubilee National Hospital. Opportunities are being explored to expand this.
One of the implications of the pandemic has been the need to pre-assess all endoscopy patients. Pre-pandemic this was only done for the smaller cohort of patients referred by the national bowel screening service. This pre-assessment requirement has been added to the nursing role in endoscopy, and at a time when nursing resource is very limited, the capacity
17 of 38 to pre-assess patients prior to endoscopy has become a significant constraint in preventing further mobilisation. The operational team are working to develop a plan to address this shortfall longer term.
The endoscopy services continues to deliver around 50% of its pre-COVID-19 capacity. Capacity is being prioritised for patients referred with an Urgent Suspicion of Cancer, or on an ‘Urgent’ basis.
To support clinical triage and to ensure the patients are investigated in a timely fashion, quantitative faecal immunochemical testing (qFIT) was implemented from 6th September 2020 for new referrals. Due to the reduced capacity, no routine referrals are being investigated and therefore qFIT testing will be rolled out to the routine patients already on the waiting list which will then be followed up with a telephone review starting in early March 2021.
Two nationally supported initiatives are also supporting the endoscopy service. The Cystosponge session as an alternative to endoscopy for Barrett’s patients was initiated and delivered on 18th January 2021 and will be ongoing on a fortnightly basis.
Imaging
Imaging services have remobilised to around 75% of pre-COVID activity, and are currently impacted by infection control measures and staff absence due to illness or self-isolation.
Overall, there has been a reduction in new referrals for CT and MRI in recent months however there is an increased demand for scanning for unscheduled care presentations and for those with an urgent suspicion of cancer, both of which are being prioritised, and as a result there is limited activity for routine referrals.
Overall waiting lists for MRI have decreased from 2,331 at February 2020 to 1,441 at January 2021. In contrast, the CT waiting lists had increased from 1,696 at February 2020 to 2,542 at December 2020 but have since decreased slightly to 2,304 at January 2021. It should be noted that CT waiting lists are however reducing following a recorded high of 3,098 at October 2020.
A comparison of the number of patients waiting for CT and MRI is outlined below:
Number waiting As at 29th As at 31st As at 31st (including February 2020 December 2020 January 2021 unavailable patients) CT >6 weeks 316 1,650 1,476 <6 weeks 1,380 892 828 All waits 1,696 2,542 2,304 MRI >6 weeks 1,112 720 768 <6 weeks 1,219 787 673 All waits 2,331 1,507 1,441 Source: Local monthly management reports, Information Team
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Diagnostics – Improvement Actions
A number of contingency plans have been implemented including continuation of the mobile MRI van on extended working days, introduction of a temporary (staffed) mobile CT scanner at Ayrshire Central Hospital for 3 months from January 2021, use of scanning capacity at Golden Jubilee National Hospital and NHS Louisa Jordan and engagement of a locum ultra- sonographer.
Demand and capacity analysis has demonstrated the need for significant additional permanent MRI and CT scanning capacity, and a business case is being developed.
The CT pods at NHS Louisa Jordan are being decommissioned in March 2021 at which time one will replace the mobile CT scanner currently based at ACH.
There has also been funding agreed to staff the current CT scanner a further 2 days meaning this will be able to run 5 days a week.
National Waiting Times – Diagnostics Targets
The limited Endoscopy and Imaging capacity has in turn impacted on the number of patients waiting and as a direct consequence affected compliance against the National Waiting Times Diagnostic targets. The re-mobilisation process has prioritised planned care patient activity on the basis of clinical urgency rather than length of wait, therefore Endoscopy and Imaging compliance is expected to remain at a lower level. A comparison of compliance in January 2021 and January 2020 is outlined below. Future reporting will represent a move away from measuring compliance, to measuring activity and trajectories outlined in the RMP3.
Diagnostics
19.7% 59.8% Jan 2021 Jan 2020 of patients were waiting fewer than 6 weeks for Endoscopy 100%
51.5% 66.6% 100% Jan 2021 Jan 2020 of patients were waiting fewer than 6 weeks for Imaging
Compliance against the 6 weeks Access Target for Endoscopy has decreased by 1.7 percentage points, from 21.4% at December 2020 to 19.7% at January 2021. Prior to the impact of COVID-19 performance at February 2020 was 63.8%.
