GREATER HUDDERSFIELD CLINICAL COMMISSIONING GROUP DESIGNATE CHIEF OFFICERS REPORT – 22 January 2013 Subject
Summary
Quality and Safety
Quality is a key governance priority for Greater Huddersfield, recognising the role of CCGs in creating a culture which supports continuous improvement. As a subcommittee of the Cluster Board the CCE has the responsibility for scrutinising and gaining assurance in relation to the three domains of quality; safety, effectiveness and experience and the role of the Quality Group is to provide this assurance to the CCE. The group receives regular reports which collate information about quality, safety and experience from various sources.
Actions
Since the last report the CCE Quality Group has met on, 19th September, 17th October, 21st November and 19th December 2012 where information on the following key quality metrics were reported:EMSA There were no breaches for September, October and November 2012. VTE Risk Assessment
EMSA No actions required
CHFT continue to achieve VTE risk assessment performance in line with CQUINs requirements Quarter 2 achievement 90.3%
VTE Risk assessment No Actions
National Patient Safety alerts
required
CHFT have one alert open past the closure date of 2 April 2012 – Safer spinal (intrathecal), epidural and regional devices (NPSA/2011/PSA001). The Royal College of Anaesthetists, Association of Anaesthetists and the Obstetric Anaesthetic Association produced a joint statement last year saying that they felt there were risks associated with individual Trusts doing their own small trials
Patient safety alerts Remains item on Clinical board Page 1 of 17
and felt that there should a national trial of the new devices and then a decision made and the device chosen to be implemented nationally. The NPSA responded by saying that they didn’t agree and urged Trusts to continue trialling and then implement their chosen device. The Clinical Director for anaesthetics is leading on this and has identified the risks to CHFT of trialling new devices with differing connectors with doctors who work across many sites. CHFT believe their risks of wrong spinal injection are extremely low as they are generally caused by wrong injection of chemotherapy agents into CSF, which they do not undertake as patients are referred to Leeds for intrathecal chemotherapy). Further advice is awaited from the College and there are other Trusts who have made the same decision on the back of the joint statement. This has been discussed at Clinical Quality Board and assurance received on mitigating actions.
until closed
There were no open alerts for SWYPFT or YAS as of October 2012. CQC Compliance The following table details the outcomes of recent inspections: Provider
CHFT – Calderdale Royal Hospital
BMI Healthcare Ltd – BMI The Huddersfield Hospital
Date of Review
November 2012
November 2012
Type of Review
Planned routine inspection
Planned routine inspection
Link to Report
Calderdale Royal Hospital – Nov 12
BMI Huddersfield Hospital Nov 12
Compliant
Not assessed
CQC compliance Standing item on clinical quality boards
Outcomes 01 – Respecting &
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involving people who use services 02 – Consent to care & treatment
Not assessed
Compliant
04 – Care and welfare of people who use services
Not assessed
Non compliant Moderate impact – compliance action required
The provider was not meeting this standard in the following areas: • • •
Diagnostic & screening procedures Surgical procedures Treatment of disease, disorder or injury
Evidence was not available to ensure that the emergency arrangements for the urgent provision of blood and blood products including out of hours had Page 3 of 17
been tested and timed 05 – Meeting nutritional needs
Compliant
Not assessed
07 – Safeguarding people who use services from abuse
Compliant
Compliant
08 – Cleanliness & infection control
Not assessed
Not assessed
09 – Safety & suitability of premises
Not assessed
Not assessed
13 – Staffing
Compliant
Compliant
21 – Records
Non compliant
Compliant
Moderate impact – compliance action required.
People were not protected from the risks of
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unsafe or inappropriate care and treatment
One patient had an incomplete DNAR form which had not been reviewed by a doctor upon admission. Writing illegible, no written evidence in notes on how decision had been made. Patient and patient’s family had not been consulted.
Assessment record of patient regarding eating and drinking instructions found in other patient’s care records. Directions very specific to the person.
