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14 March 2008

Key Performance Indicators Key (1) Overall RAG (2) Action Plan Status (3) Financial RAG (4) PI Status (5) Overall Risk (6) Milestone RAG (7) Milestone Status (8) PI Milestone RAG (9) PI Milestone Status

Acc Ref

Accountability

Completion Date

1.a.1 Referral to treatment times milestones

31-Mar-2009

(1)

(4)

(inclusion/construction to be comfirmed) To ensure that by 2008 nobody waits more than 18 weeks from GP referral to hospital treatment. Owner Jim Barwick Sponsor

Key Achievements Since Last Report:

Carol Mckenna Admitted Quality of data has improved significantly due to improved data completeness and validation of waiting lists by acute trusts. Contuinued progress by secondary care to treat patients waiting over 18 weeks, however there remains significant risks in Orthopaedics. This is a West Yorkshire wide issue and securing aditional capacity is being coordinated by te SHA. The problem for Kirklees PCT is more acute at Mid Yorkshire where aitional activity has been sourced in the independant sector and patients are being treated. In adition the PCT is commited to a coordinated approach to all development, activities and commisioning issues relalted to Orthopaedic and Musculoskeltal Care. For Non admitted the standard has been met and sustained, we are able to forecast a sustained achievement of this position. Admitted For CHfT we have reaasurances that the standard will be met. However there are concerns as highlighted at Mid Yorks.

Current Concerns: Non admitted Early achievement of the standard. Admitted The PCT expected to see an improvement in the trajectory for RTT times reported in January, February and March and this has been the case. This is due to two main reasons; firstly, that the backlog of patients waiting over 18 weeks will be cleared; secondly, that data completeness will improve giving an accurate position. Howeevr treating the patients in Orthopaedics particularly remains a risk. Data completeness improves as Trusts validate their waiting lists and apply clock stops to patients where the clock stop has previously been unknown. Therefore, when the patients are reported as data complete it looks like they have had an 18-week+ wait. In reality, they have not; it is just that the clock has not been stopped. These are one off issues and are part of the Trusts improvement in data completeness. This work has been completed by CHfT at the end of February at will be completed by MYHT by the end of March and thereafter any reports will be accurate.

Reasons for Variance and Actions Taken:

As further reassurance, the acute trusts have reviewed patients that were referred 18 weeks ago to see if these have been treated in 18 weeks. These patients will have known clock start and clock stops and therefore robust data completeness. Encouragingly these patients have been treated within 18 weeks. Therefore as the backlogs of patients are treated and data completeness improves (both happening) we can be confident that 18 week RTT times will be inline with the trajectory. Therefore, if long waiters and incomplete data are removed, then patients are currently being seen within 18-weeks. Progress implementation plans for new pathways to support delivery and sustaining 18 weeks. Role out Route to a Solution approach to the CHfT health economy, reflecting best practice currently within the MYHT health economy. Non admitted Continued integration of actions for admitted pathways with non-admitted pathways. The main reason for a slow down in improvement has been data validation. For patients attending outpatient’s clock stops have not been indicated on the PAS system, therefore, data is incomplete. This is mainly for activity prior to 18-week rules. When clock stops are applied and data is complete it looks like patients have waited longer, when in actual fact these patients have been seen and treated. Those patients that are currently attending outpatients and being treated are in the main within 18weeks and we are confident that the standard will be met in March 2008 and beyond.

Due Date

PI

Planned (value)

Latest YTD

Variance

67

72

5

(8) (9) Comments

% of admitted patients treated in 18 weeks Mar 08

31-Mar-2008

THIS IS NOW THE WEEKLY ACTUAL RELATING TO 2 MARCH 08 AND IS NOT VALIDATED

% of non-admitted patients treated in 18 weeks THIS IS NOW THE WEEKLY ACTUAL RELATING TO 2 MARCH 08 AND IS NOT VALIDATED The number of eligible (*) admitted patients whose RTT clock stopped during the month (denominator) Completeness of data comparison on KH06/6R has Oct 07 31-Oct-2007 2062 1833 229 a time delay Mar 08

31-Mar-2008

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88.2

94

5.8

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14 March 2008

The number of eligible (*) admitted patients whose RTT clock stopped during the month who waited 18 weeks or less (<127 days) (numerator) Oct 07

31-Oct-2007

1292

1010

-282

The number of eligible (*) non-admitted patients whose RTT clock stopped during the month (denominator) Oct 07

31-Oct-2007

6582

8783

-2201

The number of eligible (*) non-admitted patients whose RTT clock stopped during the month who waited 18 weeks or less (<127 days) (numerator) Oct 07

31-Oct-2007

5026

5061

35

Not sure if below plan is Red or Green

23rd July 2007 Acc Ref

Accountability

Completion Date

ET03

1.a.2 Number of inpatients waiting longer than the standard

31-Mar-2008

(1)

(4)

Maintain a maximum wait of 26 weeks for inpatients Owner Rachel Carter Sponsor Key Achievements Since Last Report:

Carol Mckenna The current waiting time guarantee for inpatient treatment is 26-weeks. The PCT has breached this limit on 7 occasions in 2007/08; these are detailed in the Breach Report section.

Current Concerns:

There was a further 26 week breach in January for a patient listed at LTHT; this same patient had breached 26 weeks at the end of December. This is a specialist spinal patient referred to neurosurgeon Mr Towns. The breach was due to lack of elective capacity to treat at LTHT. Mr Towns is not prepared to operate on his long waiters at the Nuffield, so escalation for treatment there is not an option. These cases are also not appropriate to transfer to other surgeons to operate.

Reasons for Variance and Actions Taken:

The SHA is actively performance managing LTHT in relation to this and other capacity issues, as is the host commissioner Leeds PCT. Kirklees PCT is adding its influence where practicable, but as a minor commissioner from this provider this has limited impact.

PI

Due Date

Planned (value)

Latest YTD

Variance

(8) (9) Comments

Number of inpatients waiting 26 weeks or more at the date of measurement The number of patients waiting 26 weeks or more for an elective (inpatient ordinary or daycase) admission. The value will be made up of a count of the number of patients waiting 26 weeks or more at the end of each month summed across the months April 2007 to March 2008 divided by the total number of general and acute first finished consultant episodes (FFCEs) for elective activity (inpatient ordinary and day case admissions) minus the number of planned elective admissions using cumulative figures reported in the March 2008 Monthly Monitoring Return, expressed as a percentage One breach in month from LTHT. The same patient Jan 08 31-Jan-2008 0 1 -1 that breached in December.

Monthly monitoring return (Financial year 2007/2008)

28th March 2007 Public consultation prior to the production of the NHS Plan indicated that the public wanted to see reduced waiting times in the NHS. The NHS Plan sets out the goal that by December 2005, the maximum wait for inpatient treatment will be 26 weeks. Urgent cases will continue to be treated in accordance with clinical need

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14 March 2008

Acc Ref

Accountability

Completion Date

1.a.3 Number of outpatients waiting longer than the standard

31-Mar-2008

(1)

(4)

Maintain a maximum wait of 13 weeks for an outpatient appointment. Owner Rachel Carter Sponsor

Carol Mckenna

Current Concerns:

The PCT has reported an additional breach of this target (total now 4) in January 2007. This took place at LTHT. This is not expected to impact on the PCT's HC rating. Due Date

PI

Planned (value)

Latest YTD

Variance

(8) (9) Comments

Numbers of outpatients waiting 13 weeks or more at the date of measurement The number of patients waiting 13 weeks or more for a first outpatient appointment following a GP written referral. The value will be made up of a count of the number of patients waiting 13 weeks or more at the end of each month between April 2007 and March 2008 divided by the total number of patients seen following a GP written referral request for a first outpatient appointment using cumulative figures reported in the March 2008 Monthly Monitoring Return, expressed as a percentage. Jan 08

31-Jan-2008

0

1

-1

Monthly monitoring return (Financial year 2007/2008)

28th March 2007 Public consultation prior to the production of the NHS Plan indicated that the public wanted to see reduced waiting times in the NHS. The NHS Plan sets out the goal that by December 2005, the maximum wait for an outpatient appointment will be 13 weeks. Urgent cases will continue to be treated in accordance with clinical need. Acc Ref

Accountability

Completion Date

PSA13h

1.a.9 PSA13h: Number of patients waiting longer than the standard for 15 key diagnostic tests and procedures for period April 2007 to March 2008

31-Mar-2008

(1)

Owner

Abby Tebbs

Sponsor

Carol Mckenna

Current Concerns:

Waitig times reducing satisfactorily against profile for 6 week target overall, however, 11 breaches of the 13 week target Due Date

PI

Planned (value)

Latest YTD

Variance

(4)

(8) (9) Comments

Number of patients waiting 13 weeks or more, for 15 key diagnostic tests and procedures, at the date of measurement Dec 07

31-Dec-2007

0

11

-11

Number of patients waiting 6 weeks or more, for 15 key diagnostic tests and procedures, at the date of measurement Dec 07

31-Dec-2007

533

243

290

23rd July 2007

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Acc Ref

Accountability

Completion Date

1.b.2 Access to a primary care professional

31-Mar-2008

(1)

(4)

Guaranteed access to a primary care professional within 24 hours and to a primary care doctor within 48 hours Owner Mark Jenkins Sponsor

Carol Mckenna

Key Achievements Since Last Report:

Achievement increased from 98.6 % to 99.4% UPDATE FEB 08 - PCAS takes place Quarterly, next survey to take place during April with figures made available to performance accelerator early May 08.