Imaging compliance as a whole for all four modalities (CT, MRI, Barium Studies and Non - obstetric Ultrasound) against the 6 weeks Access Target of 100% has de creased by 0.9 percentage points, from 52.4% at December 2020 to 51.5% at January 2020. Prior to the impact of COVID-19, performance at February 2020 was 73.0%.
Cancer
Throughout the COVID-19 outbreak, Cancer cases continued to be assessed and treated on a selected and risk -assessed case by case basis in most specialties, with the exception of colorectal and upper gastrointestinal cancer surgery, where the risks were deemed too high.
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Some urgent/urgent cancer suspected (UCS) outpatient activity continued using a combination of telephone, video and face to face consultations as deemed appropriate.
Performance against the 31 day and 62 day Cancer targets are shown in the infographic below.
Performance against the 31 day Cancer target of 95% has been consistently met and maintained throughout the COVID-19 outbreak with performance reaching 100% in September 2020 and 100% being maintained through to December 2020.
Compliance against the 95% 62 day Cancer target has increased by 5.8 percentage points, from 79.7% in November 2020 to 85.5% in December 2020. This compares to 87.9% in December 2019. Prior to the outbreak of the pandemic, the 62 day Cancer target was on an improving trajectory, reaching 89.6% in February 2020. Performance levels remained high for the 62 day Cancer Target until August 2020, but started to decrease as newly diagnosed cancer patients require treatment. December 2020 performance levels show a positive change in direction.
Cancer – Improvement Actions
The remobilisation of cancer services continues to be a priority and restart is being guided by clinical priority, equitable access and delivery of care in the safest possible environment. Unfortunately, the extreme pandemic pressures in January 2021 led to the need to pause most cancer surgery from 6 January 2021. Contingency arrangements have since been put in place through the use of Golden Jubilee National Hospital and independent sector hospitals which are partly mitigating this, and the backlog of cancer surgery which resulted from this pause has since been addressed. However it is expected that this pause in cancer surgery will be reflected in future performance reports.
As at mid-January 2021, breast cancer surgery is being undertaken at Golden Jubilee National Hospital and Nuffield Hospital, colorectal cancer at BMI Rosshall Hospital, some gynaecology cancer diagnosis and surgery at BMI Rosshall Hospital, and some melanoma surgery at BMI Carrick Glen Hospital. Plans are being finalised for ENT cancer diagnosis and surgery which is expected to be at Golden Jubilee National Hospital, and through a networked arrangement across the West of Scotland for Upper GI cancer surgery. In each of these arrangements, Scottish Government has ‘leased’ the facility and NHS Ayrshire & Arran surgeons are operating in these hospitals. Urology cancer surgery is currently able to continue at UHA.
There continues to be pressure on the diagnosis stage of the cancer pathways, particularly in upper GI endoscopy and colonoscopy as previously outlined. This means that many patients have exceeded the 62-day target before they have the investigation which diagnoses their cancer.
20 of 38 NHS Ayrshire & Arran has been selected to be a pilot site, by Scottish Government, for the introduction of Early Cancer Diagnostic Centres across Scotland. We have been granted £85,000 of funding to recruit to a 12 month fixed term post for an Advanced Nurse Practitioner (ANP) and development of Multidisciplinary Team and admin processes to support this function.
The referrals for this centre will be patients who do not currently meet the site-specific Scottish Referral Guidelines for Suspected Cancer criteria but who have symptoms which are concerning to their GP. The centre will mean that patients will be able to access appropriate diagnostic testing and consultation with a specialist ANP within a 2 week timeframe with the aim of then referring on to the most appropriate specialist pathway or discharging back to their GP once diagnosis is confirmed. We expect that 85% of patients referred will not have a cancer diagnosis but potentially other serious life-affecting illness and this pathway will ensure they are referred on as soon as possible. This will run for a 12 month period with ongoing evaluation throughout to ensure best practice and long term feasibility.
Mental Health Mental Health Services (including Learning Disabilities and Addiction Services) within Ayrshire and Arran continued to provide health and social care interventions based on contingency planning and RAG rating throughout the COVID-19 outbreak. Some aspects of care requiring or requested to be put on hold included; day care, respite, support packages and group work. However, alternative support arrangements were put in place to safeguard the individuals that this affected.
