Page 1

Appendix C

Mid-Year Performance Report 2008/09

Produced by: Performance Team – November 2008


CONTENTS Page 1.

National & Local Objectives – Summary

1

2.

Access to Services

9

Secondary Care Access Primary Care Access Access to NHS Dentistry Ambulance Response Times Choose & Book

9 20 21 23 26

Improving Health of the Population/Reducing Health Inequalities

28

Obesity Immunisation Smoking Sexual Health Infant Mortality Diabetes

28 30 32 33 39 44

4.

Long-Term Conditions

46

5.

Patient /User Experience

48

Patient Choice Patient Safety/Infection Control Patient & Public Involvement

48 50 55

Clinical Priority Programmes

58

Cancer Substance Misuse Mental Health Learning Difficulties Physical Disabilities & Sensory Impairment Children Older People Cardiovascular Disease (CVD)

58 64 67 72 75 78 85 89

Cross-Cutting Strategies

93

3.

6.

7.

Local Area Agreement Corporate Governance Equality & Diversity Practice Based Commissioning Workforce Clinical Governance Information Management & Technology Prescribing Performance Report – November 2008

93 95 96 97 99 106 108 112


NATIONAL & LOCAL PRIORITIES – SUMMARY Access to Services

Pages 9 - 27

Secondary Care Access: As the responsible Commissioner, the PCT, must ensure no-one is waiting for treatment longer than the national waiting times standard. By December 2008, the whole patient journey will be managed and measured as one and no-one should be waiting longer than 18 weeks from GP referral through the different stages of hospital treatment, i.e. diagnostics, outpatients and inpatients. As at 30th September 2008 there were 12 breaches of the national inpatient waiting time guarantee and for outpatient national waiting time guarantee, there were 11 breaches. Referral to treatment waiting time non validated data for week ending 9th November shows:18-weeks+ referral to treatment (admitted) Target 90%, Actual 93.6% 18-weeks+ referral to treatment (non-admitted) Target 95%, Actual 98.6% 26-week+ Inpatient waiting time guarantee Target 0, Actual 12 13-week+ Outpatient waiting time guarantee Target 0, Actual 11 18-week Supporting Measures As at 30th September 2008

A & E Waits: The NHS target requires that at least 98% of patients spend four hours or less in any type of A&E from arrival to admission, transfer or discharge. 'Our Health, Our Care, Our Say and the supporting Operating Framework for 2008/09 sets out that NHS organisations are required to maintain achievement of this target. PCTs are assessed on their commissioning of A&E services and on any A&E services they may provide, such as minor injuries units and Walk-In Centres. PCT year to date performance as at week ending 9th November 2008 shows:Total time in A & E: four hours or less Target 98% and Actual 97.44%

Primary Care Access: All patients who wish to do so should be able to see a GP within 2 working days and a primary healthcare professional within 1 working day – achievement of this target is seen as an indicator of progress on the overall reform of the NHS. The PCT’s reported performance in the October 2008 survey is:Access to a GP – 100% Access to a Healthcare Professional – 100% Primary Care Access – Supporting Measures

The surveys are carried out quarterly and the next survey will be carried out in January 2009. Performance Report

November 2008

Page 1 of 116


Access to NHS Dentistry: Since 1st April 2006 PCTs have had responsibility for commissioning primary care dental services to reflect local needs and priorities. This includes ensuring that an appropriate out-of-hours emergency care service is available for local patients receiving continuing care from a local practice, local patients not receiving continuing care, and visitors to the area. It also includes an obligation on PCTs to provide appropriate access to urgent dental care, both in and out of core working hours. PCT performance as at 30th September 2008 shows:Number of patients with access to an NHS dentist Target 252,997 and Actual 248,894

A & E Ambulance Response Times: From 1 April 2008, the clock starts when the call is connected to the ambulance control room. Ambulance trusts and PCTs are assessed against this new standard from 2008/09 onwards. Ambulance Trusts should respond to 75% of category ‘A’ calls within 8 minutes, 95% of category ‘A’ Calls within 19 minutes and 95% of Category ‘B’ calls within 19 minutes. PCT performance as at 22nd October 2008:% response to Category A calls within 8 minutes: Target 75%, Actual 67.84% % response to Category A Calls within 19 minutes Target 95%, Actual 95.7% (As at 30th September) % response to Category B calls within 19 minutes: Target 95%, Actual 90.8%