Current Concerns:

One Kirklees practice did not meet the 24hr target for accessing a Primary Care Professional. The practice concerned was contacted on a Thursday and does not have a Primary Care Professional in post on Fridays. On this occasion an appointment was not available with the practice GP within 24hrs so the practice failed to meet the target. UPDATE FEB 08 - The only practice that didn't meet the PCT target in the previous Quarterly PCAS has now confirmed that there is now access to a Nurse Practitioner on Fridays so it is expected that they will acheive the target in future surveys.

Reasons for Variance and Actions Taken:

See 'Current Concerns' above. The contracting team are to approach the practice concerned to discuss the issue and ensure that arrangements are put in place to guarantee that the practice meets the target in future. The acheivement of this target has improved each Quarter and the PCT is confident that 100% of the target will be met in future. UPDATE FEB 08 - Practice who didn't meet the PCP target have been approached and it is expected that they will meet PCT targets in future surveys. Due Date

PI

Planned (value)

Latest YTD

Variance

(8) (9) Comments

Percentage of population able to see a Primary Care Professional within 1 working day For each month: total practice list size for those practices within the PCT with an appointment system who can offer an appointment to see a primary care professional within one working day divided by the total practice list size for those practices within the PCT with an appointments system in place to see a primary care professional. The indicator value will be the weighted average of the 12 monthly figures, i.e. the sum of all the 12 monthly numerators divided by the sum of the 12 monthly denominators. Jan 08

31-Jan-2008

100

99.4

-0.6

Primary care access survey (Financial year 2007/2008)

28th March 2007 There is a Priorities and Planning Framework (2003 - 2006) target to ensure that from December 2004 100% of patients who wish to do so can see a primary care professional within one working day and a GP within two working days. The NHS in England: the Operating Framework for 2007/2008 (2.4) reaffirmed that PCTs need to ensure they continue to meet existing Government commitments, and that progress on this would continue to be assessed by the Healthcare Commission. This indicator measures activity in practices with an appointment system to see a primary care professional. It allows such practices to include access under an agreement with a local NHS Walk-In Centre (or local access clinic) covering referring or diverting patients, that has been signed off by the PCT as offering appropriate access. This indicator is based on results from the Primary Care Access Survey (PCAS). The Healthcare Commission and Department of Health have been working towards incorporating views of patients into the assessment of this target. In 2007/2008 this has been achieved for the part of the target which relates to 48 hour access to a GP, through the use of data from the new GP Patient Survey. For the part relating to 24 hour access to a primary care professional, primary care trusts are encouraged to work with practices to ensure that PCAS results more accurately reflect the experience of patients.

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Acc Ref

Accountability

Completion Date

1.d.1 Category A calls meeting 8 minute target

31-Mar-2008

(1)

(4)

All ambulance trusts to respond to 75% of category A calls within 8 minutes. Owner Rachel Carter Sponsor

Carol Mckenna

Current Concerns:

Performance in January recovered slightly, with monthly performance for YAS at 73.2% (December 69.2%) against a target of 75%. This is an annual target; year to date performance has dropped further to 73.7%. At this point in the year it will difficult for YAS to raise Category A 8 minute performance to a level that will achieve the cumulative annual 75% target - i.e. it is now likely that YAS will not achieve the Cat A 8 minute target. As this is a YAS-wide performance it will reflect on most PCTs within Y&H. The Kirklees position is worse than the YAS overall performance - 70.5% for both January 2008 and year-to-date.

Reasons for Variance and Actions Taken:

The PCT has agreed additional funding to facilitate delivery towards the 75% target. Due Date

PI

Planned (value)

Latest YTD

Variance

(8) (9) Comments

Percdentage of category A calls resulting in an emergency response arriving at the scene of the incident within 8 minutes The number of category A calls receiving a first response within eight minutes divided by the number of category A calls. KA34 Ambulance Services (Financial Year 2007/2008), expressed as a percentage. Performance of the ambulance trusts will be mapped to the PCTs Performance is monitored against YAS overall Jan 08 31-Jan-2008 75 73.7 -1.3 performance, not PCT specific

KA34 ambulance services (Financial year 2007/2008)

28th March 2007 This indicator measures performance in response to category A calls. Department of Health requirements are that seventy five per cent of category A calls (defined as urgent and life-threatening) should receive an emergency response at the scene of the incident within eight minutes. Acc Ref

Accountability

Completion Date

1.d.3 Category B calls meeting national 19 minute target

31-Mar-2008

(1)

(4)

All ambulance trusts to respond to 95% of category B calls within 19 minutes. Owner Rachel Carter Sponsor

Carol Mckenna

Current Concerns:

Performance in January recovered to 93% in-month (December 89.7%) against a target of 95%. This is an annual target and year to date performance is 92.3%. It is now unlikely that YAS will be able to improve performance for the remainder of the year to a level that would secure the cumulative target of 95%, i.e. it is likely that this target will not be achieved. As this is a YASwide target, this will reflect on most PCTs within Y&TH. Performance for Kirklees PCT patients is below overall YAS performance at 91.7% in-month and 90.8% YTD.

PI

Due Date

Planned (value)

Latest YTD

Variance

(8) (9) Comments

The number of category B calls resulting in an emergency response arriving at the scene of the incident within 19 minutes Number of category B calls receiving a response (as defined in the 2007/2008 KA34 technical guidance) within 19 minutes divided by number of category B calls receiving a response (as defined in the 2007/2008 KA34 technical guidance). KA34 Ambulance Services (Financial Year 2007/2008), expressed as a percentage. Performance of the ambulance trusts will be mapped to the PCTs Performance is monitored against YAS overall Jan 08 31-Jan-2008 95 92.3 -2.7 performance, not PCT specific

KA34 ambulance services (Financial year 2007/2008)

28th March 2007 This indicator measures performance in response to category B calls. Department of Health requirements are that ninety five per cent of all category B calls (defined as urgent but not immediately life-threatening) should receive an emergency response at the scene of the incident within 19 minutes.

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Acc Ref

Accountability

Completion Date

1.e.1 Convenience and choice - PCT booking

31-Mar-2008

(1)

(4)

Ensure that by the end of 2005 every hospital appointment will be booked for the convenience of the patient, making it easier for patients and their GPs to choose a hospital and consultant that best meets their needs. By December 2005, patients will be able to choose from at least four different health care providers for planned hospital care, paid for by the NHS. Owner Rachel Carter Sponsor

Carol Mckenna

Key Achievements Since Last Report:

Performance has improved from 35% in November, reported in last report (projecting 32% in December). Latest data has been drawn from weekly C&B reports (i.e. not official SHA report) but indicates performance of 40% in January, projecting 41% in February. Continued under-achievement will impact on the PCTâ&#x20AC;&#x2122;s 2007/08 Performance Rating. Although PCT performance has improved, there is reason to believe that it may not be improving as quickly as other PCTs.

Current Concerns:

Reasons for Variance and Actions Taken:

Performance on recognition of offer of Choice is reported quarterly. Official figures are not yet available for the Nov 07 - Feb 08 period, but early data suggests an improvement in performance for Kirklees PCT. Previously reported data (October - November 07) was 39% recollection amongst definitive responses (i.e. excluding don't knows and not stated) compared to national performance of 47%. Indicative figures for Nov 07 - Feb 08 show Kirklees performance as 44% against national performance 46% and Y&TH performance of 41%. As previously reported, an action plan has been implemented. Due Date

PI

Planned (value)

Latest YTD

Variance

(8) (9) Comments

Percentage of referrals received by providers for first consultant outpatient appointments that are made through choose and book The number of patients added each month to the outpatient waiting list for first outpatient appointment, where the source is GP written referral, and where the patient was booked through Choose and Book. The value is the sum of the months from April 2006 to March 2007. Expressed as a percentage. Performance will be assessed against the planned percentage in the 2006/2007 PCT Choose and Book Utilisation Plan. This is latest available information from weekly C&B Jan 08 31-Jan-2008 90 40 -50 reports, rather than official SHA figure.

