Report Author: Chris Dowse, Designate Chief Officer, NHS North Kirklees CCG Report to: CKW Cluster Board 22 January 2013 Subject Quality and Safety
Summary Quality is a key governance priority for North Kirklees, recognising the role of CCGs in creating a culture which supports continuous improvement. As a subcommittee of the Cluster Board the Governing Body 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 and Safety Group is to provide this assurance to the Governing Body. The group receives regular reports which collate information about quality, safety and experience from various sources.
Actions
Patient Safety Early Supportive Discharge On 19th of December and following their latest review, Mid Yorkshire Hospitals Trust received accreditation for their stroke services at level 2, hyper-acute (including acute and rehab). This result was achieved by the willingness and dedication of the team and partners to improve stroke services for patients across mid Yorkshire and the surrounding area. This is a particularly impressive performance when noting the level of improvement made over the last 12 months and we commend the exceptional teamwork demonstrated across the patient pathway. HSMR Mid Yorkshire Hospital Trust was reported as an outlier in the Dr Foster good hospital guide (October 2012). There has been a significant amount of work undertaken to deliver sustained improvements in the position particularly through clinical coding and
This is monitored via the MYHT ECB/ EQB on a monthly basis. 1
palliative care coding. As a result, the HSMR position for April – September 2012 has reduced to 93; which would currently rebase to 98. In addition, the palliative care coding for the Trust is now at national levels. The Trust has established processes to ensure that that these improvements are monitored regularly. 111 North Kirklees and Wakefield CCGs have submitted their local readiness plan to the national team. As part of this plan, the CCGs have established a Clinical Governance reference group in preparation for the soft launch of 111 planned for 5 March 2013 and the formal launch on 1 April 2013. The first meeting took place with providers and commissioners w/c 7 January to agree the format of the meeting. Dr Adam Shepherd (Wakefield CCG) will chair this meeting with Dr Farhad Kohi (North Kirklees) as the Vice Chair. The national team will be visiting on 5 February 2013 to approve North Kirklees and Wakefield CCGs’ plan. Experience MYHT Patient Safety Walkabouts As agreed as part of the MYHT risk summit in November 2012, a programme of Wakefield and North Kirklees commissioner-led Patient Safety Walkabouts has commenced. The first Walkabout took place on the 19th of December 2012 in conjunction with the SHA.
Patient Safety Walkabouts will continue on a monthly basis
Friends and Family Test All local providers (CHFT, MYHT, Spire and BMI) have declared readiness to implement the Friends and Family test from 1 April 2013 in the mandated areas 2
(Acute services and A&E). To declare readiness each provider has had to evidence: • • • • • • • • •
Date the Provider Implementation Plan is signed off by their Board as evidenced by board level minutes. Planned date that the first ward will have 15% of eligible patients answering the FFT question (i.e. 15% return rate) Planned date that ALL wards by the provider for ALL sites will have at least 15% of eligible patients answering the FFT question
To be monitored through Quality Board and contracting routes. Reported to Q,F&P Group
Planned date that local reporting of FFT for ALL wards will start. Planned date for the first complete data submission ( ALL wards, ALL sites at least 15% return rate ) Actual date that the first ward is 15% of eligible patients answering the FFT question (i.e. 15% return rate) Actual date that ALL wards by the provider for ALL sites will have at least 15% of eligible patients answering the FFT question Actual date that local reporting of FFT for ALL wards will start. Actual date for the first complete data submission ( ALL wards, ALL sites at least 15% return rate )
The FFT will be introduced into Maternity Services from October 2013. 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. Through 3
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Quality Board arrangements Locala, MYHT and SWYPFT have been asked to provide assurance that action is being taken in response to this letter. Locala provided assurance to NHS North Kirklees CCG via the Clinical Quality Board mechanism. MYHT discussed the letter at the Patient Safety Panel and Trust Board in December 2012, and a patient safety briefing was circulated to staff as a result. SWYPFT have provided assurance to NHS Calderdale who requested this information on behalf of the CKW CCGs. The letter has been shared with non-NHS providers, such as Spectrum CIC and Spire Methley for similar assurances. In addition the CCE needs to be assured that all reasonable steps have been taken to ensure that the CCG employment processes are robust in relation to Criminal Records Bureau checks. In January 2013, the report compiled by the NSPCC and the Metropolitan Police Service (MPS) into the Savile allegations was published. This report summarised the extent of Savile's known (alleged) offending, from 1955 to 2009 and includes a chronology of offending in NHS premises. One of the entries in the chronology refers to one assault in 1969 at Dewsbury Hospital. There is no information in the body of the report detailing this incident. In response, MYHT are investigating the allegations relating to Dewsbury. A formal response will be presented to the Quality Board in January 2013. At this time, there is no information that suggests any other NHS location within the CKW PCT Cluster area has been used by Savile to perpetrate abuse against vulnerable adults or children.