Choose & Book: Giving patients more choice about how, when and where they receive treatment is one cornerstone of the Government's health strategy. The PCT is committed to ensuring an increase in the level of choice offered each year, offering routine choice of hospital provider at point of booking for all patients. As at 30th September, 2008, PCT performance shows:Unique Booking Reference Number as a % of GP referrals Target 90%, Actual 45%

Improving Health of Population/Reducing Health Inequalities

Pages 28 - 45

NHS Trusts have a key role in helping to improve the health of communities and prevent disease. The Government’s White Paper ‘Choosing Health’, published in November 2004, set out a programme of action for the NHS to achieve this. Priorities within the White Paper include tackling inequalities in health, reducing the numbers of people who smoke and halting the year-onyear rise in obesity in children through diet and physical activity.

Performance Report

November 2008

Page 2 of 116


Immunisation: The immunisation programme in the UK continues to evolve, meeting the demand to improve the control of infectious diseases through vaccination. The objectives of the national immunisation programme include providing clear, evidence-based communications that meet the needs of parents and health professionals, and ensuring that those working in primary care are provided with the support required to implement vaccination programmes effectively Obesity: is associated with many illnesses and is directly related to increased mortality and lower life expectancy. Tackling obesity is a national and local priority. Smoking: A national and local priority is the reduction in the numbers of people who smoke, helping people stay ‘stop’ smoking and smoking prevention. Smoking is proven to lead to heart disease, stroke, cancer and many other fatal diseases. From national and local consultation exercises, many people feel this is an area in which they needed more support in addressing the problem. Because many people were concerned about the affects of second-hand smoke; and because many parents were concerned about their children taking up smoking. PCT performance as at 30th June, 2008 shows:4-week smoking quitters Target 556, Actual 584 Smoking prevalence among people aged 16 and over (per 100,000 population) Target 175.06, Actual 183.37

Sexual Health (including screening): The PCT is actively working with all partners by improving access to services, information and support to improve the sexual health and well-being of the people of Kirklees. PCT performance as at 30th September, 2008 is shown as:Reduce teenage conception rates % of patients offered appointments to be seen at GUM clinic within 48 hours Target 100%, Actual 100% % of patients seen at GUM clinic within 48 hours Target 88.54%, Actual 87.55% % of people aged 15-25 accepting Chlamydia screening Target 7.44%, Actual 5.53%

Infant Mortality: The Government is fully committed to the promotion of breastfeeding, which is accepted as the best form of nutrition for infants to ensure a good start in life. It also recognises that helping pregnant women give up smoking leads to health benefits for themselves and their unborn children. Since the inception of the NHS Stop Smoking Services in 1999, local Services have had a particular focus on helping pregnant women who smoke to give up. PCT performance as at 30th September, 2008:% of mothers known to be smoking at the time of delivery in Dewsbury and Batley Prevalence of breastfeeding at 6-8 weeks Performance Report

November 2008

Page 3 of 116


Target 85%, Actual 55.23% Early Access for Women to Maternity Services – 12-week Assessment % of mothers known to be smoking at the time of delivery Target 15.4%, Actual 14.8% % of mothers initiating breastfeeding Target 66.5%, Actual 70.3%

Diabetes: is a chronic and progressive disease that has an impact upon almost every aspect of life. It affects infants, children, young people and adults of all ages, and is becoming more common. Diabetes is the leading cause of blindness in people of working age in the UK. PCT performance as at 30th September 2008:% of diabetic patients offered diabetic retinopathy screening – 100%

Long Term Conditions

Pages 46 - 47

The recognised outcome of improving the management of patients with enduring chronic disease is to significantly improve their quality of life. This will be achieved through a particular focus on:   

Effective management of disease related symptoms, and a Reduction in the overall impact of frequent hospital admission through the provision of alternative models of care. Recruitment of community matrons

Consequently, there is an imperative to progress work that reduces the overall number of patients who develop chronic diseases and the timely diagnosis of patients so that appropriate management of their symptoms can be established. As at 30th September, 2008, PCT performance shows:Emergency Bed Days Target 44,635, Actual 53,464 Rate of hospital admissions for ambulatory care sensitive conditions Target 1,808, Actual 1,656 Number of Modern Matrons and Case Managers Targets 25 and 0, Actuals 25 and 2