Other aspects of care required to be expedited in order to deliver the Scottish Government’s directive to redirect individuals away from Emergency Departments, such as the implementation of Mental Health Practitioners (MHP’s) across Ayrshire to support screening and signposting at GP practice level, as well as the provision of care locally and safely through the use of digital technologies. A successful tender for Distress Brief Intervention (DBI) was completed and went live as planned with a “soft launch” on 25 January 2021 across Ayrshire. The first pathway being developed is Primary Care and will see MHPs being trained and having direct referral pathways into the DBI commissioned service (Penumbra). This pathway will be closely followed by developments to support the ED pathway.
Inpatient services have continued to be delivered throughout the COVID-19 outbreak, albeit with an increased threshold for admission for only those most at risk, and some realignment of services to afford specific isolated assessment provision and specific areas to support those confirmed positive for COVID-19.
Current performance against National Waiting Times targets for Psychological Therapies and CAMHS are outlined in the infographic below.
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Mental Health – Psychological Therapies
Psychological Therapies waiting times continue to remain below the 90% compliance standard, however waiting times through the COVID-19 period has shown signs of improvement with compliance of 87.6% at December 2020 being the highest recorded position. There has however been a reduction of 6.8 percentage points at January 2021, with compliance of 80.8%. This reduction is in part related to the seasonal impact of leave and reduced clinical activity. Prior to the impact of COVID-19, performance at February 2020 was 74.9%.
Referral demand reduced between April and October 2020 which enabled staff to work through existing cases and to start new patients. Numbers of accepted referrals in April 2020 were 65% lower than 2019 rates but have returned to pre-COVID-19 rates since November 2020.
While acknowledging that waiting times had improved through the COVID-19 restrictions to December 2020, those improvements reported must be considered with caution. The improvements may reflect recent changes to service delivery such as the positive increase in patients accessing the new computerised cognitive behavioural digital options being offered as well as the re-instatement of face-to-face clinics and the selection of cases who had not yet breached the waiting times standard on the grounds of urgency and high risk.
Psychological Therapies – Improvement Actions
Provision of Psychological Therapies has been maintained, as close to business as usual, from the outset of the pandemic using remote delivery (telephone and NearMe). While some Psychological Service staff time has been refocused on supporting staff wellbeing, the majority of staff retain their usual work focus and continue to deliver a blend of remote and face-to-face working.
While the reduced referral demand has enabled overall waiting time compliance to improve since March 2020, there is considerable variability in waiting times across the Psychological Specialties. The COVID-19 restrictions and pause in Acute outpatient clinics resulted in considerably reduced referrals to the Clinical Health and Neuropsychology Specialties, enabling staff to clear the historical backlog and introduce new service developments to maintain improvements. In contrast, there has been a negative impact on waiting times within the Specialties of CAMHS and Community Paediatrics, where there has been low acceptance and suitability for remote working. This relates to the predominance of neurodevelopmental and neuropsychological work within these Specialties, and the limited evidence base and options to deliver these specialist assessments to children remotely.
22 of 38 The recent increase in referral rates to pre-COVID-19 levels will slow down the improvements seen in waiting times and numbers waiting through 2021. It is expected that waiting time progress will stabilise but with an overall gradual improvement through the year ahead based on a stabilisation in referral demand, increased capacity and activity, and the ability to implement service adaptations, innovations and redesign.