Monthly monitoring return (Financial year 2007/2008) Choose and Book Extracts (Financial year 2007/2008) 28th March 2007 Building on the NHS Plan commitments, this target aims to drive improvements in the experience of patients of the NHS by making it more responsive to the needs of the patients. It focuses on improving convenience and choice, mainly through the choose and book programme which is intended to enable patients to work with GPs and general dental practitioners to choose from a number of outpatient services and book their appointments in advance, and also by ensuring that inpatient appointments are booked in advance. The NHS Plan sets the target that by the end of 2005 all patients will go through a booking system giving a choice of a convenient time within a guaranteed maximum waiting time to replace the current waiting list for appointments and admission. 'The NHS in England: Operating Framework for 2006/07' set a milestone for the use of Choose and Book of 90% by March 2007. This indicator assesses trusts performance against the milestone during 2007/2008. Acc Ref

Accountability

Completion Date

2.c.1 Teenage conception rates

31-Dec-2009

(1)

(4)

Reducing the under-18 conception rate by 50% by 2010 (from the 1998 baseline), as part of a broader strategy to improve sexual health. Owner Rachel Spencer Sponsor

Judith Hooper Due Date

PI

Planned (value)

Latest YTD

Variance

(8) (9) Comments

Conception rate per 1000 females ages 15-17 The difference between planned and actual under-18 conception rates for calendar year 2006 divided by the planned under-18 conception rate for calendar year 2006, expressed as a percentage 2006

31-Dec-2007

36.26

43.9

7.64

288

349

-61

7942

7942

0

Number of conceptions to under-18 year olds 2006

31-Dec-2007

Population of females aged 15 to 17 2006

31-Dec-2007

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PCT local delivery plans (Calendar year 2006) ONS (Calendar year 2006) 23rd July 2007 Britainâ&#x20AC;&#x2122;s teenage birth rates are the highest in Western Europe. Teenage mothers are more likely to suffer poor health outcomes. The teenage pregnancy strategy seeks to halve the under-18 conception rate by 2010 (from the 1998 basline) through a wide ranging programme of coordinated activity, including improved advice and contraceptive services for young people. The NHS Plan also set an interim target of achieving a 15 percent reduction in the under-18 conception rate by 2004. In addition to national targets, local under-18 conception rate targets have been agreed with teenage pregnancy partnership areas, which are co-terminous with top tier local authority areas in England. These local targets range between a 40% to 60% reduction by 2010. Each PCT is signed up to the target for their teenage pregnancy partnership area. Acc Ref

Accountability

Completion Date

2.c.2 Access to GUM clinics

31-Mar-2008

(1)

(4)

Access to genito-urinary medicine (GUM) clinics within 48 hours Owner Rachel Spencer Sponsor

Judith Hooper

Key Achievements Since Last Report:

As a result of the NST visit, numerous changes have been implemented in the Princess royal clinic including the introduction of nurse led clinics. CaSH staff are being trained in tier 2 STI work to enable them to offer tier 2 by April 08 thereby reducing the pressure on GUM.

Current Concerns:

Chadwick clinic is meeting 48 hour access for offered appointments, Princess Royal has improved and as a result Kirklees PCT is on trajectory for 100% 48 hour access by April 08. Progress against the 'seen' trajectory is still on amber as this is unlikely to be met by April 08, however the 'offered' target is the crucial one.

Reasons for Variance and Actions Taken:

Recruitment in progress to fill consultant vacancies, although there has been no interest in the post. A locum consultant has been recruited which should ensure progress towards target is continued as the reliance on one person will be less. A nurse consultant vacancy has been created which should reduce some of the pressure. Additionally, health advisers are being employed to support the less consultant focussed approach to the GUM service. CaSH on target to provide tier 2 STI screening by April 08 Due Date

PI

Planned (value)

Latest YTD

Variance

(8) (9) Comments

Number of first attendances at a GUM service who were offered an appointment to be seen within 48 hours of contacting a service Jan 08

31-Jan-2008

654

841

187

Number of first attendances at a GUM service who were offered an appointment to be seen within 48 hours of contacting a service Chadwick Clinic Jan 08

31-Jan-2008

0

355

0

Number of first attendances at a GUM service who were offered an appointment to be seen within 48 hours of contacting a service Princess Royal Jan 08

31-Jan-2008

0

418

0

Number of first attendances who were seen within 48 hours of contacting a GUM service Jan 08

31-Jan-2008

620

737

117

Number of first attendances who were seen within 48 hours of contacting a GUM service Chadwick Clinic Jan 08

31-Jan-2008

0

304

0

Number of first attendances who were seen within 48 hours of contacting a GUM service Princess Royal Jan 08

31-Jan-2008

0

378

0

Percentage: first attendances who were seen within 48 hours of contacting a GUM service Jan 08

31-Jan-2008

90.1

84.9

-5.2

Percentage: first attendances who were seen within 48 hours of contacting a GUM service Chadwick Clinic Jan 08

31-Jan-2008

90.1

85.6

0

Percentage: first attendances who were seen within 48 hours of contacting a GUM service Princess Royal Jan 08

31-Jan-2008

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90.1

85.5

0

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Percentage: people attending a GUM service who were offered an appointment to be seen within 48 hours of contacting a service HC will assess performance will be assessed against planned percentage in the 2007/2008 local delivery plan (LDP). Jan 08

31-Jan-2008

95.1

96.9

1.8

Percentage: people attending a GUM service who were offered an appointment to be seen within 48 hours of contacting a service Chadwick Clinic Jan 08

31-Jan-2008

95.1

100

0

Percentage: people attending a GUM service who were offered an appointment to be seen within 48 hours of contacting a service Princess Royal Jan 08

31-Jan-2008

95.1

94.6

0

868

180

Total number of first attendances at the GUM service Jan 08

31-Jan-2008

688

Total number of first attendances at the GUM service Chadwick Clinic Jan 08

31-Jan-2008

0

355

0

Total number of first attendances at the GUM service Princess Royal Jan 08

31-Jan-2008

0

442

0

Health Protection Agency (Financial year 2007/2008) DH GUM clinics waiting times collection (GUMAMM) (Financial year 2007/2008) PCT local delivery plans (Financial year 2007/2008) 23rd July 2007 Annual numbers of sexually transmitted diseases diagnosed in genito-urinary medicine (GUM) clinics in England rose by 43% between 1996 and 2002, with an overall increase in clinic workload of 79% for the same period. The white paper, 'Choosing health: making healthier choices easier' (Department of Health, 2004), included a number of commitments, including improved access to GUM clinics, and efficient and convenient screening services. The percentage of patients attending GUM clinics who are offered an appointment within 48 hours of contacting a service should increase with time and reach 100% by 2008. The percentage of patients attending GUM clinics who are seen within 48 hours of contacting a service should also increase with time. (The target of 100% relates to the offer of an appointment for the patient to be seen within 48 hours of contacting the service rather than an offer of an appointment that is made within 48 hours of contacting the service but to be seen at a later date.)

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Acc Ref

Accountability

Completion Date

2.c.3 Access to reproductive health services - Part two - chlamydia screening

31-Mar-2008

(1)

(4)

Access to chlamydia screening Owner Rachel Spencer Sponsor

Judith Hooper

Key Achievements Since Last Report:

See ‘action taken’ below

Current Concerns:

The PCT are unlikely to meet its trajectory for 07/08. This can be attributed to the following factors •Unwillingness of some staff to promote screening •Unwillingness of some independent contractors to provide screening without payment •Difficulty ‘signing up’ some local services •Lack of clarity on GP provision incentives •Schools are difficult to access •Some colleges are difficult to access •Seems initially to be a lot of enthusiasm amongst agencies and partners to receive training and to do Chlamydia screening, however, there is a slow (sometimes zero) return of samples post training. On contacting individual agencies/partners lack of time is the main obstacle. Also some apathy and ambivalence amongst some screening venues. •Some agencies/partners indicate they hadn’t realised staff hadn’t started screening. •Some agencies do not have the staff in place to provide the screening service currently and are relying on the CSO staff to deliver the screening via Pee in a pot days. •There needs to be greater advertising of the service to allow young people to know where to access screening. •Some young people who are sexually active just don’t want to screen! They don’t think its relevant to them/not a priority/ ‘I’m ok’ ‘I’ve already been checked’

Reasons for Variance and Actions Taken:

The following actions are being taken to improve performance •Continuing to work closely with and provide encouragement to screening venues that have been trained to provide screening whilst identifying new obstacles/barriers to delivery. •£10,000 Advertising campaign January to March 2008 in partnership with Calderdale PCT. •Appointment of 0.5 wte HCA to work within CASH services early 2008 with a specific remit to support Chlamydia screening •Using screening data to encourage larger venues to screen larger volumes by identifying the number of 15-24 year olds in their population •Contacting Occupational health departments within large organisations to train staff to offer screening. •Currently working with the Sexual Relationships Education team in Kirklees PCT to develop a website for young people on sexual health with heavy focus on Chlamydia screening and signposting built in. •Contacting commercial managers of cinemas/football grounds to offer PIP events •Working with GUM clinics to facilitate the directing of asymptomatic worriers towards the service. •Ensure all student handbooks containing contact details of the screening programme •Links with cytology/family planning courses at the university – ensure programme information included in course material to facilitate signposting. •Creating and maintaining links with C-Card Venues •Creating and maintaining links with Teenage pregnancy Coordinators •Developing eye catching and popular poster material, •Offering all young people free condoms and ‘lollies’ for doing a test. The sweets make the screening more popular, they all want freebies! •Provide ‘out of hours’ screening venues •Facility whereby individuals may email us for a testing kit •Regular Mail shots to GP’s Health Centres who have not yet made contact with the CSO to encourage sign up •Range of screening venues covering large geographical area within South/central Kirklees •Support to all screening venues re: strategies to increase screening •The screening programme is working with the labs to identify all screens that are processed and identify if they can be incorporated into the programme. •Rolling out of an EHC, pregnancy testing and Chlamydia screening locally enhanced service to pharmacies Due Date