Patient/User Experience

Pages 48 - 57

Patient Choice: Giving patients more choice about how, when and where they receive treatment is one cornerstone of the Government's health strategy. The PCT is committed to ensuring an increase in the level of choice offered each year, offering routine choice of hospital provider at point of booking for all patients. As at 30th September, 2008, PCT performance is showing:patient reported measure of choice of hospital Target 80%, Actual 44% Performance Report

November 2008

Page 4 of 116


Patient Safety/Infection Control: Keeping patients safe is a key priority for the PCT and the PCT is actively working with partners; to ensure year-onyear reductions in MRSA & Clostridium Difficile infections, expanding to cover other healthcare associated infections as data from mandatory surveillance becomes available through service level agreements and contracts. Working relations with Mid Yorkshire Hospital Trust have been excellent, with good robust engagement from both partners, this needs reflecting with Calderdale & Huddersfield Hospital Foundation Trust. PCT performance for 2007/08 as at 31st March, 2008, shows:Number of MRSA Number of Clostridium Difficile

Patient & Public Involvement: Kirklees PCT is committed to actively involving and working in partnership with the public and service users, to design, review, monitor and deliver quality services that meet the local population’s health needs by:   

Making Patient and Public Involvement an integral part of PCT working when designing, reviewing and delivering services and using information to improve service user experience. Implementing a two way process of communication between the PCT, the public and service users. Recognition of the diversity of the public and service users. Raising awareness and promoting active involvement of staff in the principles of Patient and Public Involvement.

A ‘Stronger Local Voice’ sets out the Government's plans for the future of patient and public involvement in health and social care. These plans included the establishment of Local Involvement Networks (LINks) which l replaced patient forums. LINks work with existing voluntary and community sector groups, as well as interested individuals to promote public and community influence in health and social care. Clinical Priority Programmes

Pages 58 - 92

Cancer (including cancer screening): The PCT continues to work collaboratively to ensure the sustained delivery throughout 2008/09 of a maximum waiting time of 2-week from urgent GP referral to first outpatient appointment for all urgent suspected cancer referrals one month from diagnosis to treatment for all cancers and 2 months from urgent referral to treatment for all cancers. PCT performance as at 30th September, 2008 shows:2-weeks Target 100%, Actual 99.82% one month Target 98%, Actual 98.9% two months Target 95%, Actual 93.38%

Performance Report

November 2008

Page 5 of 116


For 2008/09 onwards, national cancer waiting time guarantees are extended to cover no-one waiting more than 31 days for a second or subsequent cancer treatment and no-one waiting more than 61 days from referral to treatment through National Screening Programmes or by hospital specialists. Robust systems and processes to collect this additional data still being developed and implemented at time of reporting. Cancer Screening - Breast: One in 9 women will develop breast cancer at some time in their life. Breast cancer is more common in women over 50. Breast screening can help find changes in the breast before there are any other signs or symptoms. If changes are found at an early stage, then there is a good change of a successful recovery. PCT position as at 30th September, 2008 shows:% of women screened within 36 months Target 70%, Actual 72%

Cancer Screening - Bowel: evidence suggests that implementation of a National Bowel Cancer Screening Programme should reduce cancer mortality by around 15% in those people screened and should contribute to the delivery of the Public Service Agreement (PSA) target for all cancers that will achieve a reduction in mortality by 2010. Substance Misuse: Problem drug use and harmful alcohol use are public health and social issues that are exacerbated by deprivation or personal problems experienced by individuals and a lack of awareness about the risks involved. If not addressed effectively, there are wider consequences for the community in terms of increased crime, family breakdown and anti-social behaviour. number of people in successful drug treatment programmes st as at 31 October 2008 – Target 1507, Actual 1492