Effectiveness CQC Compliance W/c 31December 2012, the CQC began a programme of inspection of Locala CIC. To date there has been no verbal feedback available.
Performance reported in the quality and performance report and the performance 4
The CQC undertook a routine unannounced inspection at Pontefract Hospital (12 November) to check essential standards were being met and inspections at Pinderfields Hospital (12/13 November) and Dewsbury and District Hospital (12 November) to check whether improvements had been made following a previous inspection. The subsequent report published on the 9th of January 2013 confirmed that Hospitals in Mid Yorkshire have seen major improvements in standards of patient care and experience.
dashboard.
Maintaining Quality & Safety – ‘How to’ handover guide Version two of the Quality Handover Document was submitted to the SHA on behalf of the NHS NoE on 7 December 2012. The quality handover document locks down as legacy quality issues and positions on behalf of NHS Kirklees as a sender organisation. The report sets out the process the CKW cluster will take to handover to the CCGs in March 2013. Quality assemblies are being planned for March to share the information with receiver organisations. Safeguarding children CQC/Ofsted Inspection of Safeguarding Children Action Plan
PCT to hand over Quality Document to NKCCG as part of Quality Assembly in March 2013. The Cluster Governance Committee oversees the Quality Handover Document progression on behalf of the CKW Board
The CQC/Ofsted inspection of Safeguarding and Looked After Children’s Services began on 3 October 2011 and the joint inspection report published on 18 November 2011. The CQC report on the outcome of the Integrated Inspection of Safeguarding and Looked After Children’s Services in Kirklees was published on 21 December 2011. This action plan has now been completed in full.
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Health Visitor Placements The SHA has allocated the following student health visitor placements for the 2013/14 academic year. MYHT 32 students, Locala CIC 27 student placements and CHFT 6 students. All providers have confirmed that these student placement can be accommodated and for the next academic year. Safeguarding Adults Winterbourne View On 10th December 2012, the government published its final report into the events at Winterbourne View hospital and set out a programme of action to transform services so vulnerable people no longer live appropriately in hospital and are cared for in line with best practice. This report contained a series of recommendations based on investigations and Serious Case review findings Lead commissioners in Continuing Care Teams for learning disability placements are working with colleagues across Yorkshire and Humber to look at ways of sharing intelligence to strengthen commissioning arrangements. Mental Capacity Act and Deprivation of Liberties From 1 April 2013 and in line with national guidance, the responsibility for both MCA and DoLs assessments will transfer to the Local Authorities. A task and finish group has been set up which includes the Kirklees Safeguarding Adults Board and both NK and GH CCGs to oversee the transition of responsibilities safely on behalf of NHS Kirklees.
Work is underway to develop an action plan in response to the final Winterbourne View report, including milestones and reporting requirements to the SHA /NHSCB/ LAT. First submission is due 28 February 2013.
Task and Finish Group taking forward transition to completion.
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Performance
18 Weeks RTT As at November 2012 the 18 weeks RTT admitted pathway performance for NHS Kirklees at MYHT is 89.1% against a standard of 90% and the non-admitted performance is 95.7% against a standard of 95%. The specialties not achieving the 90% standard individually for November for NHS Kirklees at MYHT are; Trauma & Orthopaedics 85.9%, General Surgery 89.9%, ENT 73.5%, Ophthalmology 89.5%, Plastics 85.3% and Urology 81.2%.