PI

Planned (value)

Latest YTD

Variance

(8) (9) Comments

Percentage of 15 - 24 year old persons screened or tested for chlamydia HC will assess actual performance will be assessed against planned performance as set out in the 2007/2008 local delivery plan (LDP). Qtr 3 07/08

31-Dec-2007

5

1.1

-3.9

The number of 15 - 24 year old persons screened or tested for chlamydia Qtr 3 07/08

31-Dec-2007

© Dynamic Change Limited 2008 Key Performance Indicators

2650

598

-2052

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The number of 15 - 24 year old persons screened or tested for chlamydia Calderdale and Huddersfield Program Q3 07/08

31-Dec-2007

0

535

0

The number of 15 - 24 year old persons screened or tested for chlamydia Wakefield and North Kirklees Program Q3 07/08

31-Dec-2007

0

143

0

53002

53002

0

The population aged 15 - 24 years Q3 07/08

31-Dec-2007

Needs to be validated on Exeter System

PCT local delivery plans (Financial year 2007/2008) Chlamydia Screening Programme Returns (Financial year 2007/2008) Special data collection (As at March 31st 2008) 28th March 2007 Ensuring wide and appropriate access to reproductive health services for the sexually active population is vital to the successful delivery of any local strategies to improve sexual health, and will in turn help to deliver national objectives for improved sexual health. In November 2004, the Government published the white paper ‘Choosing Health: Making Healthy Choices Easier’. The white paper highlights that the provision of contraception is an essential health care service and plays a pivotal role in protecting against both unplanned pregnancies and sexually transmitted infections (STIs). Both ‘The national strategy for sexual health and HIV commissioning toolkit’ (Jan 2003) and the Department of Health commissioned and endorsed ‘Recommended standards for sexual health services’ (March 2005) also highlight the importance of provision of open access services that offer the full range of contraceptive methods. Chlamydia is the most common sexually transmitted infection (STI) and there is evidence that up to one in 10 young people aged under-25 may be infected. It often has no symptoms, but if left untreated can lead to pelvic inflammatory disease, ectopic pregnancy and infertility. Chlamydia is very easily treated. The national chlamydia screening programme (NCSP) has a community focus and concentrates on opportunistic screening of asymptomatic sexually active men and women under the age of 25 who would not normally access, or be offered a chlamydia test, and focuses on screening in non-traditional sites (youth services, military bases, universities, contraception services, primary care). Acc Ref

Accountability

Completion Date

2.d.1 Infant health & inequalities: smoking during pregnancy

31-Mar-2008

(1)

(4)

Reduce health inequalities by 10% by 2010 as measured by infant mortality (from a 1997 - 1999 baseline) and life expectancy at birth (from a 1995 - 1997 baseline Owner Rachel Spencer Sponsor

Judith Hooper

Key Achievements Since Last Report:

The specialist midwife has been in post since January and is working towards reducing the numbers of women smoking during pregnancy.

Current Concerns:

The PCT has a very challenging trajectory, which is the lowest across Yorkshire and Humber. The other PCTs trajectories range from 12.0% to 32.1%. In terms of actual performance the range across the SHA area is from 9.9% to 29.4%, with Kirklees PCT performing slightly better than the SHA average of 17.7%. The smoking at delivery by locality figures (which exclude South Asian women) reflect a target that has been set to to reduce the percentage smoking by 1% over the course of 07/08 in those localities that are at or under the SHA figure of 18% and to reduce those localities that are over this figure to 18%. The data shows quite significant quarterly fluctuations, which do not necessarily reflect a significant change in behaviour. it is anticipated that the annual total will reflect activity more accurately.

Reasons for Variance and Actions Taken:

Throughout Q4, awareness raising and training have been taking place within childrens centres to facilitate more access to the local stop smoking service. Additionally, a cohort of midwives have been trained in brief interventions within both Mid Yorkshire and CHFT. Finally, a stop smoking drop in clinic has been set up in within Mid Yorkshire on the acute ante natal ward. Due Date

Planned (value)

Latest YTD

Variance

31-Dec-2007

1314

1353

-39

31-Dec-2007

0

80

0

0

39

0

0

0

0

PI

(8) (9) Comments

Number of Maternities Q3 07/08 Number of Maternities Batley Q3 07/08

Number of Maternities Birstall and Birkenshaw Q3 07/08

31-Dec-2007

Number of Maternities Denby Dale & Kirkburton Q3 07/08

31-Dec-2007

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Number of Maternities Dewsbury Q3 07/08

31-Dec-2007

0

123

0

0

0

0

CHFT do not provide broken down by locality

31-Dec-2007

0

0

0

CHFT do not provide broken down by locality

31-Dec-2007

0

34

0

0

136

0

0

0

0

0

0

0

Number of Maternities Huddersfield North Q3 07/08

31-Dec-2007

Number of Maternities Huddersfield South Q3 07/08 Number of Maternities Mirfield Q3 07/08

Number of Maternities Spenborough Q3 07/08

31-Dec-2007

Number of Maternities The Valleys Q3 07/08

31-Dec-2007

CHFT do not provide broken down by locality

Number of mothers with smoking status not known Q3 07/08

31-Dec-2007

Number of women known not to be smokers at the time of delivery Q3 07/08

31-Dec-2007

1205

1148

57

Number of women known not to be smokers at the time of delivery Batley Q3 07/08

31-Dec-2007

0

49

0

Number of women known not to be smokers at the time of delivery Birstall Q3 07/08

31-Dec-2007

0

29

0

Number of women known not to be smokers at the time of delivery Denby Dale and Kirkburton Q3 07/08

31-Dec-2007

0

0

0

CHFT do not provide broken down by locality

Number of women known not to be smokers at the time of delivery Dewsbury Q3 07/08

31-Dec-2007

0

78

0

Number of women known not to be smokers at the time of delivery Huddersfield North Q3 07/08

31-Dec-2007

0

0

0

CHFT do not provide broken down by locality

Number of women known not to be smokers at the time of delivery Huddersfield South Q3 07/08

31-Dec-2007

0

0

0

CHFT do not provide broken down by locality

Number of women known not to be smokers at the time of delivery Mirfield Q3 07/08

31-Dec-2007

0

26

0

Number of women known not to be smokers at the time of delivery Spenborough Q3 07/08

31-Dec-2007

0

106

0

Number of women known not to be smokers at the time of delivery The Valleys Q3 07/08

31-Dec-2007

0

0

0

205

-96

CHFT do not provide broken down by locality

Number of women known to be smokers at time of delivery Q3 07/08

31-Dec-2007

109

Number of women known to be smokers at time of delivery Batley Q3 07/08

31-Dec-2007

0

31

0

Number of women known to be smokers at time of delivery Birstall Q3 07/08

31-Dec-2007

0

10

0

Number of women known to be smokers at time of delivery Denby Dale and Kirkburton Q3 07/08

31-Dec-2007

0

0

0

CHFT do not provide broken down by locality

Number of women known to be smokers at time of delivery Dewsbury Q3 07/08

31-Dec-2007

0

45

0

Number of women known to be smokers at time of delivery Huddersfield North Q3 07/08

31-Dec-2007

Š Dynamic Change Limited 2008 Key Performance Indicators

0

0

0

CHFT do not provide broken down by locality

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Number of women known to be smokers at time of delivery Huddersfield South Q3 07/08

31-Dec-2007

0

0

0

CHFT do not provide broken down by locality

Number of women known to be smokers at time of delivery Mirfield Q3 07/08

31-Dec-2007

0

8

0

Number of women known to be smokers at time of delivery Spenborough Q3 07/08

31-Dec-2007

0

30

0

Number of women known to be smokers at time of delivery The Valleys Q3 07/08

31-Dec-2007

0

0

0

CHFT do not provide broken down by locality

Percentage of mothers known to be smokers during pregnancy The actual number of women known to be smokers at the time of delivery divided by the actual number of maternities, expressed as a percentage. Performance will be assessed against the planned percentage in the 2007/2008 local delivery plan (LDP). PCTs should note that a high percentage of mothers with smoking status not known will impact upon performance against this indicator Q3 07/08