The PCT, working with all health, criminal justice and social care partners, is committed to reducing the harm caused by drug and alcohol misuse through various promotions of prevention initiatives and provision of treatment programmes. Mental Health: The National Service Framework (NSF) for Mental Health addresses the mental health needs of working age adults up to 65. It sets out national standards, national service models, local action and national underpinning programmes for implementation; and a series of national milestones to assure progress, with performance indicators to support effective performance management. An organisational framework for providing integrated services and for commissioning services across the spectrum is also included. PCT performance as at 30th September, 2008 shows:number of people receiving early intervention services Target 128 Actual 62 (actual in line with (agreed part year trajectory) number of people receiving crisis resolution services Target 850, Actual 506 Performance Report

November 2008

Page 6 of 116


Number of people receiving assertive outreach services Target 170, Actual 105

Learning Difficulties: working collaboratively, the PCT is actively implementing standards and milestones within ‘Valuing People’. Physical Disabilities and Sensory Impairment: The NHS Kirklees is working collaboratively to actively contribute to the development and implementation of a Physical and Sensory Impairment and Long Term Conditions Strategy. Children: The National Service Framework (NSF) for Children, Young People and Maternity services is a 10-year plan that is expected to be delivered by 2014. The NSF standards are split into 11 key areas. The delivery of the standards outlined within the NSF is key to the delivery of the Every Child Matters agenda. Older People: A strategic aim for the PCT is to improve and maintain the quality of life of Kirklees older citizens by promoting partnerships to deliver healthy living activities, sustain peoples’ independence and to promote positive views of ageing. The Vision for Older People’ sets the key areas of importance for older people living in Kirklees, which was the product of a 3 month consultant period, and is used as a tool for shaping the delivery of older peoples’ services across Kirklees, in partnership with health and social care agencies. CVD: cardiovascular disease – heart disease, stroke and related conditions account for about two thirds of all premature deaths in England. Since the launch of the Coronary Heart Disease National Service Framework in March 2000 much progress has been made across Kirklees to develop services which are more effective, modern and timely. Cross-Cutting Strategies

Pages 93 - 116

Local Area Agreement (LAA): The Kirklees Local Area Agreement (LAA) is a three year agreement between the health and social care organisations which make up the Kirklees Partnership and central government. It sets out our shared priority targets that need to be achieved to improve the quality of life in Kirklees. Corporate Governance: All healthcare organisations should apply the principles of sound clinical and corporate governance; actively support all employees to promote openness, honesty, probity, accountability and the economic, efficient and effective use of resources; undertake systematic risk assessment and risk management (including compliance with the controls assurance standards); challenge discrimination, promote equality and respect human rights.

Performance Report

November 2008

Page 7 of 116


Equality & Diversity: by ‘equality’ we mean treating people fairly and by ‘diversity’, we mean “valuing people’s differences”. The PCT is committed to ensuring that staff and service users are treated equally and the principle of embracing quality and diversity are common in relation to race, gender, age, sexuality religion and belief or disability. Practice Based Commissioning: Practice Based Commissioning (PBC) is described by the Department of Health as “playing a vital role in health reform.” Across Kirklees, PBC is lead by four consortia and eleven stand alone practices. They have a key remit in agreeing strategic direction with the PCT, engaging primary care practitioners in service redesign based on the needs of their populations and enabling the resourced shift of services from secondary to primary care. PBC also brings a much greater link between commitment of resources, through prescribing and referral into secondary care for example and responsibility for those resources through the allocation of an indicative budget. Workforce: NHS Kirklees has a role both as an employer and a strategic leader in workforce issues. A skilled, motivated workforce is critical to the delivery of our strategic goals, and to our Delivering Healthy Ambitions in Yorkshire and Humber and world class commissioning agendas. The changing demographic profile and health needs of our local population also mean that NHS Kirklees must take a lead role in workforce planning across the local health economy. Further, the 2008 / 2009 Operating Framework places a responsibility on NHS Kirklees to work with both its own workforce and that of providers to ensure that the right workforce is in place to deliver services to the local population both now and in the future. Clinical Governance: is the process by which the NHS seeks to improve the quality of its services commissioned and/or provided and safeguard high standards of care. It was introduced to the NHS in 1999 in ‘A First Class Service, Quality in the NHS’. Information Management & Technology: All healthcare organisations use effective and integrated information technology and information systems which support and enhance the quality and safety of patient care, choice and service planning and commissioning. Prescribing: The Medicines Management Team have consistently delivered improvements in both the cost effective use of resources and improvements in the quality of medicines management and prescribing across the PCT. Actively working with key stakeholders to develop equity and evidence based prescribing.