18 Weeks is monitored through the contract meetings. Commissioners continue to support the Trust with additional funding in specific areas where capacity requires increasing. I.e. Plastic Surgery.
The number of incomplete pathways over 18 weeks (which may include data issues) at MYHT has reduced from 2139 in October 11 to 1538 in October 12 showing continuous improvement over the last year. Waiting times are monitored through the Yorkshire Cancer Cancer Waiting time Standards: 62 Days – Consultant Upgrade Network on a weekly basis to Six patients in total with 3 breaching the national waiting time standard: 2 x Lung patients: One patient was referred from MYHT to Leeds on day 93 of the 62 pick up on any potential breaches. day pathway and one patient, treated at Leeds and referred to CHFT, initially classed as unfit for diagnostics, therefore causing a delay in treatment; 1 x Sarcoma patient: at Leeds- MDT was thought to be benign so treated as routine. MRSA The total number of MRSA cases attributable to North Kirklees CCG as at October is 5 cases against a cumulative trajectory of 3 cases and a 2012/13 Plan figure of 4 cases. From root cause analysis investigation the following recurrent themes emerged: • • •
Issues with completion of VIP scores Issues with cannula care removal not being documented Issues with CVC line on going care management
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From 7/1/13, no-one will be allowed to insert IV cannulae or take blood cultures unless they are ANTT competent and Bactec trained (latter for blood cultures). (This is in line with present policy). 7
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Compliance with ANTT training and assessment of competence Appropriate technique and adherence to standards when taking blood cultures.
C.Difficile There were 11 Clostridium Difficile infections reported in October. The breakdown by CCG is: • 6 allocated to NHS North Kirklees CCG; • 5 allocated to NHS Greater Huddersfield CCG
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Commence daily drop-in ANTT and Bactec training sessions from 17/12/12 until 7/1/13 – end date to be reviewed • To intensely focus on line care and VIPS from Monday • Need to identify an additional ANTT trainer to be seconded to this work from next week • To survey where blood cultures are being taken and whether there is a need for some clinical areas to have registered nurses competent in blood culture taking • To expedite ANTT training of phlebotomists
The cumulative total is 77 against a cumulative target of 61 Choose and Book Performance for Kirklees is above the Regional average of 49.3%, and National average of 47.2%, standing at 55.3% for November.
The CCG is working closely with the Choose & Book team to develop a more practice 8
The current performance is a combination of issues which include lack of practice support, lack of practice engagement, slot issues particularly at MYHT, processes and time for making bookings.
focused service, to support them to use C&B. NK CCG Choose and Book champion is working with practices to understand the issues that practices are experiencing. Appointment Slot issues (ASI) are being addressed by the MYHT Contract Management Group and ASIs have begun to reduce. NK CCG and Wakefield CCG are currently in discussions with CSU about the level of provision for Choose & Book that is expected.
Finance, QIPP and Contracting
Finance • • •
Financial Position balanced, and forecasting achievement of financial targets at year end. Proposals for non-recurrent investment in year to support delivery of transformational work streams will be approved in January 2013. Allocation and running costs confirmed. Plan to be submitted 24th January. Early indications suggest no significant additional risks from planning
Monitored currently through F&P Group and, from March 2013, Q,F&P when new governance arrangements kick in.
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assumptions already made in CCG MTFP. Risks are the impact of the tariff locally and the new maternity tariff. Also the actual impact of SCG going forward.
QIPP •
QIPP plans in place for 12/13, monitoring being done using Performance + system. Forecasting achievement of overall total at year end.
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QIPP proposals for 13/14 have completed planning documentation in place covering financial, activity and quality targets. Key implementation milestones and Lead Managers identified.
Risks •
Risk that MYHT financial position is not able to be managed by the Trust itself without the support of commissioners.
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Failure to deliver the required level of QIPP over the next 3 years.