31-Dec-2007

8.3

15.2

-6.9

Percentage of mothers known to be smokers during pregnancy Batley Q3 07/08

31-Dec-2007

0

39

0

Percentage of mothers known to be smokers during pregnancy Birstall Q3 07/08

31-Dec-2007

0

26

0

Percentage of mothers known to be smokers during pregnancy Denby Dale and Kirkburton Q3 07/08

31-Dec-2007

0

0

0

CHFT do not provide broken down by locality

Percentage of mothers known to be smokers during pregnancy Dewsbury Q3 07/08

31-Dec-2007

0

37

0

Percentage of mothers known to be smokers during pregnancy Huddersfield North Q3 07/08

31-Dec-2007

0

0

0

CHFT do not provide broken down by locality

Percentage of mothers known to be smokers during pregnancy Huddersfield South Q3 07/08

31-Dec-2007

0

0

0

CHFT do not provide broken down by locality

Percentage of mothers known to be smokers during pregnancy Mirfield Q3 07/08

31-Dec-2007

0

24

0

Percentage of mothers known to be smokers during pregnancy Spenborough Q3 07/08

31-Dec-2007

0

22

0

Percentage of mothers known to be smokers during pregnancy The Valleys Q3 07/08

31-Dec-2007

0

0

0

0

0

0

0

0

0

CHFT do not provide broken down by locality

Percentage of mothers with smoking status not known Q3 07/08

31-Dec-2007

0

Percentage of mothers with smoking status not known Batley Q3 07/08

31-Dec-2007

0

Percentage of mothers with smoking status not known Birstall Q3 07/08

31-Dec-2007

0

Percentage of mothers with smoking status not known Denby Dale and Kirkburton Q3 07/08

31-Dec-2007

0

0

0

Percentage of mothers with smoking status not known Hudderfield North Q3 07/08

31-Dec-2007

0

0

0

Percentage of mothers with smoking status not known Huddersfield South Q3 07/08

31-Dec-2007

0

0

0

0

0

Percentage of mothers with smoking status not known Mirfield Q3 07/08

31-Dec-2007

0

Percentage of mothers with smoking status not known Spenborough Q3 07/08

31-Dec-2007

Š Dynamic Change Limited 2008 Key Performance Indicators

0

0

0

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Percentage of mothers with smoking status not known The Valleys Q3 07/08

31-Dec-2007

0

0

0

LDPR standard collection (Financial year 2007/2008) PCT local delivery plans (Financial year 2007/2008) 23rd July 2007 Infant mortality numbers are too low to use as a basis for setting PCT plans. Smoking during pregnancy is a good proxy indicator for infant health. Smoking during pregnancy is a key determinant of low birth weight which in turn is the single most important risk factor in perinatal and infant mortality. It is much more prevalent among young mothers, and those that are from more disadvantaged groups. Acc Ref

Accountability

Completion Date

2.d.2 Infant health & inequalities: breastfeeding initiation rates

31-Mar-2008

(1)

(4)

Reduce health inequalities by 10% by 2010 as measured by infant mortality (from a 1997 - 1999 baseline) and life expectancy at birth (from a 1995 - 1997 baseline) Owner Julie Tolhurst Sponsor

Judith Hooper

Key Achievements Since Last Report:

Improved recording of breastfeeding status maternity wards. Continued implementation of Kirklees PCT Breastfeeding policy. Service level agreement for Huddersfield Baby cafe approved - increased numbers of women attending for BF support. Baby cafe at Batley Childrens centre due to commence Jan 08. Due Date

Planned (value)

Latest YTD

Variance

31-Dec-2007

1314

1353

39

549

398

-151

765

947

182

3

3

PI

(8) (9) Comments

Number of maternities Q3 07/08

Number of mothers known not to initiate breast feeding Q3 07/08

31-Dec-2007

Number of mothers known to initiate breast feeding Q3 07/08

31-Dec-2007

Number of mothers with breastfeeding status not known Q3 07/08

31-Dec-2007

0

Percentage of mothers known to initiate breastfeeding The actual number of mothers known to initiate breastfeeding divided by the actual number of maternities, expressed as a percentage. Performance will be assessed against the planned percentage in the 2007/2008 local delivery plan (LDP). PCTs should note that a high percentage of mothers with breastfeeding status not known may impact upon performance against this indicator. Q3 07/08

31-Dec-2007

58.22

69.9

11.68

29.4

-29.4

Percentage of mothers with breastfeeding status not known Q3 07/08

31-Dec-2007

0

PCT local delivery plans (Financial year 2007/2008) LDPR standard collection (Financial year 2007/2008) 23rd July 2007 Infant mortality numbers are too low to use as a basis for setting PCT plans. Breastfeeding initiation is a good proxy indicator for infant health, but is much less prevalent amongst more disadvantaged groups. In general, mothers who do not initiate breastfeeding tend to be younger, less well educated and from lower income groups. Infants who are not breastfed are five times more likely to be admitted to hospital with infections in their first year of life. NHS staff should be following best practice in increasing initiation and duration of breastfeeding.

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Acc Ref

Accountability

Completion Date

2.d.3 Data quality on ethnic group

31-Mar-2008

(1)

(4)

Reduce health inequalities by 10% by 2010 as measured by infant mortality (from a 1997 - 1999 baseline) and life expectancy at birth (from a 1995 - 1997 baseline). Owner Helen Bridges Sponsor

Peter Flynn

Key Achievements Since Last Report:

The Healthcare Commission Target for monitoring ethnicity coding is separated into two parts:1. Etnicity codes recored against Mental Health Care Spells (Apr-Jan)and 2. Ethnicty codes recorded against acute Finished Consultant Episodes (Apr-Jan) The combined % achievement in 06/07 was 84.83% and the national threshold for achievement of the target was 80%. The Healthcare Commission has not stipulated a target % that should be achieved by January 2008. The PCT has set its own internal milestone to slightly improve on already high performance. The % achieved between April 2007 and December 2007 is 91.63%.

Current Concerns:

None

Reasons for Variance and Actions Taken:

Not Applicable Due Date

PI

Planned (value)

Latest YTD

Variance

(8) (9) Comments

% of care spells (commissioner basis) for PCT on Mental Health Minimum Dataset (MHMDS) with valid 2001 census coding for ethnic category A two part indicator, the overall value is the weighted mean of the values calculated in parts 1 and 2 expressed as a percentage. Part 2: The number of care spells (commissioner basis) for PCT on Mental Health Minimum Dataset (MHMDS) with valid 2001 census coding for ethnic category (excluding 'not stated' and â&#x20AC;&#x2DC;not known') divided by the number of care spells (commissioner basis) for PCT on MHMDS, expressed as a percentage. Q3 07/08

31-Dec-2007

100

92.3

-7.7

% of first consultant episodes (FCEs) (commissioner basis) for PCT on Hospital Episode Statistics (HES) with valid 2001 census coding for ethnic category A two part indicator, the overall value is the weighted mean of the values calculated in parts 1 and 2 expressed as a percentage. Part 1: The number of Finished Consultant Episodes (FCEs) (commissioner basis) for PCT on Hospital Episode Statistics (HES) with valid 2001 census coding for ethnic category (excluding 'not stated' and â&#x20AC;&#x2DC;not known'). (FCEs with mental health specialties will be excluded as this activity is covered in part 2 of the indicator) divided by the number of FCEs (commissioner basis) for PCT on HES, expressed as a percentage Q3 07/08

31-Dec-2007

100

91.6

-8.4

Hospital Episode Statistics (HES) (April 2007 to January 2008) MHMDS (Financial year 2007/2008, quarter 1 to quarter 3 data only, as provided Nov 2007 and Mar 2008) 23rd July 2007 In order to monitor the reduction of health inequalities related to ethnic diversity, it is essential that data sources used for this purpose include adequate information on ethnic group. This indicator underpins local and national monitoring of performance against the target. Service planning and delivery must be appropriate for the needs of local communities to reduce barriers to healthcare. Data should be used to monitor if there are unequal outcomes between different ethnic groups, and public authorities are required to take action to promote greater equality and to prevent direct and indirect discrimination. In addition to providing crucial information to support individualised patient care which takes account of the different risks of disease and the cultural appropriateness of services, good quality data on patient ethnicity are essential at a population level for service planning and to monitor progress on health inequalities across ethnic group. Acc Ref

Accountability

Completion Date

2.e.2 Practice based registers - patients called for review

31-Mar-2008

(1)

(4)

In primary care, update practice-based registers so that patients with coronary heart disease and diabetes continue to receive appropriate advice and treatment in line with national service framework standards and, by March 2006, ensure practice-based registers and systematic treatment regimes, including appropriate advice on diet, physical activity and smoking, also cover the majority of patients at high risk of coronary heart disease, particularly those with hypertension, diabetes and a BMI greater than 30. Owner James Williams Sponsor

Judith Hooper

PI

Due Date

Planned (value)

Latest YTD

Variance

(8) (9) Comments

% of patients with diagnosed CHD called for review in last 12 months This indicator contains two measures. The results from parts 1 and 2 will be combined to produce an overall score. Part 1: The number of people at risk of coronary heart disease who have been called for review within the last twelve months divided by the number of people at high risk of coronary heart disease, expressed as a percentage. Performance will be assessed against the planned percentage in the 2005/2006 local delivery plan.