Performance Report

November 2008

Page 8 of 116


Access to Services 1.

Secondary Care Access: Stages of Treatment Director Lead: Carol McKenna The specific measures of progress made towards 18 weeks referral to treatment (RTT) are: 1.1

Number of pathways completed within 18 weeks Director Lead Carol McKenna Lead Manager Jim Barwick

Data is being collected to look at how many admitted and non-admitted pathways/patients are seen within 18 weeks. By December 2008:90% of patients admitted for care within 18 weeks. 95% of patients on non-admitted pathways commencing treatment or being discharged within 18 weeks.

• •

18-Week Referral to Treatment – Admitted

NHS Kirklees - Total Percentage Of Admitted Patients Treated within 18 Weeks - 2008/09

90%

85%

80%

75%

70%

06

13

20 April

Actual

27

04 11

18 25 May

01

08

15 June

22 29

6

13

20 July

27 3

10 17 Aug

24

31

7

14

21 28 5 Sep

12

19

26 2

Oct

9 Nov

88.7 84.5 88.7 85.9 85.2 87.6 84.2 87.0 86.7 84.6 82.6 86.8 84.6 87.0 86.3 88.9 86.2 89.2 86.5 87.5 87.3 85.6 89.2 88.9 89.9 88.4 88.6 90.7 88.5 88.0 88.7 93.6

Trajectory 85.0 85.0 85.0 85.0 85.5 85.5 85.5 85.5 86.0 86.0 86.0 86.0 86.0 86.5 86.5 86.5 86.5 86.5 86.5 86.5 86.5 86.5 87.5 87.5 87.5 87.5 88.5 88.5 88.5 88.5 89.5 89.5

Key Achievements The validated September position (most recent validated data) shows 88.4% Admitted patients treated within 18 weeks and 97.7% Non Admitted treated within 18 weeks. Targets 90% and 95% respectively for December 2008. Whilst the Non Admitted position is not of concern there has been an improvement in the Admitted position.

Performance Report

November 2008

Page 9 of 116


Kirklees PCT : 18 Weeks Referral to Treatment (Admitted)

90%

80%

70% Mar-08

Apr-08

May-08

Jun-08

Jul-08

Aug-08

Sep-08

Oct-08

Nov-08

Actual

86.3%

85.9%

87.0%

84.6%

86.2%

85.6%

88.4%

88.0%

93.6%

Profile

85.0%

85.0%

85.5%

86.0%

86.5%

86.5%

87.5%

88.5%

89.5%

Dec-08

Jan-09

Feb-09

90.0%

90.0%

90.0%

18-Weeks Referral To Treatment - Non Admitted Kirklees PCT : 18 Weeks Referral to Treatment (Non Admitted)

95%

90%

85%

80%

75%

70% Mar-08

Apr-08

May-08

Jun-08

Jul-08

Aug-08

Sep-08

Oct-08

Nov-08

Actual

96.0%

96.3%

97.2%

98.0%

97.2%

98.2%

97.7%

98.1%

98.6%

Profile

90.0%

90.0%

90.5%

91.0%

91.5%

91.5%

92.5%

93.5%

94.5%

Performance Report

November 2008

Dec-08

Jan-09

Feb-09

95.0%

95.0%

95.0%

Page 10 of 116


NHS Kirklees - Total Percentage Of Non Admitted Patients Treated Within 18 Weeks - 2008/09

95% 90% 85% 80% 75% 70%

06

13

20

April Actual

27

04

11

18

25

01

08

15

May

June

22

29

6

13

20

27

3

July

10

17 Aug

24

31

7

14

21

28

5

12

Sep

19

26

Oct

2

9 Nov

95.0 96.6 95.8 96.3 97.4 97.0 98.0 97.2 96.7 97.8 97.4 97.1 98.0 97.1 97.7 97.9 97.2 98.0 97.8 98.3 97.1 98.2 97.6 96.7 96.4 97.7 98.2 97.6 98.2 98.1 98.3 98.6

Trajectory 90.0 90.0 90.0 90.0 90.5 90.5 90.5 90.5 91.0 91.0 91.0 91.0 91.0 91.5 91.5 91.5 91.5 91.5 91.5 91.5 91.5 91.5 92.5 92.5 92.5 92.5 93.5 93.5 93.5 93.5 94.5 94.5

