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Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Chief Officer Designate Subject Quality and safety



The CCE Quality Group met on 16 August 2012 where information on the following key quality metrics was discussed. These were also reported to the CCE on 21 August 2012:-

Mitigating actions to address the areas of risk have been discussed for the following areas:-

Quality Assurance • On 3 August 2012 the CQC issued MYHT with a formal warning notice in relation to Outcome 01 (Respecting and involving people who use services) and Outcome 13 (Staffing) following an inspection on Ward 2 (DDH) in July 2012 • Minor concern noted against Outcome 17 (Complaints) at the inspection, although the CQC noted that the recently improved complaints process was robust and includes the additional checks and balances to reduce the extended waits for a response. • On 6 September 2012 the CQC undertook an unannounced inspection on the surgical day unit at PGH. A verbal update of the outcome will be given at the meeting. • Positive CQC Reviews for SWYPFT (Chantry Unit and Poplars CUE), MYHT (Pinderfields) and Spectrum (HMP Wakefield) • Improved CQUIN achievement at Q1 for MYHT (acute and community) and SWYPFT • Quality Accounts for all NHS providers were published on the NHS Choices website by the deadline of 30 June 2012. Other community contractors have produced quality reports for the commissioner, including Spectrum CIC, Novus Health and The Grange Medical Centre.

Ward 2, DDH The action plan to address compliance with Outcomes 01 and 13 was formally received at Executive Contract Board (ECB) on 23 August 2012, and assurance was given that all actions had been completed. The measures put in place include: • Strengthened leadership of the nursing team • Review of staffing levels • Introduction of daily safety briefings, walk rounds at visiting times by ward sisters, and unannounced inspections by members of the clinical and management team • Improved communication with relatives. The original action plan was focused on improvements on Ward 2, but as this ward was a temporary ward and has since been closed, the action plan has been broadened to be implemented across all sites and divisions, to ensure lessons are learned across the Trust.

Clinical Effectiveness • Immediate risk regarding complex surgery undertaken outside NICE Improving Outcomes Guidance (IOG) at MYHT identified for the Head and Neck Cancer Peer Review • No immediate risks or serious concerns identified for Colorectal

Outcome 17 (Complaints), MYHT The action plan to strengthen the

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Chief Officer Designate •

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and Children’s Chemotherapy MYHT have made ‘great progress’ towards the development and implementation of the recommendations following the stroke accreditation visit in December 2011, but to become fully accredited assurance from NHS Kirklees about provision of Early Supported Discharge (ESD) service is required. Provisional accreditation remains with a further visit planned for December 2012. PROMs participation rates at MYHT decreased for AprilDecember 2011, compared to 2010/11. Health gain (outcome) for hip replacement is no longer flagged as a negative outlier for MYHT (PROMs) VTE risk assessment at MYHT continues to be above the national average, but is below target for Spire Methley Park Assessment against the Antenatal and newborn screening standards at MYHT identified areas of achievement – including MYHT being the first in the region to provide first trimester screening for Down’s Screening via the combined test - and some areas for concern. Most concerns will be addressed with the implementation of the new maternity IT system (Euroking).

Patient Safety • Concerns remain about the 2011/12 rebasing for HSMR, further analysis by Dr Foster has identified the coding of palliative care as the main driver. • HCAI performance for MRSA and C.diff below target at Month 4 (NHSWD and MYHT). The external review of HCAI at MYHT concluded that most of the actions to reduce HCAI are in place, but need a higher profile and a tightening of compliance assurance in each area. The principle risks relate to prudent prescribing and antibiotic stewardship; cleaning provision; and assuring competency for aseptic non touch technique (ANTT) and associated invasive procedures. The outcomes of the

governance processes around the complaints procedure was formally received at ECB on 23 August 2012, and assurance was given that all actions had been completed. Head and Neck Cancer IOG The immediate risk was discussed at ECB in April 2012 where MYHT confirmed that laryngectomy, laryngeal/pharyngeal and neck dissection surgery will only now be undertaken at LTHT. Stroke Accreditation MYHT confirmed that two new stroke/neuro consultant posts are being recruited with an intended start date of December 2012. This will allow the delivery of a 24/7 service. North Kirklees CCG provided assurance that Locala will deliver an ESD service to Dewsbury patients from 1 October 2012, while the full review of rehabilitation services is completed. HSMR Monthly progress reports are being presented to ECB. A Task & Finish Group has been established with clinical commissioner representation. Dr Foster’s additional analysis has identified that palliative care coding is