The service provision which had been paused in the initial lockdown period included non- essential face-to-face assessment and treatment; neuropsychological and neurodevelopmental assessment in children and adults, and; therapeutic groups. Much of this provision has been reinstated and will be progressed during the year ahead, within ongoing COVID-19 constraints, availability of face-to-face clinics and staff capacity, through the service adaptations and developments outlined below:
• Strong recruitment drive to fill all vacancies. A skill-mix and adaptations to existing posts have been developed to increase recruitment to difficult-to-fill- posts; • Continue remote delivery of psychological assessment and treatment where appropriate; • Continue development of remote therapeutic groups following positive evaluation of pilot groups. This will include training to expand the numbers of trained clinicians to deliver a remote trans-diagnostic group therapy for adults presenting with distress and emotional regulation problems which forms the majority of referrals to the service; • Re-instate face-to-face clinical contact in outpatient and inpatient settings, prioritising longest waits and neurodevelopmental and neuropsychological assessment. Use a blended face-to-face/remote approach to remove barriers to accessing psychological input and to increase patient choice (e.g. using remote delivery initially to engage a new patient who is anxious or restricted in their ability to attend a clinic setting); • Expand access to an increased range of SG supported digital options as part of a tiered model of service delivery. This follows the award of pilot projects for Silvercloud Cognitive Behaviour Therapy based modules for Generalised Anxiety Disorder, Perinatal Mental Health and Children and Young People. Further increase in access is expected as these options are extended to the Acute Services. In addition, capacity increased for mild to moderate presentations with the introduction of the IESO text base therapy in January 2021; • Implement the recently developed strategic plan for psychological training and supervision, initially focused on Adult Mental Health, based on clinical care pathways, and with more explicit knowledge of what resource is available and required for delivery of the different levels of psychological work; and • Development of data systems (Trakcare and Carepartner) for Psychological and wider Mental Health Services, to improve accuracy in reporting and access to service data to inform on demand capacity analyses and clinical outcomes.
Mental Health – CAMHS
The target for CAMHS compliance is 90%, and local management information indicates that CAMHS continues to exceed the target with performance of 97.5% at January 2021. This is however a reduction of 2.5 percentage points from the previously reported high of 100% in December 2020, the first time compliance had reached 100% since February 2018. Prior to the impact of COVID-19, performance at February 2020 was 94.6%.
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CAMHS – Improvement Actions
Significant steps are being taken within CAMHS to develop relationships with stakeholders in the development of care and treatment pathways for children and young people who present to services in an unscheduled manner, this is to say via Emergency Department of Out of Hours. Coupled with this is the aspiration to reconfigure the service in such a manner which will provide accessibility to CAMHS across seven days of the week.
The introduction of a Full Time Senior Nurse to the service has also proved key to developing supervision arrangements and professional development for the nursing workforce WITH Band 6 and Band 5 peer clinical supervision groups now established.
The recruitment of two non-medical nurse prescribers to the service in January 2021 will see both successful candidates commence their training in September 2021. Their inclusion into the service will greatly increase capacity to specialist assessment, diagnosis and treatment of Attention Deficit Hyperactivity Disorder as we progress through 2021/22.
Mental Health – Drug and Alcohol Treatment
Drug and Alcohol Treatment continues to meet and exceed the target of 90% with performance of 98.6% in November 2020. Prior to the impact of COVID-19, performance at February 2020 was 98.6%. Performance against National Waiting Times is outlined in the infographic below.
Due to a technical issue with the new National Drug and Alcohol Information System (DAISy), the waiting times for services for December 2020 and January 2021 is not available for this report. DAISy is a database being developed to collect Scottish Drug and Alcohol Treatment, Outcomes and Waiting Times data from staff delivering specialist drug and alcohol interventions. It is expected that reports will be available from April 2021.
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Alcohol and Drugs Waiting Times – Improvement Actions
East Ayrshire Alcohol and Drugs Partnership (ADP) have received support in three development areas via Drug Death Task Force monies. Firstly an additional two posts, a band 6 nurse and a community peer worker, have been funded to support liaison services and community interface work around non-fatal overdose follow-up and support. In addition the redesign of treatment services is progressing which will see 1 single access point for Rapid Access to Drug and Alcohol Recovery services (RADAR) which combines NHS and commissioned treatment services under one same day assessment and access to treatment support point. This is in line with the recently published Medication Assisted Treatment Standards. Finally the last area being developed is in relation to a recovery hub for East Ayrshire. This will include access to linked satellite bases in some of our more
remote a rural communities. Central to the development of this hub are the voices of those
with lived and living experience who will help to shape and design our approach to make a real difference in the lives of those people, families and communities affected by a range of inequalities linked to alcohol and drug related issues.
East Ayrshire have also aligned an MHP to each of the GP practices. This has had a significant positive impact on waiting times for Primary Care Mental Health Team (PCMHT).
North Ayrshire services continue to meet the ‘Access to treatment’ standards whilst prioritising individuals who are the most vulnerable for face to face, in person, support alongside the use of telephone and Near Me technology. All community interventions continue be delivered and the residential facility in Ward 5, Woodland View, continues to offer the core functions of detoxification and rehabilitation hospital based support (whilst the day attendance programme is paused due to wider COVID-19 related restrictions –
these clients continue to be supported by the locality community services). The next phase of the wider Re-mobilisation Plan (covering the period of April 2021 to March 2022) is currently being finalised and being submitted for review and approval.
