University Hospitals Bristol NHS Foundation Trust – 93.0% February 2013; 94.2% Year to Date

Performance Report For the governing body of South Gloucestershire CCG, to be tabled on 24 April 2013

Purpose

The purpose of this report is to inform the board current performance of the services commissioned by South Gloucestershire CCG against key access and quality standards. The majority of the standards in this document show performance to February 2013 i.e. month 11 of the 2013/14 financial year, with the exception of urgent care performance standards which are shown to week ending 31 March 2013.

The report is intended to provide a variety of level of details. The executive summary below details the current main performance concerns of the South West Commissioning Support Unit Performance Team and is therefore provides a quick overview of current issues. There is also a scorecard attached which shows current progress against all key standards. For a more in depth commentary on performance, the sections of this report will summarise the detail of performance against key standards for:

Urgent Care Planned Care Cancer Stroke/TIA Quality indicators e.g. healthcare associated infections

The Governing Body is asked to note the contents of the report. Executive Summary

The main current areas of concern are shown in the table below:

Area Standard Current Commentary Performance Urgent 4hrs: 95% of all As at week The whole health system has been experiencing severe Care patients to be ending 31/03/13: pressure for a number of months and this has been seen, treated, maintained recently, as is demonstrated by performance admitted or 4hrs: against urgent care standards. discharged NBT: 85.76% within 4hrs of UHB: 91.48% Patient flow remains at the core of the problem, although arrival at A&E recently an increase in activity due to issues with the launch of the NHS 111 system has increased pressure Ambulance Handovers: further. Both Bristol trusts as well as community and social Handover: No NBT: 43% care providers are working together to improve the more than 10% UHB: 34% timeliness of discharge and the Trusts are anticipating that of ambulance performance will be recovered by Summer 2013. Please handovers to see the Urgent Care section for more. be completed in more than 15 minutes Planned No more than February 2013: Both Bristol Trusts have reported high levels of elective Care 0.8% of cancellations, which are the direct cause of current bed operations to UHB: 1.2% pressures. There were 56 cancellations at NBT and 82 at be cancelled at UHB in February 2013. Reductions in the level of last minute (i.e. NBT: 1.6% cancelled operations are linked to the ongoing work to on day of improve patient flow and therefore availability of beds. arrival at hospital for 2

surgery) for non-clinical reasons Diagnostics 99% of patients February 2013: Failure to meet the target is an ongoing problem. The to receive cause of the continued underperformance is a diagnostic test South longstanding backlog in gastroenterology investigations within 6 weeks Gloucestershire due to capacity issues in 2012/13. of referral CCG: 98% The size of the backlog is such that the Trust is not UHB: anticipating achieving the 99% standard until June 2013. It 92.04% should be noted that, month on month, progress against the standard is being made now that additional clinicians UHB YTD: and endoscopy rooms have been made available. 89.20% Cancer 90% of patients February 2013: As at February 2013 North Bristol NHS Trust are reporting with urgent a provisional position of 33% against the 90% urgent referral from NBT: 33% referral to treatment from national screening programme National standard. Screening Programme to Commissioners are investigating this at present. It is be treated essential to note that this is a provisional position and may within <62 days change on validation; an update will be provided verbally of referral at presentation of this report.

Independent verification of this position is not possible at the time of writing as South West Commissioning Support Unit staff do not currently have access to the Open Exeter system which stores cancer waiting times information following the national transition process. Nationally, work is ongoing to resolve this. Healthcare UHB Target: Year to date: With a further case of MRSA in February 2013 UHB have Associated Max incidence had 9 cases of MRSA in 13/14 against a plan of 2. Infections of MRSA 2 9 cases cases The Health Protection Agency has coordinated a point prevalence survey that was undertaken in February 2013 to look at cannula management and insertion. Results are currently being analysed and will be shared in the next report.

Detailed Performance Overview – Urgent Care South Western Ambulance Service NHS Foundation Trust Red 1 Calls (Target 75% within 8 minutes): 74.9 % February 2013; 76.4% year to date.