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Percentage of patients on registers of people with diabetes in practices in the PCT called for review in the last 12 months Actual percentage performance in 2007/2008 will be assessed against the planned percentage performance in the 2005/2006 local delivery plan, expresses as a percentage Oct 07

31-Oct-2007

100

98.4

-1.6

PCT local delivery plans (2005/2006) LDPR standard collection (2007/2008) 28th March 2007 Both the coronary heart disease and diabetes national service frameworks have standards on the establishment of registers in all practices of people with and at risk of coronary heart disease and diabetes. GPs and primary health care teams should identify all people with or at significant risk of cardiovascular disease and diabetes but who have not yet developed symptoms and offer them appropriate advice and treatment. Primary healthcare teams will be better able to offer systematic care to all patients to maximise their quality of life, to minimise their incidence of disease, and to predict future service requirements if they have an effective means of identifying (and intervening with) patients at risk - registers are the means by which these patients will be identified. As an existing commitment to be maintained, this indicator is based on plans submitted by PCTs for 2005/2006 as part of the 2003-2006 local delivery plan round. Following changes to the approved methodology for identification of people at risk of CHD, from those with a 30% risk of CHD over the next ten years to those with a 20% risk of cardiovascular disease (CVD) over the next ten years, the plans for CHD risk set for 2005/2006 are no longer directly applicable for action in 2007/2008. Therefore this indicator has been amended to focus only on registers of patients with diabetes. A key purpose of these registers is still to enable GPs systematically to address risk assessment and management for patients at risk of CHD. Paragraph 3.4 of the Diabetes National Service Framework Delivery Strategy says â&#x20AC;&#x2DC;To deliver this target PCTs will need to update diabetes practice based registers using them as the basis for systematic treatment regimens with advice and treatment in line with Diabetes National Service Framework Standards.â&#x20AC;&#x2122; This includes regular reviews (at least annual) involving a named contact offered measurement of blood pressure (BP), blood sugar (HbA1c), cholesterol, urinary microproteinuria, foot examination, recording of smoking cessation, referral to structured education which meets National Institute for Health and Clinical Excellence (NICE) and Department of Health/Diabetes UK consensus criteria including information on reducing cardiovascular risk, and an agreed care plan offered. Acc Ref

Accountability

Completion Date

3.a.1 Community matrons & Additional Case Managers

31-Mar-2008

(1)

(4)

To improve health outcomes for people with long term conditions by offering a personalised care plan for vulnerable people most at risk; and to reduce emergency bed days by 5% by 2008 (from the expected 2003/2004 baseline) through improved care in primary care and community settings for people with long term conditions. Owner Monica Plested Sponsor Key Achievements Since Last Report:

Sheila Dilks In November 2007 interviewed for Community Matron, two Discharge Co-ordinators and a Lead Community Matron. Four Community Matron applicants were offered positions. 3 have accepted and are progressing to appointment. As at 9th January referneces had been received for two of the candidates with the thirds being followed up by HR. In Janaury interviewed and appointed to Case Manager post and it is hoped they will commence at the beginning of March Unable to appoint to Discharge Co-ordinator post and Lead Community Matron.

Current Concerns: As of the mid January one of the Case Managers will be leaving the team following promotion. The Discharge Co-ordinator posts are now to be covered by short term secondments whilst permanent appointments are made. Reasons for Variance and Actions Taken:

Discussions are on going regarding The Lead Community Matron as to whether to immediately readvertise or to offer a short term secondment. Discussions with Social Service are ongoing as regards appointment to the imminient Case Manager vacancy. Due Date

PI

Planned (value)

Latest YTD

Variance

(8) (9) Comments

Number of Community Matrons (whole time equivalent) at date of measurement The actual number of whole time equivalent (WTE) staff in the community matron role providing case-management in primary and community settings for people with complex long term conditions and high intensity needs, as at March 31st 2008. Actual performance percentage will be assessed against the planned performance percentage in the 2007/2008 local delivery plan Q3 07/08

31-Dec-2007

25

13.4

-11.6

11.4 Community Matrons plus 2 Case Managers

Number of Other Case Managers (whole time equivalent) at date of measurement The actual number of whole time equivalent (WTE) staff in the additional case managers role providing case-management in primary and community settings for people with complex long term conditions and high intensity needs, as at March 31st 2008. Actual performance percentage will be assessed against the planned performance percentage in the 2007/2008 local delivery plan Q3 07/08

31-Dec-2007

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0

2

2

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LDPR standard collection (As at March 31st 2008) PCT local delivery plans (As at March 31st 2008) 23rd July 2007 Patients with complex long-term conditions who are not managed effectively in a primary and secondary care setting are more likely to become frequent unscheduled users of secondary care services. By managing this cohort of patients effectively, PCTs can contribute to reducing the number of emergency bed days. The initial focus of the long term conditions strategy is on proactive case management of very high intensity users (VHIUs). There is a need to build upon the existing good practice of care for patients with long term conditions. As set out in both ‘Supporting People with Long Term Conditions – an NHS and Social Care Model’ and 'Supporting people with long term conditions - liberating the talents of nurses who care for people with long term conditions' (Department of Health, 2005), we would expect whole health systems should work together to deliver a more systematic care planning approach to better benefit all patients with long term conditions. Community matrons and additional case managers will provide case management. Within the cohort of VHIUs there is a group of patients who can only be managed by community matrons, who will be nurses. Other practitioners may also work as additional case managers where there is strong evidence that they will deliver similar outcomes both for patients and in terms of bed day reductions. Case management is also the first step to creating an effective delivery system and implementing the wider NHS and Social Care Long Term Conditions Model. Community matrons and very high intensity users are both process indicators that provide a suitable environment for personalised care plans to be developed and supported. It is the intention of the Healthcare Commission that our assessment evolves further to incorporate a measure of how many applicable patients are offered a personalised care plan, thus avoiding a proxy measure of the target. We anticipate being in a position for future assessments of having Department of Health guidance on personalised care plans to support such an assessment. Acc Ref

Accountability

Completion Date

3.a.2 Number of very high intensity users

31-Mar-2008

(1)

(4)

To improve health outcomes for people with long term conditions by offering a personalised care plan for vulnerable people most at risk; and to reduce emergency bed days by 5% by 2008 (from the expected 2003/2004 baseline) through improved care in primary care and community settings for people with long term conditions. Owner Monica Plested Sponsor

Sheila Dilks Due Date

PI

Planned (value)

Latest YTD

Variance

(8) (9) Comments

Number of VHIUs at date of measurement Actual performance percentage will be assessed against the planned performance percentage in the 2007/2008 local delivery plan. The indicator is the actual value divided by the planned value, expressed as a percentage. Q3 07/08

31-Dec-2007

1910

434

1476

LDPR standard collection (2007/2008) PCT local delivery plans (2007/2008) 23rd July 2007 Patients with complex long term conditions who are not managed effectively in a primary and secondary care setting will become frequent unscheduled users of secondary care services. By measuring and managing this cohort of patients effectively, this will have a direct positive impact on the emergency bed days target. Whole health systems should work together to deliver more systematic care planning to better benefit all patients with long term conditions. The initial focus of the long term conditions strategy is on proactive case management of very high intensity users (VHIUs). There is a need to build upon the existing good practice of care for patients with long term conditions. We would expect whole health systems to work together to deliver a more systematic care planning approach to better benefit all patients with long term conditions. Community matrons and very high intensity users are both process indicators that provide a suitable environment for personalised care plans to be developed and supported. It is the intention of the Healthcare Commission that our assessment evolves further to incorporate a measure of how many applicable patients are offered a personalised care plan, thus avoiding a proxy measure of the target. We anticipate being in a position for future assessments of having Department of Health guidance on personalised care plans to support such an assessment.

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Acc Ref

Accountability

Completion Date

3.a.3 Emergency bed days

31-Mar-2008

(1)

(4)

To improve health outcomes for people with long term conditions by offering a personalised care plan for vulnerable people most at risk; and to reduce emergency bed days by 5% by 2008 (from the 2003/2004 baseline) through improved care in primary care and community settings for people with long term conditions. Owner Jim Barwick Sponsor

Carol Mckenna Due Date

PI

Planned (value)

Latest YTD

Variance

(8) (9) Comments

Number of emergency bed days in period The actual number of emergency bed days for April 2007 to January 2008 in Hospital Episode Statistics (HES) data minus the planned number of emergency bed days in the local delivery plan for ten months of the financial year 2007/2008 divided by the planned number of emergency bed days in the local delivery plan for ten months of the financial year 2007/2008, expressed as a percentage. PCTs are assessed on a commissioner basis. Q3 06/07

31-Dec-2006

170812

145500

-25312

AHC Figure used in 2006/07 assessment

Hospital Episode Statistics (HES) data (April 2007 to January 2008) PCT local delivery plans (Financial year 2007/2008) 23rd July 2007 The provision of proactive and co-ordinated care in primary and community settings for the most at risk people should help to maintain their health and avoid unnecessary use of acute inpatient hospital services. The focus of the long term conditions strategy is on proactive case management for very high intensity users (VHIUs). Whole health systems should work together to deliver more systematic care planning to better benefit all patients with long term conditions.