Items escalated from F&P Group No specific financial items escalated. Contracting Current pressures on our contracts continue to be, as before, within emergency activity. The increased activity is based on both last year’s data and against our plan. Emergency spells at MYHT continue to grow and at month 3 flex are 16% above planned levels. Any Qualified Provider 10
Assessment of the AQP suppliers of Adult Hearing Services has now concluded and letters have been sent to successful and unsuccessful suppliers by the regional Qualification Centre of Excellence. The procurement processes for prioritised AQP services are now drawing to a close. The Governing Body received an update and agreed recommendations covering the following key areas: AQP procurement for Cluster-wide Adult Hearing Services, MRI and Non-Obstetric Ultrasound has followed a nationally-coordinated process. Following national checks and regulatory assessment, service-specific review of providers has been carried out for CKW by assessment teams involving clinical, quality, service and contract/management leads from across the four CCGs. A standard national assessment framework has been used throughout, together with an electronic assessment tool that has ensured compliance and maintained an audit trail of the process. The overall process has been supported and monitored throughout by the relevant regional Qualification Centre of Excellence. Adult Hearing Services: Procurement process has concluded. Successful and Unsuccessful bidders have been notified. Successful bidders are being contacted to finalise contracts and agree mobilization. Diagnostics: NOUS and MRI: Advert window has closed. Assessment is at an advanced stage. The expected contract value to each new supplier is likely to be less than ÂŁ100k for the contract period (to 31st March 2013). However because of the uncertainty associated with introducing new suppliers, a cautious assumption of value up to ÂŁ250k has been 11
agreed with Ian Currell when considering appropriate governance routes and to ensure compliance with Standing Financial Instructions. This means that each new contract will be signed by a Designate Chief Officer and either Cluster Chief Executive or Cluster Director of Finance. The expectation is that CKW will meet the DH requirement for three AQP services to be operational by end September 2013.
Governance and Risk
Risk NHS North Kirklees CCG continues to present all high level risks to the Governing Body on a monthly basis. In addition each month a Head of Service presents all of their service risks. In July the quality and safety risks were presented and in August the Finance risks were presented. NHS North Kirklees CCG has 15 risks logged on the risk register; 3 of these scoring above 15. • • •
Risk that MYHT financial position is not able to be managed by the Trust itself without additional financial support from commissioners over and above the level of income earned by the Trust from delivering services. The transformational work streams for unplanned care do not deliver the required change and financial benefit to mitigate the increase in demand and the impact of the trusts’ clinical services strategy. NHS Kirklees has breached its HCAI objectives due to present trajectory/ National HCAI objective for MRSA bacteraemia is no more than 10 cases in 2012/13.
Development of the Governance Processes and Structure Further to the last update, the following items have progressed within governance arrangements for North Kirklees; 12
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Transition Plan in place for migration to revised committee structure Terms of reference, Agenda and Annual Work-plans in place for Governing Body and subcommittee structure Draft Assurance Framework is now in place and will be further developed over the next couple of months A revised set of North Kirklees Policies and Procedures is being drafted
Meeting in Public NKCCG’s Governing Body is planning to hold its first meeting in public in February 2013. Managing the transition and workforce
Authorisation The submission of the application for authorisation was successfully completed within timescales on 1 November 2012. The initial Desk Top Review Report was received articulating areas that required clarification and further explanation. The report demonstrated that 63 out of the 119 areas of consideration would require review at the site visit. The site visit took place on 12 December 2012 and was considered a successful process by all. Only two areas remained red at that point: one in relation to the Information governance Toolkit Baseline Assessment and the other in relation to a MoU with Kirklees Council. An opportunity to resolve the IG Toolkit issue has been taken and this has been submitted to the panel prior to receipt of the site visit report. The site visit report was most positive and the initial feedback was as follows; 13
“This is an excellent CCG, which has made good progress in setting out its clinical and service priorities.� A response has been made accordingly to clarify one element of the report. Overall there have been no significant areas of concern raised. This gives North Kirklees a sound base from which to develop as a statutory organisation from 1 April 2013. The CCG is now developing its Establishment Plan which includes legacy issues and handover as a receiver organisation.
Oversight and delivery of the Establishment Plan is carried out by SMT and reported to Governing Body.
Workforce Transition The HR transition of staff to roles within NKCCG commenced at the end of 2012. All senior roles are now filled, though many staff are yet to join our CCG. There remain a small number of vacancies which we expect to recruit to over the next few weeks.