The Trust has underachieved the 75% standard in February 2013 but continues to achieve year to date. Red 2 (Target 75% within 8 minutes): 75.8% February 2013; 76.7% year to date. The Trust continues to achieve this target both in the month and for the year to date. Accident and Emergency waiting Times > 4 hours (Target 95%) North Bristol NHS Trust – 94.0% February 2013; 93.4% year to date. University Hospitals Bristol NHS Foundation Trust – 93.0% February 2013; 94.2% year to date. Ambulance Handover Performance Overall Ambulance Handover Breach Rate (Target Max 10% of all Ambulance Handovers >15 minutes) Overall in Bristol, North Somerset and South Gloucestershire, the rate of ambulance handover breaches remains higher than the target maximum of 10%. This is a worsening position and the South Western Ambulance Service NHS Foundation Trust has been reviewing their Standard Operating Protocol for handovers to Trusts in response to this decline in performance.

North Bristol NHS Trust Handover Performance – 2012/13 average 38%; w/e 31/03/13 43%

North Bristol NHS Trust Ambulance Handover breach rates remain higher than the target. Weekly performance management teleconferences are in place to monitor provider performance against urgent care standards including ambulance handover. Commissioners have stressed the importance of ensuring that sufficient senior representation is available from the Trusts for escalation teleconferences. The main reason for breaches continues to be slow patient flow due to a lack of beds. North Bristol NHS Trust is carrying out a number of actions to address these issues further details of which are in this document under four hour performance.

University Hospitals Bristol NHS Foundation Trust Handover Performance – 2012/13 average 28%; w/e 31/03/13 34%

University Hospitals Bristol NHS Foundation Trust handover performance has continued to worsen in recent weeks, in line with wider operational and patient flow problems. Similar to North Bristol NHS Trust, due to not being able to access data for handover delays below 20:00 minutes, the Trust is focussing on data quality to eliminate discrepancies between the Trust and ambulance service data sources. The Trust holds fortnightly handover meetings to monitor progress towards 90%. Actions being undertaken to improve patient flow and therefore improve the handover process are detailed as part of the section below on 4 hour performance.

Accident and Emergency 4 Hour Performance

North Bristol NHS Trust 4 hour Performance – 2012/13 92.15%; w/e 31/03/13 85.76%

The above graph presents performance against the 95% 4 hour standard. The Trust has been unable to maintain performance to the required standard with March 2013 and into April 2013 being particularly challenging. As reported in the previous month, the Trust has shared a recovery plan with commissioners and delivery of the 4 hour standard is planned for by the end of Q1 2013/14. The action plan sets out a package of measures to improve patient flow and recover performance. In addition to the action plan, commissioners have been negotiating with the Trust to define a CQUIN for 2013/14 which will provide a robust framework for supporting and monitoring the Trusts delivery of recommendations in the Emergency Care Intensive Support Team report. Identified actions that were strongly recommended include: improving internal surge management through use of a ‘full capacity protocol’; improvements to the internal ‘take’ system; and improving patient flow through a number of initiatives, for example, reviewing weekend medical cover, daily consultant-led board rounds and multi professional discharges.

University Hospitals Bristol NHS Foundation Trust 4 hour Performance – 2012/13 94.00%; w/e 31/03/13 91.48%

In February 2013, University Hospitals Bristol NHS Foundation Trust has struggled with capacity with a significant number of breaches over the 4 hour standard. As with all providers, the Trust has been in close liaison with commissioners, other providers and the ambulance service to ensure the whole community understand the pressure points. The main contributory factors to failing against the standard in February 2013 were significant bed pressures associated with Norovirus related bed closures, an increase in the number of emergency admissions in comparison to the same period last year and the community being unable to quickly accommodate delayed discharge patients. In addition to delivery of the recovery plan, the Trust has a joint patient flow project with KPMG with workshops established to prioritise the work to be undertaken.