Across South Ayrshire Community Addiction Services, staff continue to scope out new
developments including a Test of Change pilot using Medication Assisted Treatment (MAT) standards. Staff from the Community Addiction Service continue to work closely with the multi- agency service Connect 4 Change and the wider recovery networks within South Ayrshire.
Musculoskeletal Services
Performance against National Waiting Times targets for Musculoskeletal Services has improved since the outset of the pandemic and current performance is outlined in the infographic below.
MSK
81.7% 53.1% 90% Feb 2021 Jan 2020 of adult patients were waiting fewer than 4 weeks for MSK services
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Local management information indicates 81.7% of patients were waiting fewer than 4 weeks at February 2021, an increase of 7.5 percentage points from 74.2% at January 2020. Prior to the impact of COVID-19, performance at February 2020 was 53.1%.
Musculoskeletal – Improvement Actions
As part of the Allied Health Professionals (AHP) Continuity Plans, the resurgence of COVID-19 and the associated increased workload that would bring to AHP services in the acute setting, some MSK staff were re-deployed back to acute services. From October 2020, a phased and blended approach was taken to bring more physiotherapists in from MSK to acute services.
COVID-19 illness and self-isolation has also reduced capacity which will impact on waiting lists and other service provision.
Patient Initiated Reviews, opting in for new appointments and Active Clinical Referral Triage have targeted a reduction in waiting times, which are currently averaging 8 weeks.
Escalation pathways to orthopaedic Advanced Practice Physiotherapists are in place for patient safety. As we resume, the new norm will be virtual consultations, with face to face consultations guided by strict guidelines.
Outpatient areas have been risk assessed and face to face consultations re-started, albeit on a significantly reduced capacity due to infection prevention and control measures and loss of clinical space.
Digital, Social media and the public facing web page have been increased significantly to provide self-management and exercise advice. Enhanced self-management information is being integrated in to the clinical pathways which are currently being re-vamped to include virtual consultations and digital access for the whole patient pathway across whole systems.
Qualitative feedback has been sought for telephone and Near Me consultations with very positive feedback from patients and staff. The service will continue to evaluate new ways of working and are currently developing pathways for a whole systems approach.
Many MSK staff have been re-patriated to MSK services after working in the acute sector to help with the COVID-19 pandemic. These staff are now trained to return to the acute sector and downstream areas if required.
2.3.3 Quality/patient care
As we seek to balance re-mobilising our services with continued response to COVID-19 and deal with the normal impact of winter on our system as a whole, systems and procedures continue to be in place to monitor and manage the impact on performance in our provision of unscheduled and planned care for our citizens to ensure high quality of care for patients.
2.3.4 Workforce
A sustainable workforce and recruitment levels are imperative across all services as we provide services within the current circumstances.
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Workforce implications identified relate to COVID-19 related staff absences to ensure appropriate levels of capacity are maintained to manage demand.
2.3.5 Financial
The health and care system is ensuring appropriate levels of capacity are maintained to restart services but also to manage the demand throughout the current resurgence of COVID-19.
The impact of COVID-19 on the delivery of key performance targets and trajectories are routinely being assessed and monitored.
2.3.6 Risk assessment/management
There is a significant risk to the organisation in failing to manage the impact of COVID-19, however detailed plans are in place to ensure that the safety of patient care is prioritised.
Risks remain that unforeseen circumstances, e.g. ward closures due to illness or staff absence, could adversely affect system flow. Staff and service leads have contingency plans in place where possible.
The impact of COVID-19 on the delivery of key performance targets and trajectories are routinely being assessed and monitored.
2.3.7 Equality and diversity, including health inequalities
An Impact Assessment has not been completed as this paper provides an update on performance of the health and care system during the COVID-19 pandemic.
2.3.8 Other impacts
Best value: Successful management of waiting times requires leadership, and engagement with clinical staff. Local performance management information is used to provide as up to date a position as possible in this report. Some information may change when the data is quality assured by Public Health Scotland in readiness for publication.