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Acc Ref

Accountability

Completion Date

4.b.1 Infection Control

31-Mar-2008

(1)

(4)

Achieve year on year reductions in methicillin resistant Staphyloccus aureus (MRSA) levels, expanding to cover other health care associated infections as data from mandatory surveillance becomes available. Owner Jane O'Donnell Sponsor

Judith Hooper

Key Achievements Since Last Report:

In February 2008 the first Health Economy meeting between KPCT, CHFT & CPCT occured. Monthly meetings are now in place for partnership working. MYHT, MRSA Bacteraemia. The number of MRSA bacteraemia reported in January 2008 was 5; 3 reported as Post 48 hour admissions and 2 pre 48 hour admissions. This brings the total to date as 58 The main findings from the Root Cause Analysis (RCAs) are: * Screening policy not adhered to. * Poor documentation around peripheral line care. * Problems with Central Venous Catheter, Hickman lines. * Likely poor practice with urinary catheter care. During March 08 education and training will be carried out at ward level with partcipation from the PCT.

Current Concerns:

Clostridium difficile infections MYHT The total for January was 48, of which 26 cases were 65 years and over, for both hospital and Community Cases. of the 48, 19 resided in Kirklees PCT, 13 were inpatients and 6 community infections. There was no links between the 6 community case. Nationally figures increased in January 08. CHFT, MRSA Bacteraemia. The number of cases for January 2008 was 2; therefore the total to date is 29. Of the 2 cases reported one case in the medical division post 48 hour admission MRSA bacteraemia and 1 pre 48 hour case in children's and womens division. None of these cases resided in Kirklees. Clostridium difficile infections The total of 206 cases of these 171 cases are against trajectory which monitors those aged 65 yrs and over. This means that CHFT are 1 case over trajectory April- January 2008. 4 Community cases reported in Kirklees PCT residents in 2-64 years. CHFT have reviewed their case definition in line with the CMOs and CNOs letter dated january 2008.

Reasons for Variance and Actions Taken:

Kirklees PCT Provider Services An action plan has been developed with Provider Services and Infection Control for the reduction of healthcare associated infections.which will be tabled at Infection Control Committee on the 11.3.08 Deep cleaning at Holme Valley Memorial Hospital will take place on the 28th,29th and 30th March 2008. Due Date

PI

Planned (value)

Latest YTD

Variance

(8) (9) Comments

1. Has the organisation board approved an agreement outlining its collective responsibility for minimising the risks of infection and the general means by which it prevents and controls such risks? (100=Yes, 0=No). The responses to the six questions will be combined to give an overall indicator score, with each answer carrying equal weight. All questions relate to the position as at 31st March 2008 Q3 07/08

31-Dec-2007

100

100

0

2. Does the organisation have a Director of Infection Prevention and Control (DIPC) accountable directly to the board? (100=Yes, 0=No) The responses to the six questions will be combined to give an overall indicator score, with each answer carrying equal weight. All questions relate to the position as at 31st March 2008 Q3 07/08

31-Dec-2007

100

100

0

3. Does the organisation have a programme of audit to ensure that key policies and practices are being implemented appropriately? (100=Yes, 0=No) The responses to the six questions will be combined to give an overall indicator score, with each answer carrying equal weight. All questions relate to the position as at 31st March 2008 Q3 07/08

31-Dec-2007

100

100

0

4. The organisation has made a suitable & sufficient assessment of risks patients may encounter whilst receiving care, identified steps to control these risks & recorded its findings? (100=Yes, 0=No) The responses to the six questions will be combined to give an overall indicator score, with each answer carrying equal weight. All questions relate to the position as at 31st March 2008 Q3 07/08

31-Dec-2007

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100

100

0

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5. Has the organisation appropriate methods in place to monitor the risks of infection ? (100=Yes, 0=No) The responses to the six questions will be combined to give an overall indicator score, with each answer carrying equal weight. All questions relate to the position as at 31st March 2008 Qtr 3 07/08

31-Dec-2007

100

100

0

6. Has the organisation made available suitable and sufficient information on the organisation's general systems and arrangements for preventing and controlling healthcare associated infection? (100=Y The responses to the six questions will be combined to give an overall indicator score, with each answer carrying equal weight. All questions relate to the position as at 31st March 2008 Qtr 3 07/08

31-Dec-2007

100

100

0

Cumulative number of MRSA blood stream infections - Calderdale & Huddersfield Foundation Trust (CHFT) Jan 08

31-Jan-2008

13

29

-16

Cumulative number of MRSA blood stream infections - Mid Yorkshire Hospital Trust (MYHT) Jan 08

31-Jan-2008

30

58

-28

171

-1

272

151

Number of Clostridium Difficile infections in period at CHFT Jan 08

31-Jan-2008

170

Number of Clostridium Difficile infections in period at MYHT Jan 08

31-Jan-2008

423

Special data collection (As at March 31st 2008)

23rd July 2007 Tackling healthcare associated infection cannot be left to clinical staff alone; senior management commitment, local infrastucture and systems are also vital. The code of practice for the prevention and control of health care associated infections was introduced under the Health Act (2006) and published on October 1st 2006. The code of practice will help NHS organisations to plan and implement how they can prevent and control healthcare associated infections. It sets out criteria by which managers of NHS organisations are to ensure that patients are cared for in a clean environment and where the risk of healthcare associated infections is kept as low as possible. The code of practice is available from the Department of Health website, publications and statistics section. http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en? CONTENT_ID=4139336&chk=6oAPfi This indicator is intended to reinforce the self assessment that must be conducted by NHS organisations for the 2007/2008 assessment of core standards. The National Institute for Health and Clinical Excellence (NICE) guideline G2: 'Infection control' sets out how organisations should deal with the prevention of healthcare associated infection in primary and community care. Acc Ref

Accountability

Completion Date

5.a.3 All cancers: two month GP urgent referral to treatment

31-Mar-2008

(1)

(4)

Achieve a maximum waiting time of two months from urgent referral to treatment for all cancers by December 2005. Owner Janet Cawtheray Sponsor

Carol Mckenna

Key Achievements Since Last Report:

LTHT have put additional outpatient sessions on and increased clinical capacity

Current Concerns:

Half the breaches are at both trusts MYHT & CHFT relating to Leeds Teaching Hospital Trust. Even with the additional outpatient sessions on at LTHT and increased clinical capacity we are still expecting breaches due to the backlog of work. Despite the additional capacity Leeds are still forecasting breaches in Feb and March due to backlog of activity. The Cancer Network and the Strategic Health Authority are aware.

Reasons for Variance and Actions Taken:

THere has been a lot of operational disruption for LTHT with the tranfer of services from Cookridge to Jimmys in December and January Due Date

PI

Planned (value)

Latest YTD

Variance

(8) (9) Comments

Percentage of patients receiving their first definitive treatment for cancer within two months (62 days) of GP or dentist urgent referral for suspected cancer. Number of patients receiving their first definitive treatment for cancer within two months (62 days) of GP urgent referral for suspected cancer divided by the total number of patients receiving their first definitive treatment for cancer who were GP urgent referrals for suspected cancer. Performance will be calculated based on the managed population of the PCT, using the NHS number to link patients to their PCT. Patients who cannot be linked to a PCT are excluded from the indicator. Jan 08

31-Jan-2008

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95

94

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Cancer waits database (Financial year 2006/2007 - quarterly returns)

28th March 2007 The NHS Cancer Plan sets the ultimate goal that no patient should wait longer than two months (62 days) from a GP urgent referral for suspected cancer to the beginning of treatment except for good clinical reasons. PCTs are assessed as commissioners of services and are expected to maintain the target throughout 2007/2008. Acc Ref

Accountability

Completion Date

5.d.2 Commissioning of crisis resolution/home treatment services

31-Mar-2008

(1)

(4)

Improve life outcomes of adults and children with mental health problems by ensuring that all patients who need them have access to crisis services by 2005 (and a comprehensive Child and Adolescent Mental Health service by 2006). Owner Vicky Dutchburn Sponsor

Carol Mckenna The number of people receiving a service through Crisis Resolution Team is currently being under-achieved. Clarity on definitional guidance has been sought from the SHA and they are in discussion with National Leads.