NHS 111 The full launch of NHS 111 whereby the current NHS Direct service would be discontinued and their calls transferred to the new 111 service was delayed until after Easter 2013. Performance in the first month of operation during the ‘soft launch’ has not been as expected. The main concerns has been an inability of Harmoni to hit their key performance target of answering calls 95% of the time within 60 seconds and there is also concern that a high number of calls are abandoned. In addition, there are concerns with high numbers of

referrals to the ambulance service for ambulance dispatch and an inability to utilise the provided directory of services to its full potential. Activity has been high across the health and social care system with Harmoni joining at one of the busiest times of the year. Harmoni has put in place a number of mitigating actions in conjunction with South Western Ambulance Service NHS Foundation Trust and commissioners. Key actions include: Production of a medium term staffing plan to address the issue of slow processing of calls and the ability to meet the quality standards for call answering. Newly trained and inexperienced Health Advisors has been identified as a short-term issue whilst they build up experience. A joint audit approach in place between South Western Ambulance Service NHS Foundation Trust and NHS 111. An individual case review of all non-conveyed patients. Identification of a discrepancy between the Directory of Services recognised locally and the one available to NHS 111 Health Advisors. This has been escalated to the highest level of Harmoni to understand the problem, technical causes, and identify resolution actions. The key commissioners and the Department of Health have and will continue to conduct daily conference calls seven days a week focussing on actions to remedy performance. Harmoni are working very hard to bring their service up to the standards we would expect of it however we are currently still not in a position where we can, as commissioners, be assured of their future performance. Each weekend we have been asking for staffing profiles to ensure adequate cover.

Winter Planning An evaluation of the effectiveness of the winter planning process and allocation of monies is being carried out. A report will be produced in May 2013 and a summary of the findings will be provided in the June 2013 Performance Report. Detailed Performance Overview – Planned Care Referral to Treatment (RTT) Key targets: 18 Week Admitted Pathways – Achieved 90%, Failed 85% 18 Week Non-Admitted Pathways – Achieved 95%, Failed 90% Incomplete Pathways – Achieved 92%, Failed 83%

North Bristol NHS Trust – RTT North Bristol Reported Performance for BNSSG NHSTrust Pathway Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Type Admitted 93.80% 92.10% 90.90% 92.71% 90.41% 90.35% Pathways Non-Admitted 94.50% 97.90% 97.80% 97.91% 97.94% 97.07% Pathways Incomplete N/A N/A N/A N/A N/A N/A Pathways

Specialities by Exception Reporting Only Trauma & Orthopaedics Admitted 18w - failed at 79.3%, performance static since January 2013 (79.3%). North Bristol NHS Trust still have a backlog of long waiters, and work continues to be outsourced to the private sector to meet reduce this backlog. North Bristol NHS Trust is expecting to achieve the standard by the end of Quarter 1 2013/14. Neurosurgery Admitted 18w – underachieved at 87.27%, improving from January (78.8%). North Bristol NHS Trust is reporting a different position to that shown by commissioner SUS data and this is being investigated. Incomplete Pathways North Bristol NHS Trust did not repeat Incomplete Pathways in February 2013 due to ongoing data validation following Cerner implementation. However, at the time of writing the Trust had nearly completed validation of records and expects to report incomplete pathways in April 2013.

University Hospitals Bristol NHS Foundation Trust – RTT

University Hospitals Reported Performance for BNSSG Bristol NHS FT Pathway Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Type Admitted 93.80% 94.30% 92.30% 91.30% 91.05% 92.56% Pathways

