Paper 16 Ayrshire and Arran NHS Board Monday 19 August 2019 Performance Report Author: Sponsoring Director: Paul Dunlop, Senior Performance Officer Kirstin Dickson, Director for Transformation Steven Fowler, Senior Performance Officer & Sustainability Donna Mikolajczak, Performance Manager Date: 2 August 2019 Recommendation The NHS Board is asked to note Performance across NHS Ayrshire & Arran based on key measures of Unscheduled and Planned Care. Summary This is the second consolidated report to NHS Board on overall Performance across NHS Ayrshire & Arran. A set of two infographics are provided in Sections 1.1 and 2.1 to provide NHS Board members with an overview of Performance ‘At a Glance’ in relation to Unscheduled Care and Planned Care; and to ensure that Board members are sighted on the corresponding impact of underperformance across the system as a whole. Section 1 includes a summary of performance in relation to Unscheduled Care across Health and Social Care. Appendix 1 includes detailed analysis on a range of Unscheduled Care measures: • ED 4hr Compliance • ED Attendances • CAU Presentations • Medical and Surgical Admissions from Emergency Department (ED) and Combined Assessment Unit (CAU) • Delayed Discharges • Ministerial Strategic Group (MSG) for Health and Community Care Indicators Section 2 summarises performance against the National Waiting Times and Access targets and also provides an update on progress in relation to the Scottish Government Waiting Times Improvement Plan. Appendix 2 includes detailed analysis on the following targets and measures: • Inpatient and Day Case 12 Weeks Treatment Time Guarantee • New Outpatient 12 Weeks Access Target 1 of 43 • 18 Weeks Referral to Treatment • Diagnostics Waiting Times • Cancer Waiting Times • Mental Health Services • AHP MSK Waiting Times Key Messages The number of NHS Ayrshire & Arran patients who were delayed in their discharge from hospital reached its highest recorded position of 72 in May 2019. This, combined with increased levels of ED attendances and CAU presentations, continue to impact on compliance against the Emergency Department (ED) 4 hour standard. Although below target, and the compliance recorded in May 2018, there has been an improvement against the 62 day Cancer target between April 2019 and May 2019. Inpatient and Day Case compliance against the National 12 week Treatment Time Guarantee continues on a positive trajectory. However, challenges continue in relation Child and Adolescent Mental Health Services (CAMHs) despite an improvement between April 2019 and May 2019. NHS Ayrshire & Arran recently submitted their Annual Operational Plan (AOP) for 2019/20 to the Scottish Government. NHS Boards were asked by the Scottish Government to include the key planning assumptions and expected levels of performance against a suite of Unscheduled Care and Planned Care measures, including Mental Health. The AOP sets out the planned deliverables over the next year and highlights how these will lead to improvements throughout this period. 2 of 43 Glossary of Terms ABIs Alcohol Brief Interventions ACE Acute Care of the Elderly AEC Ambulatory Emergency Care AHP Allied Health Professional AMG Access Monitoring Group AOP Annual Operational Plan CAMHS Child and Adolescent Mental Health Services CAU Combined Assessment Unit CMT Corporate Management Team DDD Daily Dynamic Discharge ED Emergency Department EDD Estimated Discharge Date GJNH Golden Jubilee National Hospital HIS Health Improvement Scotland HSCP Health and Social Care Partnership IHO Institute of Healthcare Optimisation IP/DC Inpatient/Daycase ISD Information Services Division LDP Local Delivery Plan MDT Multi-Disciplinary Team MSG Ministerial Strategic Group (for Health and Community Care) MSK Musculoskeletal NES NHS Education for Scotland OT Occupational Therapy PGC Performance Governance Committee PR Pulmonary Rehabilitation RTT Referral to Treatment SHREWD Single Health Resilience Early Warning Database SMR Scottish Morbidity Record TTG Treatment Time Guarantee UCD Unscheduled Care Delivery UGI Upper Gastrointestinal UHA University Hospital Ayr UHC University Hospital Crosshouse WTIP Waiting Times Improvement Plan 3 of 43 1. Unscheduled Care 1.1 Unscheduled Care – At a Glance To evidence progress and to give assurance to the NHS Board in relation to Unscheduled Care, performance monitoring is based on the following three main themes: • reducing emergency admissions by providing accessible community alternatives; • reducing occupancy and length of stay by improving systems and processes within the acute hospital; and • reducing delays in discharge by providing appropriate community capacity. * Inpatient Admissions from the ED admitted directly into Medical or Surgical ward (excluding CAU) and Inpatient admissions from the CAU admitted to CAU (regardless of source) who are transferred to a medical or surgical ward (excluding discharges directly from the CAU) 4 of 43 • ED