Current Concerns:

Reasons for Variance and Actions Taken:

The number of people receiving a service through a Crisis Resolution Team is currently being under-achieved. Clarity on definitional guidance has been sought from the SHA and they are in discussion with National Leads.A number of issues have been raised relating to the crisis activity targets, many of which had been reported by other mental health providers and commissioners. The SHA have advised that there will be no change to the definition or agreed counting against this target until feedback from the regional and national reviews has been received. A national review has been undertaken to review crisis activity. NIMHE have been tasked to undertake the regional review looking at crisis activity in Yorkshire & The Humber. SWYMHT representatives met with NIMHE on 31st August, to review how crisis services are delivered. Due Date

PI

Planned (value)

Latest YTD

Variance

(8) (9) Comments

Number of separate episodes of home treatment provided by crisis resolution teams The number of separate episodes of home treatment provided by crisis resolution teams to people for which the PCT has commissioning responsibility divided by the PCT's allocation of national target number of people to receive crisis resolution services (December 2005) (For the purposes of performance assessment, this target is taken to be equivalent to the number of separate episodes of home treatment.). Expressed as a percentage. Jan 08

31-Jan-2008

850

393

-457

Number of separate episodes of home treatment provided by crisis resolution teams as a percentage of allocated national target The number of separate episodes of home treatment provided by crisis resolution teams to people for which the PCT has commissioning responsibility divided by the PCT's allocation of national target number of people to receive crisis resolution services (December 2005) (For the purposes of performance assessment, this target is taken to be equivalent to the number of separate episodes of home treatment.). Expressed as a percentage. Jan 08

31-Jan-2008

100

46

-54

Agreed PCT allocation of national target (As at December 2005, reallocated to match new PCT) LDPR standard collection (Financial year 2007/2008) 28th March 2007 Crisis resolution services provide intensive support in the home for people in mental health crisis. The Priorities and Planning Framework (2003-2006) sets out the following national target: 'Offer 24-hour crisis resolution to all eligible patients by 2005'. This target is based on the NHS Plan (2000) which envisaged 100,000 people being treated by crisis resolution/home treatment services each year once services were fully implemented. Each PCT is required in each year after the target date to continue to deliver its allocated share of the 100,000.

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Acc Ref

Accountability

Completion Date

5.h.3 Blood Pressure

31-Mar-2008

(1)

(4)

Substantially reduce mortality rates by 2010 from heart disease and stroke and related diseases by at least 40% in people under 75, with a 40% reduction in the inequalities gap between the fifth of areas with the worst health and deprivation indicators and the population as a whole. Owner Sara Fletcher Sponsor

Jim Barwick

Current Concerns:

GP Practices are identifying patinets with Hypertension as per plan, however control poor and not on target to hit plan.

Reasons for Variance and Actions Taken:

Have asked performance team to look into our target as suspect that they may be based on South Kirklees' target's and not Kirklees' target's. GP Practices are incentifised through QOF to try and achieve optomen control of Blood Pressure. Target range is 40-70% which we are achieveing. To discuss at Cardiology HIT how we can adress this issue by offering GP practices more support/education/training where required to achieve target. This is also an area where medicines management can offer support, which can also be explored at the cardiology HIT. Unlikely that target to be achieved by March 08 if target figures in plan correct. Due Date

PI

Planned (value)

Latest YTD

Variance

48729

3929

(8) (9) Comments

Number of patients on practices' hypertension registers H1 07/08

30-Sep-2007

44800

Number of patients on practices' hypertension registers as a percentage of the total number of people predicted to be hypertensive according to application at PCT level of local prevalence model. HC will assess performance will be assessed against planned percentage in the 2007/2008 local delivery plan (LDP). H1 07/08

30-Sep-2007

47.66

51.8

4.14

Number of patients on practices' hypertension registers whose last blood pressure reading (measured within the last 9 months) is 150/90 or less H1 07/08

30-Sep-2007

29000

20023

-8977

Percentage of patients on GPs' hypertension registers whose last blood pressure reading (measured within the last 9 months) is 150/90 or less. HC will assess performance will be assessed against planned percentage in the 2007/2008 local delivery plan (LDP). H1 07/08

30-Sep-2007

64.73

41.09

-23.64

Percentage of patients predicted to be hypertensive according to application at PCT level of local prevalence model whose last blood pressure reading (measured within last 9 months) is 150/90 or less H1 07/08

30-Sep-2007

30.85

21.3

-9.55

Percentage of patients predicted to be hypertensive according to application at PCT level of local prevalence model whose last blood pressure reading (measured within last 9 months) is 150/90 or less. Total number of people predicted to be hypertensive according to application at PCT level of local prevalence model. H1 07/08

30-Sep-2007

94000

94000

0

LDPR standard collection (Financial year 2007/2008) PCT local delivery plans (Financial year 2007/2008) 23rd July 2007 High blood pressure is a risk factor for heart disease and for stroke. Effective treatment for high blood pressure is primarily drug therapy, supported by lifestyle approaches including diet and exercise. Management of blood pressure through drug treatment will save lives and represents a more effective use of NHS resource (such as reducing unnecessary hospitalisation). At present we know there is significant room for improvement: this indicator will give added impetus to this process. It also has the potential to tackle health inequalities and obesity. From April 2007 local delivery plans include new lines for PCTs to report the expected prevalence of the number of people with high blood pressure. This will act as an aid to assessing the coverage of registers of patients with high blood pressure, and focus efforts on identifying patients with high blood pressure who are not on registers and offering them therapy and advice.

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Acc Ref

Accountability

Completion Date

5.h.6 Practice-based registers

31-Mar-2008

(1)

(4)

Substantially reduce mortality rates by 2010 from heart disease and stroke and related diseases by at least 40% in people under 75, with a 40% reduction in the inequalities gap between the fifth of areas with the worst health and deprivation indicators and the population as a whole. Owner Sara Fletcher Sponsor

Jim Barwick

Current Concerns:

Many practices have yet to develop registers as not incentivised to do so and have higher priorities. A number of practices which had developed registers in Nth Kirklees have not updated and/or used their registers and therefore can not be included in the final numbers. So actual numbers of practices with validated registers has now dropped. Target number of practices for March 2008 is 58 (75%).

Reasons for Variance and Actions Taken:

Secondary prevention incentive monies withdrawn in South due to QOF payment overlap, however it was suggested that monies should be reinvested in practices to develop primary prevention services, but this was was not agreed by the PCT. Business case to expand Primary Prevention Nursing team already in Nth across into Sth was turned down by PCT. Currently contacting practices in Kirklees to ask if they have registers and hopefully can validate some more by March 08. Tool was developed by Nth Kirklees PCT to develop registers in Nth and the tool can be adapted for EMIS system to develop registers in Sth who have EMIS. This can then be ran at practice level or centrally to pull off registers. However this has capacity implications and will require the permission of our practices. Realistically this is probably not an achieveable target this year. We need to discuss at cardiology HIT a long term solution to develop registers and review patients based on risk. A review of the PP Nursing service is underway and this needs to be included in the over plan for next year.

PI

Due Date

Planned (value)

Latest YTD

Variance

(8) (9) Comments

Number of GP practices with PCT- validated registers of patients without symptoms of cardiovascular disease with an absolute risk of CVD events greater than 20% over the next 10 years. Percentage of GP practices with PCT- validated registers of patients without symptoms of cardiovascular disease with an absolute risk of CVD events greater than 20% over the next 10 years Performance will be assessed against the planned percentage in the 2007/2008 local delivery plan. The number of GP practices

PCT local delivery plans (Financial year 2007/2008) LDPR standard collection (Financial year 2007/2008) 28th March 2007 The establishment of registers of at risk patients in all practices is a standard in the National Service Framework for Coronary Heart Disease: 'general practitioners and primary health care teams should identify all people at significant risk of cardiovascular disease, but who have not yet developed symptoms and offer them appropriate advice and treatment to reduce their risks'. The local reviews by the Commission for Health Improvement (CHI) and Healthcare Commission have found implementation to be patchy. Primary care teams will be better able to offer systematic care to all patients to maximise their quality of life, to minimise their incidence of disease, and to predict future service requirements if they have an effective means of identifying (and intervening with) patients at risk - registers are the means by which these patients will be identified. Effective disease prevention in at risk patients will make an important contribution to the overall public service agreement (PSA) mortality target. In previous years risk registers have been based on identifying patients with a greater than 30% risk of CHD over the next ten years. Recent guidance from the National Institute for Health and Clinical Excellence (NICE) and from the Joint British Societies suggests the threshold for at risk patients should be a 10-year cardiovascular (CVD) risk of 20% or greater (which equates to a 10-year CHD risk of 15% or greater). The expectation, therefore, is that plans and performance in 2007/2008 will have moved to the 20% CVD risk model. Key (1) Overall RAG (2) Action Plan Status (3) Financial RAG (4) PI Status (5) Overall Risk (6) Milestone RAG (7) Milestone Status (8) PI Milestone RAG (9) PI Milestone Status

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