Non-Admitted 95.10% 95.50% 95.70% 95.75% 95.67% 96.75% Pathways

Incomplete 92.10% 92.40% 92.40% 92.51 92.61% 92.76% Pathways

Overall performance remains achieved but there are a number of speciality level exceptions Specialities by Exception Reporting Only Cardiology Admitted 18w – underachieved at 85.06%, improved on January 2013 (80%). Non Admitted 18w – underachieved at 94.12% improved on January 2013 (90.51%). Incomplete Pathways – underachieved at 87.43%. Cardiology continues to fail 18 weeks due to the size of the admitted backlog in the speciality. University Hospitals Bristol NHS Foundation Trust expects to report achievement of the standard from April 2013 onwards. Cardiothoracic Surgery Admitted 18w – underachieved at 87.0%, static since January 2013 (86.96%). There were 4 Bristol, North Somerset and South Gloucestershire breaches of the target in January 2013 which has led to the underachievement. Gastroenterology Incomplete Pathways – failed at (66.96%), up slightly from January (63.16%) University Hospitals Bristol NHS Foundation Trust’s failure in Gastroenterology incomplete pathways is tied to ongoing issues around diagnostic performance – see section below for more detail on this. Rheumatology Non-Admitted 18w – underachieved at 92.42% improved from January 2013 (88.33%).

The failure of the non-admitted standard in Rheumatology relates to ongoing issues with management of follow-ups which are expected to be resolved for recovery in April 2013. Thoracic Medicine Non-Admitted 18w – underachieved at 93.09%. This relates to a small number of breaches, the causes of which are being investigated. Urology Admitted 18w – underachieved at 78%, worsening from 85% in January 2013. University Hospitals Bristol NHS Foundation Trust are working to reduce the size of the Urology backlog prior to service transfer to North Bristol NHS Trust and so there has been less focus on achieving RTT 18 week targets whilst this is addressed. Discussions around assignment of breaches post service transfer are underway. South Gloucestershire CCG - RTT South Reported Performance Gloucestershire Pathway Type Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Admitted 93.60% 94.00% 94.80% 93.60% 92.92% 93.38% Pathways Non-Admitted 97.30% 96.60% 96.90% 97.30% 97.74% 97.20% Pathways Incomplete 94.4%* 94.2%* 93.2%* 93.7%* 93.27%* 93.35%* Pathways

*Reported Incomplete Performance positively affected by non-submission of incomplete figures at North Bristol NHS Trust. Diagnostic 6 Week Performance Target: 99% of patients to receive diagnostic test within 6 weeks of referral. South Gloucestershire CCG as an organisation has underachieved against the target for 99% of patients to receive a diagnostic test within 6 weeks of referral with a performance of 98%. The main source of continued failure for the wider Bristol, North Somerset and South Gloucestershire health community are the ongoing problems at University Hospitals Bristol NHS Foundation Trust. The numbers of patients from South Gloucestershire affected by the problems are quite small (as the majority of patients will attend North Bristol NHS Trust), however the performance against the 6 week target for those South Gloucestershire patients that do attend University Hospitals Bristol is reflective of the wider problems with certain tests at University Hospitals Bristol. 91.46% of patients from South Gloucestershire CCG received tests within the 6 week target in February. The table below shows University Hospitals Bristol’s performance for South Gloucestershire patients in the five tests that are of concern:

Total South Gloucestershire Total over 6 Diagnostic Tests WL weeks % under 6 wks Dexa Scan 11 1 90.9% Sleep Studies 44 14 68.2% Colonoscopy 13 4 69.2% Cystoscopy 12 6 50.0% Gastroscopy 7 3 57.1% Whilst performance remains far below target in these tests some progress is being made in terms of the percentage of patients waiting over 6 weeks compared to previous months as the backlog has been worked through.

As detailed in previous reports the Trust areas of underperformance are mainly within the specialty of gastroenterology. The Trust has stated that this is due to a reduction in activity since April 2012 due to the following:

Structural issues at the South Bristol Community Hospital (water quality) affecting ability to provide tests; Changes to nurses weekend payments reducing uptake of additional Saturday sessions; and Increases in demand above recurrent capacity, with particular impact due to national screening campaigns.

As detailed previously the Trust action plan to achieve the standard projects hitting the 99% target in June 2013. As at February 2013, the Trust is ahead of their trajectory.