Assurance has been sought from BMI that appropriate actions have been put in place. The CHFT report has been discussed at the 18th December Clinical Quality Board, where a detailed action plan was presented and assurance received on actions taken. MRSA From 1 April to 5 November 2012, eleven MRSA bacteraemia cases have been reported in Kirklees residents. Of these cases five are in Huddersfield residents. Page 5 of 17
MRSA and CDiff– Clinical ● Three post 48 hour cases, two reported by CHFT and one from Leeds Teaching Hospitals Quality Board NHS Trust. receives CHFT Infection, ● Two pre 48 hour cases. prevention and control action Work continues to progress on the use of an alert on clinical systems (acute and primary care) for plan at each of patients with MRSA infection / colonisation and clostridium difficile infection (CDI). its meetings. HCAI Group Meeting frequency has been increased The key learning from the pre 48 hour MRSA bacteraemia cases. to bi-monthly to acknowledge ● Education and training of patients that self care for urinary catheters. the risk affecting all health ● Antibiotic prescribing – primary care antibiotic formulary not followed. economy partners and ● Training provided by independent social care providers sub optimal. reports to Calderdale CCG ● Essential steps audits not completed / up to date – Locala community nursing and care Quality Group. home. A Root Cause Analysis is undertaken for ● Care plans did not contain infection prevention risk assessment. all acute and CHFT has reported three MRSA bacteraemia to date against national HCAI objective of no more than community acquired four cases. bacteraemias and reported The key learning from these cases is: HCAI Health Economy Group • Possible contaminant with lessons Page 6 of 17
• • • •
Continual need for urinary catheter unclear No catheter insertion documentation Delay in MRSA suppression treatment Inappropriate antibiotic prescribing
learnt being shared across the Health Economy.
The report from the review visit of CHFT by Helen Crombie NHS North of England HCAI lead in October 2012, has been considered at the December 18th Clinical Quality Board meeting. Risk 3206 and 3207 on corporate risk register scored at 12 in relation to failure to achieve objective and patient safety is compromised C- difficile NHS Kirklees is over the planned trajectory to date with 77 cases reported 1 April – 31 October 2012, against a trajectory of 104 cases in 2012/13, this includes all pre and post 72 hour cases. Thirty five of all the cases were reported in Huddersfield residents. Twelve of these samples were community submissions. Enhanced surveillance by the infection prevention and control team identified: • • • • • •
twelve resided in a care home three had previous history of CDI six patients were prescribed antibiotics prior to diagnosis of CDI six patients were on gastric suppressive agents seven patients had been an inpatient within the previous two months three patients received appropriate antibiotics following diagnosis.
CHFT - 3 post cases 72 hour C.difficile infections cumulative total 22, against a target of no more than 33 cases. A Clostridium difficile management plan has been agreed across the wider health economy to address Clostridium difficile issues, supported by NHS North of England. Clostridium difficile is a major part of the Calderdale and Kirklees HCAI group work plan for 12/13 and the Clostridium difficile management plan will Page 7 of 17
be monitored through this forum. CHFT have had an independent review of their CDI management, which has recommended a programme of disinfection. A business case has been submitted by CHFT IPC team. The HCAI Improvement Plan is being driven forward by the CHFT HCAI Operational Group. Never Events In July 2012 CHFT reported a wrong site surgery Never Event. The patient had a left nephrectomy on 15 March 2012 because the kidney was chronically infected and non-functioning. The following day the patient had to return to theatre because of bleeding. During the second procedure, it transpired that the left kidney remained in situ. An incident report was completed that day, and an internal investigation has been carried out. The investigators have found that during the first operation, the tail of the pancreas was removed instead of the left kidney. The never event was reported in line with Serious incident policy and procedure, the investigation report and action plan have been received, reviewed, additional information sought for clarification by the Cluster Medical Director and this case is now closed.
Patient Experience Friends and Family Test Implementation On 25 May 2012, the Prime Minister announced the introduction of the “Friends and Family Test” to improve patient care and identify the best performing hospitals in England. To support this, from April 2013, Standard NHS Contracts will include a requirement that this work be delivered by providers of all NHS funded acute inpatient and A & E departments.
Patient Experience Standing item on quality group and Clinical Quality board with CHFT
The Friends and Family Test (FFT) aims to provide a simple, headline metric, which when combined with follow-up questions, can be used to drive cultural change and continuous improvements in the quality of the health care received by NHS patients. The Question: “How likely are you to recommend our ward/A & E Department to friends and family if they Page 8 of 17
needed similar care or treatment? Organisations are expected to ask follow-up questions at the same time as the FFT, to find out more details that can help drive improvements. The number and working of follow-up questions is to be determined locally. Patients to be surveyed: • •
Adult acute inpatients (who have stayed at least one night in hospital) Adult patients who have attended A & E and left without being admitted to hospital or were transferred to a Medical Assessment Unit and then discharged.
Next steps • • •
Review completed state of readiness questionnaire for each of acute and independent sector provider organisations from CKW cluster at Quality Group. Standing agenda item on Provider Quality Boards and Contract meetings. Monthly progress reports to CCEs, through Quality and Safety paper.
Savile Allegations On 12 November 2012, Sir David Nicholson wrote to all Chairs and Chief executives of NHS organisations in relation to the Savile allegations. He has asked that NHS Trusts review, with their Boards, and working as necessary with local agencies, their own arrangements and practices relating to vulnerable people, particularly in relation to: safeguarding; access to patients (including that afforded volunteers or celebrities); and listening to and acting on patient concerns. The Secretary of State has appointed Kate Lampard, a barrister and Vice Chair of NHS South of England, to provide assurance that the Department and the relevant NHS organisations are following a robust process aimed at protecting the interest of patients. She will also look, as part of that work, at NHS wide procedures, in the light of the findings of the reviews, to see whether they need tightening. When this work has concluded we will share any learning relevant for the wider system across the service as a whole.