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Transformation
Mid Yorkshire Health and Social Care Partnership Programme Board North Kirklees CCG has agreed a set of principles which it is using to test continually the developments on MYHT’s clinical services strategy to assure itself of the robustness and acceptability of the emerging service changes. We work in partnership with Wakefield CCG to make progress on all elements of the transformation programme. The Partnership’s Programme Board oversees progress for all partners. MYHT’s Clinical Services Strategy The Cluster Board met in public on 10 January 2013 and, following debate with contributions from partners and members of the public, decided to approve the Trust’s Outline Business Case and support the process to take it to public consultation in March 2013.
Programme Management Office continues to drive progress. NKCCG’s Clinical Service Strategy Group and Governing Body oversee progress for North Kirklees
Urgent Care Transformation Board oversees progress and delivery
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The National Clinical Advisory Team commences its work on 14 January. The Service Change Assurance Process and Gateway Review follow shortly afterwards. Public consultation is expected to start in March and finish in June. The plan is then that it would be for NKCCG and WCCG to consider the feedback and make any decision to proceed to the next stage.
Care Closer to Home Board oversees progress and delivery
Transformation Programmes Urgent Care NKCCG’s specific focus for transformation is on developing coherent and robust urgent care pathways for emergency ambulatory care, paediatric assessment, 24/7 urgent care centre, 24/7 diagnostics and step up/ step down beds. This model is being developed by primary and secondary care clinicians working together closely. Care at Home/Close to Home The scope of the programme and priority areas are agreed. The overarching aim of the programme is to develop and commission high quality, cost effective, integrated services (across health, social and voluntary sector care) that will focus on promoting independence and well being, improving health outcomes, avoiding or reducing non elective admissions and faciliating speedier discharge.; The 2 key transformation work streams within the care outside hospital/ closer to home programme for 12/13 are •
Prevention & admissions avoidance – this transformation work stream will focus on the work that needs to take place at practice and neighbourhood/locality level (across health/social and voluntary care) to actively 16
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manage patients who are most at risk of being admitted to hospital and signposting to appropriate service that promote independence and well-being; Prompt discharge arrangements - this transformation work stream will focus on admissions avoidance from A/E by managing crisis and facilitating speedier discharge by adopting a ‘discharge to access approach’ through improved coordination and integration of health, social care and voluntary sector care services;
Areas of risk Capacity to meet the timescales of the planning process for the MYH&SCP for the CSS/OBC. Kirklees Health and Wellbeing Strategy (JHWS) NKCCG is a member of the Kirklees SHWB. At every meeting, we provide an update on the mid Yorkshire Transformation programme, highlighting fit with the JHWS and invite feedback and input. For the November meeting, MYHT clinicians helped us present information on the trust’s OBC. Public Health and Kirklees Council are represented on NKCCG’s Governing Body. We are working closely with colleagues to ensure that NKCCG’s transformation programme is shaped by the JSNA and the priorities of the JHWS. This is reflected in our approach to prioritisation. The Mid Yorkshire Transformation Programme workstreams now include Kirklees LA and PH representation. Kirklees Council will chair jointly with Wakefield Council the Group which oversees redesign of children’s and maternity services. Our Chief Officer Group (LA/PH/NKCCG/GHCCG) is working on the health and social care integration agenda and we have an ambition to design a single approach to commissioning services in the future to underpin integration and transformation. Our 17
focus will be on services in the community and intermediate tier. CAMHS Tier 3 Earlier this year, and following considerable discussion with partners, Greater Huddersfield CCE approved a proposal to tender the tier 3 CAMHS service currently provided by CHFT. Both North Kirklees Governing Body and Calderdale CCE also approved this proposal and a procurement programme board for this exercise is now underway. This group is made up of representatives from across the 3 CCGs, and is chaired by Carol McKenna. The procurement process is continuing to the agreed timescale with a new service provider to be in place by 01/04/2013.A recommendation on contract award will be brought to the Cluster procurement sub-committee in January. Risks – all current risks have been identified and recorded on the CCG risk logs so they can be highlighted and managed.
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