A summary of the key actions underway to achieve this are as follows:

Area of Focus Actions Increase internal Locum appointed and commence additional sessions, review internal capacity capacity to identify any additional sessions to speed up delivery, assess option for capital investment to upgrade physiology room to enable scope activity Outsourcing Subcontracting with alternative private and NHS providers, clerical process capacity (to include clinical validation) to be in place to outsource work Additional Additional clerical support to the team administrative support Clerical and Clerical validation of waiting list (and Medway), clinical validation for clinical validation outsourcing suitable capacity Performance Weekly PTL process to track delivery against plan, weekly performance monitoring reporting, review stretch case to firm up opportunities to bring delivery forward Longer term Review age extension projections for bowel screening, ensure additional service needs consultant staff in place, review SBCH capacity, consider additional endoscopist locum (agree funding) – see cancer section for further update

North Bristol NHS Trust has also failed the target in certain specialties and is underachieving overall with a performance of 98.6% for South Gloucestershire patients (98.2% for all BNSSG commissioners).

The table below shows the tests where the standard is being failed (for all BNSSG patients):

Total over 6 Diagnostic Tests Total WL weeks % under 6 wks MRI 1375 28 97.96% Non-obstetric Ultrasound 2353 35 98.51% Urodynamics 214 25 88.32% Cystoscopy 153 24 84.31%

The following table shows the numbers of South Gloucestershire CCG patients affected by this:

Total over 6 Diagnostic Tests Total WL weeks % under 6 wks MRI 648 14 97.8% Urodynamics 76 10 86.8% Cystoscopy 66 11 83.3%

The performance failure in urodynamics and cystoscopy are related to a backlog caused by previous physical capacity issues in the Urology department. These issues have been resolved and the backlog is being worked through at present.

Choose and Book – Slot Utilisation Target: Choose and Book used for 75% of all first outpatient appointment bookings.

With performance at 65% South Gloucestershire has failed against the 75% standard in February 2013. Year to date performance is 69.9%, failing the 75% target for Choose and Book performance. Performance has increased very slightly but remains below the 75% target, but conversion of referrals to bookings was above the agreed 85% target at 92.2%, year to date 87.8%. There was an increase in referrals being sent via Choose and Book, but bookings are not counting in performance as the services are not listed as First Outpatient Services (only bookings to First Outpatient Services count in performance). If all referrals counted in performance, the maximum possible performance would have been 89% in February 2013. In February 2013 there was a Choose and Book weekend upgrade resulting in issues the following week which adversely affected referrals and bookings, this will have impacted on performance for the week commencing 18 February 2013.

Performance may also have been affected by continuing slot availability issues at the local provider Trusts. University Hospitals Bristol NHS Foundation Trust slot availability has varied between 92%-97% with performance at 95% against the 96% target in February 2013. North Bristol NHS Trust slot availability has decreased slightly and varied between 97-99%. Last Minute Cancelled Operations Target: <0.8% of operations cancelled on the same day for non-clinical reasons North Bristol NHS Trust: 1.2% in February 2013; 0.8% year to date. North Bristol NHS Trust had 56 same day cancellations in February 2013, of which 26 were in Orthopaedics. These were primarily driven by issues of bed availability as the result of operational pressure. The recovery of this is therefore linked to the recovery plan to improve urgent care performance, which is expected to deliver in summer 2013. University Hospitals Bristol NHS Foundation Trust: 1.6% in February 2013, 1.5% year to date. University Hospitals Bristol NHS Foundation Trust had 95 last minute cancellations of surgery in February 2013. 49% (42 cancellations) were due to no ward beds being available. 9% (8 cancellations) were due to an emergency patient being prioritised on the day. 19% (16 cancellations) were due to a lack of theatre time due to another clinically complicated case taking longer than planned. 6% (5 cancellations) were due to repairs required to theatre. In February 2013, there were a high number of ward beds closed following the Norovirus outbreak on several wards in the Bristol Royal Infirmary and Bristol Heart Institute, as well as a high level of emergency attendances and delayed discharges, which impacted on cancellations. Due to the continued operational pressures University Hospitals Bristol NHS Foundation Trust does not anticipate achieving the standard in March 2013. The Trust reports that it is carrying out the following to recover performance: Implementing 4 hour recovery plan which should reduce cancellations related to bed availability; and Implementing improvements to patient flow which include: A review of bed occupancy and bed requirements for the Bristol Royal Infirmary and Bristol Heart Institute to try and understand how the number of medical outliers can be reduced thereby reducing impact on the elective bed base. Refreshing bed capacity model to forecast future bed requirements. Weekly meetings put in place to review scheduling to avoid booking errors. Review of demand for high care intensive therapy unit beds is being undertaken as part of the refresh of the bed capacity model.