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Chief Officer Designate

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review attracted negative media coverage following discussion at MYHT’s Trust Board. One NPSA alerts remain open past the closure date of 2 April 2012 18 Serious Incidents were reported in Q1, compared to 12 in Q4 and 8 in Q3 (2011/12). The increase is the number of SIs reported by SWYPFT for possible suicide by outpatients, and safeguarding SIs reported by NHSWD.

Patient Experience • Four Eliminating Mixed Sex Accommodation breaches at MYHT in June 2012 • National VOICES (Views of Informal Carers for the Evaluation of Services) survey for bereaved people shows the CKW cluster is rated in the highest 20% or middle 60% of PCT clusters for 10 of the 11 categories, but rates in the lowest 20% of PCT clusters for patient preference of where to die. Full details of the cluster comparisons will be published in the autumn.

driving the increase in HSMR. Other actions include a relaunch of the sepsis algorithm and the roll-out of safety briefings across the Trust. HCAI In addition to the principle risks three further issues for further assurance were identified including prompt and appropriate isolation; addressing levels of MRSA colonisation/carriage; and applying RCA as a cross-professional learning exercise. The resultant action plan was reviewed at the Quality Review Group in August 2012. It includes the establishment of a Task and Finish Group with six key workstreams to address the principle risks and areas requiring further assurance. The workplans for the six key workstreams will be reviewed in September as additional assurance of the action being taken, particularly in view of the negative media coverage. NPSA Alerts An alert relating to minimising risks of mismatching spinal epidural and regional devices with incompatible connectors remains open (NPSA/2011/PSA001). MYHT have accepted the risk of delaying

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Chief Officer Designate implementation of the new equipment – a view also shared with the Association of Anaesthetics, and other acute Trusts. Implementation timescale has been agreed as April 2013.


Cancer Waits 62 days – Qtr 1 validated position is 83.78% against a target of 85%. The consultant upgrade remains below target at 84.62% against a target of 85%.

TIA Validated position for Qtr 1 is 31.1% achievement against a target of 60%. However the unvalidated data shows significant improvement July 58%, August 66% (incomplete month) with an expectation that the Qtr2 position will achieve the target and that performance will then sustained above target levels.

EMSA 4 unjustified breaches (1 NHSWD, 3 NHSK) occurred in June on Ward 8 (Respiratory) at DDH when a female patient requiring non-invasive ventilation (NIV) was placed in a male bay as this was the only bay with the equipment to administer NIV. This is not classed as Level 1 treatment. MYHT were managing a high bed occupancy on this day with no flexibility to move patients to resolve the situation. The associated contract penalties were discussed at Executive Contract Board in July. Further discussions to take place with the Yorkshire Cancer net work and the SHA in September to review progress against MYHT 62 day remedial action plan

MYHT have several actions in place to ensure achievement of this indicator, including weekly monitoring by MYHT Directors; individual analysis of missed targets; transport resolutions; Stoke

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Chief Officer Designate Assessment Nurses taking sole responsibility for booking of patients and recruitment of new consultants – interviews in September. The Stroke Lead feels confident that they are on track to see considerable improvements. RTT An improving picture for MYHT in the delivery of RTT pathways. The validated position for June; Admitted -90.4% achievement against a target of 90% Non-admitted – 97.18% achievement against a target of 95% Incomplete – 94.5% achievement against a target of 92%

MYHT are working to recovery plans and are showing signs of sustainable performance

The unvalidated position shows that 7% of incomplete pathways are treated within tolerance of the RTT guidance against target of 8% 8.5% admitted patients were also treated within tolerance against a target of 10%. It is now recognised that many of the patients managed in tolerance either require complex procedures/increased theatre time or are patient choice. 52+ week Waiters As at 6th September there are 6 patients on the admitted RTT pathway waiting in excess of 52+ weeks, • • •

3 have been given TCI dates in September and October which were due to patient choice and Independent Service Providers 2 patients are pathway validation issues and will be removed 1 patient has not got TCI date booked.