Compliance with Corporate Objectives: The achievement of the waiting times targets set out within this paper complies with a number of the corporate objectives: improving health; safety/outcomes; quality of experience; equality; transforming and patient flow; supply and demand.
Local outcomes improvement plans (LOIPs): The achievement of the targets provides better access to healthcare services and should therefore have a positive effect on the health inequalities priority within local LOIPs. The achievement of the patients awaiting discharge targets will have a positive contribution towards the Outcomes for Older People priority.
27 of 38 2.3.9 Communication, involvement, engagement and consultation
There is no legal duty for public involvement in relation to this paper. Any public engagement required for specific service improvement plans will be undertaken as required.
2.3.10 Route to the meeting
The content discussed in this paper has been considered by the Senior Responsible Officer for each area and the Strategic Planning and Operational Group (SPOG). They have either supported the content, or their feedback has informed the development of the content presented in this report.
2.4 Recommendation
NHS Board members are asked to discuss the information provided in this report which provides assurance that systems and procedures are in place to monitor and manage the impact of COVID-19 on our provision of unscheduled and planned care for our citizens.
3. List of appendices
There are three appendices to support this report. Appendix 1 provides detailed trend charts for elements of the planned and unscheduled care performance as described within those sections in this paper. Appendix 2 includes a breakdown of the latest National Data in relation to both planned and unscheduled care performance. To provide additional context, Appendix 3 provides trends in the number of COVID-19 inpatients in our hospitals.
28 of 38 Appendix 1
Trends in Unscheduled Care and Planned Care Performance
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Comparison with National Data
Planned Care Waiting Times Performance – NHS Ayrshire & Arran (+) Improving position; (-) Worsening position; QE – Quarter ending
Measure Latest National Latest Latest Latest Published Data Local Local Published NHS A&A Data Data Scotland NHS compared Data A&A to Published data New Outpatients 45.1% 35.8% (-) 46.5% QE Sept 2020 Jan 2021 QE Sept 2020 Referral to 71.1% 74.5% (+) 73.8% Treatment* Dec 2020 Jan 2021 Dec 2020 Inpatients/Daycases 31.0% 30.9% (-) 30.0% QE Sept 2020 Jan 2021 QE Sept 2020 CAMHS 100% 97.5% (-) 72.9% Dec 2020 Jan 2021 Dec 2020 Psychological 86.4% 80.8% (-) 83.2% Therapies Dec 2020 Jan 2021 Dec 2020 Drug and Alcohol 99.2% 98.6% (-) 97.2% QE Sept 2020 Nov 2020 QE Sept 2020 MSK 56.2% 81.7% (+) 52.5% QE Sept 2020 Feb 2021 QE Sept 2020 Cancer 31 Day 98.6% 100% (+) 98.4% QE Sept 2020 Dec 2020 QE Sept 2020 Cancer 62 Day 94.8% 85.5% (-) 87.3% QE Sept 2020 Dec 2020 QE Sept 2020 Endoscopy 21.4% 19.7% (-) 32.2% Dec 2020 Jan 2021 Dec 2020 Imaging 52.4% 51.5% (-) 66.7% Dec 2020 Jan 2021 Dec 2020
* NHS Ayrshire & Arran data for July 2017 to May 2020 contain estimates for this measure. These estimates are deemed statistically robust by PHS.
37 of 38 Unscheduled Care Performance – NHS Ayrshire & Arran
(+) Improving position; (-) Worsening position
Measure Latest Latest Latest Latest National Local Local Published Published Information Information Scotland Data versus Data Published data ED 4 HR 79.0% 79.0% (=) 86.0% Compliance Jan 2021 Jan 2021 Jan 2021 (%) Delayed 16 9 (+) 274 Discharges Jan 2021 w/c 22nd Jan 2021 > 2 weeks Feb 2021 (excluding code 9s)
Appendix 3
Trends in COVID-19 inpatients
Number of COVID-19 positive inpatients across all NHS Ayrshire & Arran hospitals
Definition: The number of COVID-19 confirmed positive patients in hospital the previous day at 8am (including in ICU). Data will include patients who first tested positive for COVID-19 within the 14 days prior to admission or during their current hospital stay. Any in-patients who first tested positive more than 28 days before are excluded. Source: COVID 19 Daily Hospital Management Information (Scottish Government Return)
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