28 Day Rebooking of Last Minute Cancelled Operations Target: 95% of last minute cancelled operations rebooked for within 28 days. North Bristol NHS Trust: 71.4% in February 2013, 75.5% year to date. North Bristol NHS Trust continues to fail the 28 day rebooking target with 16 cancellations not being rebooked within 28 days. The Trust has since held workshops with the failing specialties to understand the problems and identify improvements to booking processes. Pressures on beds due to winter have exacerbated the problem. University Hospitals Bristol NHS Foundation Trust: 90.2% in January 2013, 91.1% year to date. University Hospitals Bristol NHS Foundation Trust failure equates to 9 patients. The causes of this are Consultant leave, meaning that operations could not be scheduled within the 28 day period and bed pressures. Detailed Performance Overview – Cancer Cancer Wait Times Waiting Times Reporting Unfortunately due to unforeseen changes to the Open Exeter system following the transfer of commissioning responsibility the information team in South West Commissioning Support have been unable to provide cancer waiting time information for February 2013. Therefore, in this report the position as at January 2013 is shown for University Hospitals Bristol NHS Foundation Trust. Provisional information is available for North Bristol NHS Trust for February 2013, and this has been used in this report although it should be noted that this is subject to change once validated information is available. Access to the data is being pursued nationally. North Bristol NHS Trust – Cancer Wait Times

Cancer Under 2010/11 2011/12 Achieve Indicator achieve Dec-12 Jan-13 Feb-13 YTD

Urgent Referrals to First appointment < 2 weeks 93.5% 93.6% 93% 88% 95.4% 95.8% 95.9% 95.7%

Urgent Referrals to First appointment < 2 weeks - Breast Symptoms 97.2% 97.2% 93% 88% 94.7% 88.2% 100.0% 97.1%

Cancer Diagnosis to 1st treatment < 31 days 97.4% 97.5% 96% 91% 96.0% 95.7% 96.7% 95.1%

Diagnosis to 2nd treatment (Drug) < 31 days 100.0% 100.0% 98% 93% 100.0% 100.0% 100.0% 100.0%

Diagnosis to 2nd treatment (Surgery) < 31 days 95.9% 96.9% 94% 89% 90.8% 93.4% 94.6% 95.3%

Diagnosis to 2nd treatment (Radiotherapy) < 31 days N/A N/A 94% 85% N/A N/A N/A N/A

Urgent Referral to treatment < 62 days (all cases) 87.6% 87.9% 85% 80% 94.9% 82.3% 79.8% 84.2%

Urgent Referral to treatment < 62 days (from National Screening 94.3% 96.5% 90% 85% 83.3% 85.7% 33.3% 89.1% Programme) Urgent Referrals to treatment < 62 days (consultant upgrades) 94.4% 95.1% 90% 85% 100.0% 91.7% 100.0% 84.4%

North Bristol NHS Trust has underachieved for the urgent referral to treatment within 62 days for all cases and the urgent referral to treatment within 62 days from the national screening programme. This is due to a number of late referrals and a resulting increase in shared breaches. A review of these processes is being undertaken to identify delays and potential improvements to current systems. The breaches are under investigation at the time of writing this report.