MYHT are continuing to work towards having no 52+ week waits, they are actively managing all long waiters from 40+ weeks, aiming to date before they breach 52+ weeks and discuss all individual cases at the weekly 18 week control tower. Providing suitable dates for patients has proved difficult over the holiday period.

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Chief Officer Designate On the non admitted pathway there is also 6 patients waiting in excess of 52+ weeks; • • •

2 patients have TCI dates booked in September again due to patient choice 2 patients are validation issues and will be removed 2 patients have no TCI dates booked.

A&E Waiting Times Standards MYHT has continued to achieve performance against target of 95%. The unvalidated position as at 19th August 2012 =97.1% and the latest unvalidated position as at the 9th September 2012 is 96.5%. Health Visitors Quarter 1 position is underperforming at a rate of 61.96 against a target of 65. Unvalidated data for August demonstrates a worsening position as one whole time equivalent (WTE) Health Visitor (HV) has put in their notice to leave, however there are 8.6 WTE due to commence during September and October. 3.0 WTE Qualified HV and 5.6WTE newly qualified HV.

Planned initiatives continue: • Further development of professional networks/meetings • Leadership development for band 7 team leaders. • Staff development and review of current skill mix. • Staff newsletter developed and sent out on monthly basis to inform of real time progress of implementation plan. • Communication and engagement strategy plan. • Communication and engagement strategy developed.

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Chief Officer Designate Finance and QIPP

The month 4 position as at 31st July is a surplus of £1,089k and the forecast is to achieve the planned surplus of £3,100k at end of the financial year. There is a pressure against the budget for Specialist Commissioning and Prison services but it is anticipated that this will be managed in year.

These budgets are being reviewed and budget managers are involved in the process to agree appropriate actions to bring back into line.

The QIPP is being shown as achieving in total. This is because of the nature of the contract signed with Mid Yorks and activity on emergency admissions is significantly higher than plan at the present time. This is based on 3 months data that has been received and agreed with the Mid Yorkshire Hospitals NHS Trust (MYHT). The Primary Care Transformation Scheme was considered at both the Finance and Performance Group on 9 August and the NHS Wakefield Clinical Commissioning Executive on 21 August.

Discussions with those practices which are not achieving are taking place and an action plan has been requested to come to the Finance and Performance Group in September and that the Primary Care Transformation Scheme will be a standing item on this agenda. Other actions agreed included: • review of risk scoring • how the risk was reflected in the Assurance Framework

Stanley Health Centre business case has been approved for submission to the Cluster board with acknowledgement of a potential one off revenue consequence of £500k in 2013/14. This was confirmed in part 2 of the NHS Wakefield Clinical Commissioning Executive meeting on 21 August 2012. The awarding of the Dermatology tender was also agreed at this meeting. It was also agreed at this meeting that a sub group be established to consider the transfer through a Section 75 agreement of Public Health expenditure in 2012/13. This group has met and a paper is being prepared for the cluster to approve the Section 75 agreement. A group has been set up which involves clinicians and budget managers who met on 16th August to recommend actions to be taken resulting from the in depth analysis into all budgets that the CCG will be responsible for. A subsequent report is being prepared for Finance and Performance Committee

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Chief Officer Designate The Finance and Performance Group meeting on 9th August also considered the following key issues relating to Finance and QIPP: • Clinical Commissioning Group Structures • Demand Planning/Business Planning. It was noted that the agreement of the planning assumptions was expected during September. AQP Procurement The procurement processes for prioritised Any Qualified Provider services are now drawing to a close. The CCE are receiving an update and agreed recommendations covering the following key areas: AQP procurement for Adult Hearing Services (Cluster-wide), MRI (Cluster-wide), Non-Obstetric Ultrasound (Cluster-wide) and Psychological therapies (Calderdale only) has followed a nationallycoordinated process. Following national checks and regulatory assessment, servicespecific 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

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Chief Officer Designate mobilization. Diagnostics: NOUS and MRI: Advert window has closed. Assessment is at advanced stage.