Savile allegations Assurance to be received through Clinical Quality Board
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Through the Clinical Quality Boards for CHFT and SWYPFT they have been asked to provide assurance that action is being taken in response to this letter. This information will be received by the Quality Group. In addition, the Quality Group have asked the safeguarding team to consider, which of our other commissioned services we should be securing responses from.
CQC/Ofsted Safeguarding Children Action Plan An update of the NHS Kirklees action plan associated with the CQC/Ofsted inspection of safeguarding children and looked after children services was received at the Quality and Safety Sub Group meeting on 19 December. All actions have now been completed; therefore the action plan was formally received and closed. Notification will be issued to CQC in due course
CQC / Ofsted No actions required
CQUINs The overview of the development of local CQUIN schemes including implementation, trajectories setting, improvement plans and recommending these to the relevant Contract Management Boards continues to be managed through the Clinical Quality Board arrangements.
CQuINs No action required
All providers submitted Quarter 2 returns by the specified deadline (31st October 2012). For Quarter 2, our main providers achieved the following performance in the indicators that required data submission in Q2
Provider Calderdale and Huddersfield Foundation Trust (CHFT) – acute
Q1
Q2
100%
100%
Q3
Q4
Q2 comments Achieved all indicators that required data submission and reporting in Q2
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South West Yorkshire Partnership Foundation Trust (SWYPFT)
87.5% 81.25%
Did not achieve:Improving access for people experiencing acute mental health problems – crisis referrals. Issue identified as Wakefield and MYHT Improving access for people experiencing acute mental health problems – routine referrals. Smoking cessation – there is a documentation issue relating to this indicator in Calderdale BDU Partial achievement of the patient experience indicator
Spire Elland Hospital
Yorkshire Ambulance Service (YAS)
100% 94%
100%
TBC
Achieved all indicators that required data submission and reporting in Q2 Provisional data has been submitted to NHS Bradford and Airedale and feedback has been sent back to YAS
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Locala
Performance
100%
TBC
Awaiting feedback from NHSNKCCG on agreed Q2 performance
All Key performance Indicators set out in the 12/13 Operating Framework are scrutinised by Greater Huddersfield CCG, concerns/issues are considered on a monthly basis through a performance monitoring process by the Senior Management Team and the Finance and Performance Committee with concerns escalated to the CCE:
•
Cancer 62 day’s consultant upgrade. In the month of October, 6 patients completed the 62 day consultant upgrade cancer pathway in Kirklees, 3 patients breached the national waiting time standard of 90%, in month Performance for October is 50%. This was due to the patient not being transferred in a timely manner,(IE) outside the 38 day target. Improving inter provider transfers is an area of focus across the Yorkshire Cancer Network. The ambition is to ensure patients who require a transfer of provider are referred before day 38 of their pathway to ensure they can receive their first definitive treatment with the minimum of disruption and delay.
•
18 weeks RTT. CHFT are meeting the aggregate performance standard of 90% for admitted patients, however pressures in certain specialities (ENT 80% and General Surgery 86.3%) mean the 90% by month, by specialty is not being achieved. CHFT project end of Q3 achievement of this standard. All specialties for non admitted patients have met the 95% standard.
All breaches of the standard are discussed at the Planned Care Board and the Cancer Locality Group. Root cause analysis to be identified and shared.
Performance being monitored closely through contract management mechanisms. Page 12 of 17
•
YAS A8 performance in GHCCG area. Performance continues to below the 75% threshold for some localities in GH. The Yorkshire Ambulance Service is continuing to develop action plans, and staff rota’s to address the issue of underperformance. A task and finish group was formed to consider YAS position and potential further action. CCE agreed that all reasonable actions have been considered and where appropriate implemented at the current time. NHS Bradford as ‘Host’ Commissioner for the Yorkshire Ambulance Service Contract are continuing to work with the Provider to ensure the activity profile for the year has been calculated correctly and to establish pathways to help reduce demand going forward.
Continue to monitor, liaise closely with YAS and consider further actions/solution s as these become available and known. No further specific action at this time.
•
High levels of activity for patients with ambulatory conditions and admissions that should not require hospitalisation. Potential impact for recurrent QIPP delivery. 12/13 QIPP plans not realised due to resource, GH are now prioritising plans for 13/14 with a particular focus on these indicators.