University Hospitals Bristol NHS Foundation Trust – Cancer Wait Times

In January 2013, University Hospitals Bristol NHS Foundation Trust has failed all the 62 day standards for referral from the National Screening programme to treatment and Consultant Upgrades to treatment. 62-day screening referred University Hospitals Bristol NHS Foundation Trust has identified 3 causal factors that are causing ongoing breaches of the 62 day standard: Delays to initial bowel Specialist Screening Practitioner (SSP) appointment; Delays to colonoscopy; and High levels of patient choice to defer appointments and diagnostic tests. University Hospitals Bristol NHS Foundation Trust has fed back that demand for endoscopies have been significantly above last and outstripped available capacity, which has been limited by the delayed opening of South Bristol Community Hospital’s endoscopy suite. There have also been vacancies in the Specialist Screening Practitioner team which have now been recruited to. The impact of patient choice is most pronounced for screening pathways where patients are not exhibiting symptoms and are more likely to defer.

The delays to Specialist Screening Practitioner appointment and colonoscopy were addressed in Quarter 3, but have also impacted in Quarter 4. 62-day GP referred University Hospitals Bristol NHS Foundation Trust has identified a number of reasons for breaches of the 62 day GP referred standard: Late referral from another provider (mainly affecting lung pathways); Complex case requiring multiple diagnostic tests and/or more than one potential tumour site; Patient choice to delay their pathway; Issue at another provider (e.g. delay to treatment or administrative error); and Other (including elective cancellations, no high care bed being available, medical deferral or delayed diagnostics). Recovery Plan: University Hospitals Bristol NHS Foundation Trust is taking the following actions to correct performance: Establishing additional thoracic and upper GI operating lists to increase capacity and reduce the impact of elective cancellations (by end March 2013); In depth analysis of the thoracic pathway to identify improvements to reduce the impact of elective cancellations (by end March 2013); Weekly monitoring of colonoscopy and specialist screening practitioner appointment waiting times with corrective action being taken as necessary (ongoing); All patients with delayed starts to their screening pathway continue to be tracked and tests/ treatment expedited where possible (ongoing); Reviewing administrative support for cancer services (for implementation in Quarter 1 2013/14); and Letters sent to referring trusts when a referral received after day 46 in the pathway. Bowel Cancer Screening – 14 day performance Performance of the Bristol and Weston Bowel Cancer Screening service has been maintained across both the 14 day Specialist Screening Practitioner and colonoscopy targets, with 100% for the Specialist Screening Practitioner target and 98% for the colonoscopy target achieved in February 2013. The symptomatic endoscopy waits at University Hospitals Bristol NHS Foundation Trust, following an internal review, are recovering. The latest monthly report (February 2013) shows that 92.5% of the routine referrals are seen within 6 weeks. There were 3 breaches in the colonoscopy screening service and the reasons seem to be patient choice, rather than capacity, but are being examined in detail. Additional staffing, as

part of the preparation for age extension, is now in place, including: a screening colonoscopist (North Bristol NHS Trust), 1 Specialist Screening Practitioner and admin staff. The endoscopy rooms at South Bristol Community Hospital will be ready to be operational as from beginning of May 2013, so there will be 6 endoscopy rooms available for the screening programme. Further to the meeting in January 2013 held with commissioners and the regional Quality Assurance team to discuss the issues with bowel screening and whether it is feasible to extend the range of age groups to which screening is offered, a follow up meeting was held in March 2013 which agreed to go ahead with the bid for extension, on the basis that previous capacity issues have been resolved and waiting times are being consistently delivered. The bid, together with supporting waiting times data, will be submitted to the South West Quality Assurance Reference Centre over the next few days stating that the Bristol and Weston Bowel Cancer Screening service will be ready to age extend as from 29 April 2013. The endoscopy symptomatic service recovery plan will be appended to the bid. Detailed Performance Overview – Stroke/Transient Ischaemic Attack (TIA) Stroke Target: 80% stroke patients to spend 90% of their stay on a stroke unit University Hospital Bristol NHS Foundation Trust: 80.6% February, 79.0% year to date. Performance continues to achieve in February 2013. Year to date the trust remains under the 80% target with performance at 79.0%. Transient Ischaemic Attack Target: High Risk TIA Patients Assessed and Treated within 24 Hours (60%) University Hospital Bristol NHS Foundation Trust: 44.4% February, 57.7% year to date The Trust has failed in February 2013 against the 60% achieved threshold. The main reasons for patients breaching in month include: Patients not being referred promptly by their GP; Patients being incorrectly referred by their GP to North Bristol NHS Trust; Patient choice to defer treatment; and Clinic capacity. Year to date performance against the 24 hour TIA treatment standard is just below the 60% target. The implementation of a system for receiving electronic referrals is expected to improve performance where the incorrect referral route, or use of paper based referrals, has been the source of the delay. However, this still required the referral to be made by the GP or other healthcare professional at the time of the decision to refer. The impact of patient choice is more difficult to mitigate.