Governance and risk

The expectation is that CKW will meet the DH requirement for three AQP services to be operational by end September 2012. The Audit and Governance Group met on the 9th August. External Audit confirmed KPMG had been appointed from 1st September for 5 years and the engagement with them would be the same as in 2011/12.

The Pbr assurance report was shared by District Audit for 2011/12, this work had now been outsourced to CAPITA Complaints were discussed as part of the Q1 Risk Management Report and further details were requested on how the categories were defined. Audit and Governance requested assurance from the Quality Board that the findings of the CQC be given priority regarding the Care of the elderly at MYHT. Other issues considered at the Audit and Governance Group included: • Internal Audit Progress Report • Benchmarking – CCG structures • Counter Fraud Progress Report • External Audit Update • Draft Annual Audit Letter • Q1 2012/13 Serious Incidents Report • Governance Update • Q1 Standards of Business Conduct and Receipt of Hospitality Report

Complaints. It was agreed at the meeting that future quarterly risk management reports would contain further details regarding complaints graded as ‘high’. It was further agreed that a meeting be arranged with group members to discuss complex complaints. CQC report regarding care of the elderly. It was agreed that the Head of Quality and Engagement (see Quality and Safety section) be asked to attend the meeting on 11 October to discuss the actions taken. It was further noted at the NHS Wakefield CCE meeting on 21 August that the MYHT action plan would be received by the Executive Contact Board

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Chief Officer Designate

Managing the transition and workforce

• Policies - the Being Open policy was approved at this meeting. The NHS Wakefield CCG meeting held on 21 August considered the following issues with regard to Audit and Governance: • NHS Wakefield Clinical Commissioning Group Structures. The governing and local clinical network structure was approved. • Asylum Seeker Accommodation. The issuing of a tender waiver was approved subject to approval by NHS Calderdale, Kirklees and Wakefield District. • Our desktop application for wave 1 CCG authorisation was as required by the NHSCB successfully completed on 2 July. • A full report on the desktop submission was received on 25 August. This report indicates that we have satisfactorily completed 75 of the 119 criteria for full authorisation. This is within acceptable parameters for the authorisation process. • Our constitution is now in final draft form and our local clinical network models have been agreed following considerable joint working with our member practices • We have refreshed our strategic plan for 2012/13 to encompass some of the additional policy and evidence of planning and implementation required for full authorisation. • NHS Wakefield CCG proposed staffing structure was re-issued on 31 August following consultation. We plan to enter the pooling and matching process with other CCGs across the cluster and the CSS from 10 September. • The post transition ‘core offer’ for Public Health services is agreed. • Development of a joint and integrated commissioning unit is in early discussion with the Local Authority. • A risk assessment and position statement for our CSS is in development. • Informal Board sessions in August have been focused around organisation building and the requirements of authorisation; and those in September will focus entirely upon preparation for the

An analysis of uncompleted criteria, themes and possible Key Lines of Enquiry has been completed. Gaps and issues have been identified. The final draft of the constitution will be approved at 18 September CCE. The refreshed 2012/13 strategic plan will be approved at 18 September CCE. Adhering to people transition plan.

An Order Book for Public Health is in development

First meeting 17 September OD plan to address this development need is in place.

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Chief Officer Designate ‘Site Visit’ including a mock panel exercise with external agents. • A ‘Site Visit’ from the external assessor panel will take place on 26 September. The agenda for the day is expected to be confirmed during week commencing 10 September. Transformation

Community Dermatology Procurement: Bidders have been notified of the outcome and we are now in the formal 10 day stand still period, awaiting response from the preferred provider by 3rd September.