•
High levels of activity for Emergency Admissions for Asthma, Diabetes and Epilepsy in under 19s: Initial investigations by the children’s lead have identified a number of children being admitted because of fractures and social reasons, but are coded inappropriately by their LTC. A number of children have direct access to the children’s ward and its thought that Primary Care Services are not being utilised when appropriate.
Admission avoidance model in development. Considering additional dedicated resource in specific areas. Pilot work with GP practices on further use of predictive risk techniques. The Calderdale Page 13 of 17
and Huddersfield Strategic Review have a specific work stream focusing on children and admission avoidance.
•
Coverage of NHS Healthchecks. Significant improvement has been made in Quarter 2 since the launch of the LES to GP practices in Greater Huddersfield. A quarter 2 target of 5025 health checks across the whole of Kirklees was very nearly met. Due to new systems and process being established the final number of Health Checks offered in Greater Huddersfield is yet to be confirmed. There is an expectation that the target will be met in Quarters 3&4 and overall for 12/13.
•
High levels of non-elective/emergency/A&E activity. Financial impact factored into plans.
•
Ambulance journeys: Trading above plan.
New LES agreed July 2012, 33 GHCCG practices signed up. Discussions to take place with practices opting out and the terms of intra practice referrals to be agreed. Close liaison with provider. Planned indepth work at Clinical Strategy Group. Level of overtrade being clarified as Page 14 of 17
appears inconsistent between data sources. •
Finance and QIPP
Choose and book utilization. Above regional and national performance but below 90% target.
Working with individual practices to improve utilization rates.
Financial position Month 8 2012/13 • • •
Kirklees PCT are forecasting to deliver their control total of £6.6m. The overall position for Greater Huddersfield CCG is a small under spend of £0.2m. A spending plan has been approved and is in the process of being delivered that commits £3.0m of nonrecurrent funding
Risks There continue to be a number of risks to be aware of for 2012/13: • • • •
QIPP plans don’t deliver the required level of recurrent savings, although this will not pose a financial risk in 2012/13 (fixed income contracts in place with CHFT and Leeds) it will impact on 2013/14 negotiations. The ability to fully utilise contingent and investment reserves this has been mitigated by the agreement of the spending plan. The deadline for restitution claims between April 2004 and March 2011 has now passed. Early estimates of claims that will be paid out are significant. NHS Kirklees has made a provision for these claims but any payment over and above this provision will need to be managed within the overall financial position. The ongoing re-organisation of the PCT has the potential to inadvertently reduce our focus on managing this year’s position and we must ensure that this does not happen.
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QIPP Plan 2012/13 • Governance and Risk
The CCG requires £5.3m of savings to be realised from budgets this year in order to achieve our financial targets. Our current forecast is that we will deliver this target.
Governance Further to the last update, the following items have progressed within governance arrangements for Greater Huddersfield; • Committee Structure has been prepared and a final review of terms of reference being undertaken in advance of 1 April. • Policies and procedures are under review and will be prepared ready for use from 1 April. Risk NHS GHCCG continues to pay close attention to developing and working with a robust risk management system. Each sub-group takes identifies risks as part of its core business and these are regularly reported to CCE. We are currently undertaking a focussed piece of work through our senior management team with the intention of fully embedding the risk management system in the CCG, ensuring that NHS Kirklees risk are mapped to GHCCG where required and updating the system of risk ownership to reflect the new CCG structure. At present, NHS GHCCG has 30 risks on its risk register, with two scoring over 15: • •
Transition and Workforce
Risk to delivery of QIPP over the next 3 years. Risk being addressed through establishment of processes to agree and monitor QIPP delivery within the CCG, and working with partners in the strategic review to deliver transformational QIPP schemes across the health and social care economy. Risk that quality improvements associated with reduction in pressure ulcers will not be received. Risk scoring will be reviewed following consideration of providers’ Q2 CQUIN data.
Workforce Since the last report the majority of the GHCCG management structure has been populated through the pooling and matching process, with a handful of posts outstanding. Page 16 of 17
Staff have been encouraged to respond to the draft structure of the CCGs in Kirklees and the CSS through our staff briefings. Transition GHCCG had 2 red KLOEs remaining following its site visit in October and receipt of feedback from the NHSBC Conditions Panel in December. The final decision in relation to authorisation for GHCCG is anticipated around the time of the Cluster Board meeting. We are continuing to engage in regular, constructive dialogue with the CSU, with named leads from the CCG and the CSU working closely on mobilisation . In addition to the actions described in this report that focus on building the infrastructure of the CCG, we are also working well with external partners on other elements of transition, such as the development of the Health and Well Being Board. CCG representatives are involved in the refresh of the JSNA. Transformatio n
Calderdale and Huddersfield Health and Social Care Strategic Review A progress report on the Strategic Review is available later in the agenda. GHCCG clinicians and managers are well represented on the programme’s care streams, as well as both the Steering Group and Programme Board.
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