Detailed Performance Overview – Clinical Quality Eliminating Mixed Sex Accommodation (MSA) University Hospital Bristol NHS Foundation Trust In February 2013, 9 patients were affected by Mixed Sex Accommodation breaches. In line with the NHS Standard contract these breaches are exempted due to the fact that there was a significant Norovirus outbreak at the Trust and therefore, is recorded as 0 on the performance scorecard.

Healthcare Associated Infections MRSA South Gloucestershire Incidence of MRSA: Achieved in February 2013 and year to date With 0 cases of MRSA reported against a plan of 0 South Gloucestershire has achieved in February 2013. Year to date the organisation continues to achieve with 2 cases reported against a year to date plan of 3. Actions being taken to improve performance are detailed in the acute Trust section. Acute Trust MRSA Performance North Bristol NHS Trust Incidence of MRSA: 0 cases in February 2013, 5 year to date. North Bristol NHS Trust has achieved against plan in February 2013 with 0 cases reported. University Hospitals Bristol NHS Foundation Trust Incidence of MRSA: 1 in February 2013 With 1 case reported in February 2013 the Trust has failed against a plan of 0. A further case has been reported in March 2013 taking the annual total to 10 cases. All cases attributable to the Trust are investigated by the clinical team with learning shared at the infection control operational meeting chaired by the Deputy Chief Nurse. The Health Protection Agency has coordinated a point prevalence survey that was undertaken in February 2013 to look at cannula management and insertion. Results are currently being analysed and will be shared in the next report. The Trust continues to take actions to prevent cases of MRSA including: A ward daily checklist continues looking at maintenance of intravenous cannulae and lines. The results are reported to Matrons and Heads of Nursing; Link practitioners are undertaking practical hand hygiene sessions in their areas; A training programme continues with medical staff ensuring competent practice when inserting intravenous cannulas; and A teaching programme is underway in clinical areas to remind staff of the correct application of cannula dressings. Clostridium Difficile Acute Trust Clostridium Difficile Performance North Bristol NHS Trust Incidence of Clostridium Difficile: 5 cases in February 2013, 67 year to date. North Bristol NHS Trust has reported 5 cases in line with plan in February 2013. Year to date the Trust is failing with 67 cases reported against a plan of 56. This is in excess of the full year target of 61 cases.

The infection prevention and control team continue to analyse each case to determine appropriate actions with continued focus on a review of antibiotic prescribing. Collaborative work is being undertaken with commissioning colleagues across the Bristol, North Somerset and South Gloucestershire health community. University Hospitals Bristol NHS Foundation Trust Incidence of Clostridium Difficile: 6 cases in February 2013, 48 year to date. With 6 cases reported against a plan of 3 in February 2013 the Trust have failed against plan. Year to date the Trust remains under plan with a total of 48 cases against a year to date plan of 52. The management of patients with Clostridium Difficile follows the national guidelines for prevention and the five elements of the Trust’s prevention bundle. Performance is monitored and managed through the monthly Infection control operational meetings.

Peter Benwell, Louisa Darlison, Fiona Reid and Lisa Whitlow Performance Management Team

Louise Tranmer, Director of Commissioning Delivery April 2013