Ophthalmology: The new Community Ophthalmology services in Wakefield, provided by ‘The Practice plc’ are now accepting outpatient referrals. This is the first stage in a phased implementation of the service, which will be formally launched later in the year, following extension of the service to include daycase surgery. The outpatient service is currently available at a choice of three locations: o The Grange, Hemsworth, o Ash Grove Surgery, Knottingley, o Lupset Health Centre, Lupset, Wakefield.

Out of Hospital Care Transformation Programme There are a number of key work streams aligned to this programme. Progress this period is as follows: • Discharge to assess and admission prevention scheme ‘5 a day, 10 a day’ – Project Governance structure has been agreed and Terms of Reference drafted. Membership of the Project Steering Group, which incorporates representatives from across the three organisations, has been confirmed, and the Group is meeting fortnightly. Clarification of the project vision has confirmed the scope of the project to be all individuals, aged 18 years and over, identified as medically stable for discharge, with

An action plan is in place to receive, present to and appropriately inform the external assessor panel on 26 September.

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Chief Officer Designate non-complex care needs. Representation for three “Route to a Solution” workshops, including stakeholders from across the health, social and voluntary sector, has been finalised and the workshops scheduled monthly commencing 27th September 2012 until 15th November 2012. A Project Manager has now been appointed; a start date yet to be confirmed. • Care Home and Liaison Support (C.L.A.S.S) – Business Case approved by CCE 24th July 2012. First phase of implementation to include a six month pilot, commencing October 2012 across four care homes. Based on evidence and learning from the pilot scheme, it is envisaged the service will be extended across thirtyfive Care Homes, to cover all Nursing Homes, Extra Care Housing Facilities and some Residential Homes identified as high risk and high users of services based on ambulance call outs, A&E attendance and hospital admissions.. • Improved access to hospice care across 24/7 spectrum and development of specialist palliative care community crisis intervention – The project is still on track for commencing delivery on 1st October. The project manager and provider leads are working with communications teams to implement the communications plan over the course of September and early October. Work has commenced on further modelling of up to date baseline activity and benefits tracker items. • Virtual Ward – The Evaluation Report has been completed by White Rose Surgery, and will be considered by the Urgent Care Clinical Commissioning Unit. The operational start date at The Grange was 1st August 2012. Matrons have identified patients for the caseload and continue to admit. Also established links with existing Practice and Community staff, and the Virtual ward at White Rose Surgery, in order to provide cross-cover for Social Work intervention to ensure continuity of service. Urgent Care Transformation Programme

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Chief Officer Designate • • •

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The urgent care workshop took place on 19 July 2012 and the first meeting of the Urgent Care Transformation Board was held on 28 August. The Board will have a split agenda with the first part dealing with transformational matters and the second part with operational matters. These arrangements will be kept under review. The scope of the programme and the associated projects over and above what is already in play have yet to be fully articulated, agreed and resourced. However a number of actions are being pursued i.e. the development of an Urgent Care dashboard; review of primary care provision in A&E departments; commissioning of a utilisation review; and a further At Q1 the PCTS was not delivering the anticipated reductions in urgent care activity. The scheme was discussed at both the Wakefield CCE and Executive Approvals Group in August. One of the actions agreed is visits by CCG clinical leads and support staff to a number of Wakefield practices where progress appears to be slow or emergency admission activity is demonstrating growth in excess of 30%. All practices were written to providing them with an update at individual and CCG level on performance of the scheme to date. Activity was benchmarked against peers and data quality issues addressed. As the A&E bookable option was not seeing the expected levels of demand the appointment capacity was reduced to one a day from 1 September and this is being kept under review. There will be on-going monthly monitoring of the implementation plans that each General Practice agreed to, and the impact they have had on urgent care demand. A marketing campaign is being pursued which will see a refreshing of the GP campaign with more advertising, a push at public events and information about the scheme on the A&E screens.

Clinical Commissioning Executive: Wakefield Report Author: Jo Webster, Chief Officer Designate •

Due to the failure to exhibit the required reductions in activity the first quarterly payment of 10% to practices is unlikely to be made.

Maternity, Children and Young People’s Transformation programme • The Visioning Workshop scheduled for 28 August did not go ahead due to the availability of clinicians from MYHT. To be rearranged by mid-October.