Attendances at UHC have returned to levels comparable with pre-CAU activity. Attendances at University Hospital Ayr (UHA) ED remain lower than pre-CAU levels despite an increase over the past year. At UHA, there has been a marginal 0.5% increase in the number of ED attendances between June 2018 (3,440) and June 2019 (3,456); and a 3.3% increase at UHC between June 2018 (6,277) and June 2019 (6,486). (Appendix 1: Figures 1.2 and 1.3) • ED 4-Hour Wait 95% target has been achieved in only 2 of the past 12 months (June 18 and July 18). Compliance at UHA ED has decreased by 6.6 percentage points between June 2018 (95.1%) and March 2019 (82.2%), and at UHC ED there has been a decrease of 5.8 percentage points between June 2018 (96.7%) and June 2019 (90.9%), against a 95% target. (Appendix 1: Figures 1.1,1.2 and 1.3) • CAU Presentations have risen at both sites over the past year, with a greater increase at UHA than UHC. This increase has predominantly been in the numbers of referrals from ‘Other’ sources. ‘Other’ includes referrals from out-patient clinics, the national cancer treatment helpline, and abnormalities in radiology requiring immediate attention. At UHA, there has been a 5.8% increase in the number of presentations at CAU between June 2018 (1,528) and June 2019 (1,617), as well as a 4.0% increase at UHC between June 2018 (1,438) and June 2019 (1,496). (Appendix 1: Figures 2.1 and 2.2) • Analysis of Medical and Surgical Inpatient Admissions from the EDs and CAUs for the period since the opening of their respective CAUs had shown a slight decreasing trend at both sites; however activity has been increasing recently and is higher than for the same period last year. When comparing the numbers of medical and surgical admissions for June 2019 with June 2018, there has been a 13.8% increase at UHA and a 6.8% increase at UHC. (Appendix 1: Figure 3.1) • Comparing March 2019 to March 2018, analysis of Unscheduled Bed Days for Acute Specialties from the MSG Indicator data suggests a significant reduction across Ayrshire and Arran over the past year, with a 18.4% decrease reported for East Ayrshire residents (from 9,334 to 7,614); a 30.0% decrease reported for North Ayrshire residents (from 12,506 to 8,757) and a 22.1% reduction reported for South Ayrshire residents (from 10,745 to 8,368). The scale of this decrease is primarily as a result of the closure of unfunded acute beds at both UHA and UHC. (Appendix 1: Figure 5.2.3) • Delayed Discharge >2 Weeks (excluding complex code 9 delays) have steadily been increasing since May 2017, reaching their highest recorded position of 72 delays in May 2019 (previous highest was 71 delays in November 2018). Across the HSCPs, the increase has predominantly been in South Ayrshire HSCP, with delays reaching an all-time peak of 51; delays from East Ayrshire residents continue to remain at 0. (Appendix 1: Figure 4.1) • Delayed Discharge Occupied Bed Days (OBDs) for all delays have been increasing continually since March 2017, with an increase of 13% experienced between May 2018 (3,924) and May 2019 (4,432). Delays from South HSCP residents have contributed most to this, with South OBDs reaching their highest recorded position in May 2019, whilst for North HSCP residents there has been a recent decrease following a 6-month period of continued increase. OBDs due to delayed discharge for East HSCP residents have remained consistently at or below 500 per month, and are mostly as a result of code 9 delays. (Appendix 1: Figure 4.2) 5 of 43 1.2 Unscheduled Care Priority Actions A number of prioritised transformational projects were undertaken in 2018/19 as part of whole system planning to improve performance of unscheduled care. The priority actions were summarised in the previous performance report for the Board’s consideration https://www.nhsaaa.net/media/7243/20190527bmp24.pdf . NHS Ayrshire & Arran recently submitted their Annual Operational Plan for 2019/20 to the Scottish Government (SG). NHS Boards were asked by the Scottish Government to include the key priority actions and improvement plans over the next year for Unscheduled Care. To support this, a suite of key performance measures have been agreed and performance scrutiny and appropriate action to address areas of underperformance will be discussed through the Unscheduled Care Delivery Group at both University Hospital Ayr and University Hospital Crosshouse. Delivery of the AOP will be driven by the Six Essential Actions plans. The key measures within the AOP include improving compliance with the 4 hour standard, reducing occupancy levels within UHA and UHC, and eliminating 12 hour breaches. Occasionally waits to move from ED not only extend past the 4 hour access and treatment standard but exceed 8 and 12 hours. ED waits over 8 and 12 hours have been shown to produce poor patient experiences, adverse outcomes and potential safety issues. NHS Ayrshire & Arran has recently become an outlier with regard to 12 hour breaches.