However looking at the weekly non validated reports for October and November, which give a strong indication of validated performance the following can be reported; between 90% - 89% Admitted patients treated within 18 weeks and 97% Non Admitted treated within 18 weeks. This shows an improvement in the Admitted position and gives a strong indication that the 90% admitted target will be sustained through November into December therefore NHS Kirklees meeting the 18 week standard. The Issues Calderdale and Huddersfield Foundation Trust Regarding admitted pathways, the Trust have indicated that they will be unlikely to achieve the Strategic Health Authority (SHA) stretch September target by speciality but will as an aggregated position (borne out by actual performance in September / October) meet the National 18 week standard in December. The Trust continues to report an increase in referrals into the services with waiting time challenges. Mid Yorkshire Hospital Trust Regarding admitted pathways, the Trust have indicated that they will be unlikely to achieve the SHA stretch September target by speciality but will as an aggregated position (borne out by actual performance in September / October) meet the National 18 week standard in December. We continue to work with the Trust to support and monitor the treatment of patient waiting over 18 weeks. There continues to be a risk of the scale of the back log of patients, i.e. those waiting over 18 weeks and whether this is increasing. Performance Report

November 2008

Page 11 of 116


The Action Being Taken Calderdale and Huddersfield Foundation Trust Divisions have produce action plans to reduce risk, these are being monitored by the PCT on a weekly basis. The PCT continues to meet with the Trust on a weekly basis to support and monitor progress. Mid Yorkshire Hospitals Trust Delivery on 18 weeks has two main components, ensuring that patients waiting over 18 weeks are treated over and above the activity that is required to maintain activity and not create further long waits. Both of these aspects are being monitored closely. For both Trusts we are confident that the December target will be met, however it will be very unlikely that either Trust will meet the stretch September target by specialty. Work has commenced to understand the size of the back log, by speciality and procedure in order to influence commissioning intensions so that the 18 week position is sustained.

Performance Report

November 2008

Page 12 of 116


1.2

Inpatient Internal Trajectory Waiting Time Lead Director: Carol McKenna and Lead Manager: Rachel Carter

The Issues The current waiting time guarantee for inpatient treatment is 26-weeks. The PCT has breached this limit on 12 occasions (to end of September) in 2008/09; these are detailed in the Breach Report section. There were two additional breaches in September, one in plastic surgery and one in neurosurgery. Previous Breaches all at LTHT: September - 2 (1 Plastic Surgery and 1 Neurosurgery); August - 1 (Plastic Surgery); July - 2 (Neurosurgery); June - 2 (Neurosurgery); May – 3 (Neurosurgery); April – 2 (Neurosurgery). The Action Being Taken Breaches of guaranteed waiting times are taken very seriously by both commissioners and providers. All individual breaches are investigates and discussed to identify any actions that can prevent recurrence and to minimise impact on the patients involved. Leeds Teaching Hospitals Trust (LTHT) performance is affecting a number of PCTs across Yorkshire & The Humber (Y&TH) and is being picked up collectively, both at Chief Executive level and via the Specialist Commissioning Group (SCG). There have been issues with obtaining timely and reliable information from LTHT and/or Leeds PCT and parties are working to address these. In spite of repeated assurances from LTHT there are still significant concerns about further breeches taking place in October and possibly November. The Strategic Health Authority (SHA), in discussion with Leeds PCT, has agreed a trajectory for reduction in 26 week breaches with LTHT; this was done without discussion with NHS Kirklees as an associate commissioner. 1.3

Outpatient Milestone Waiting Time

The Issues The current waiting time guarantee for outpatient activity is 13-weeks. There have been 3 further 13 week breaches at Leeds Teaching Hospitals Trust (LTHT) in September in Neurosurgery resulting in the PCT breaching the guarantee on 11 occasions. There were 3 breaches in September, 2 breaches in August, 3 in July, 3 in June, 0 in May, 0 in April. All breaches have been in Neurosurgery.

Performance Report

November 2008

Page 13 of 116


The Action Being Taken Leeds Teaching Hospital Trust performance is affecting a number of PCTs across Yorkshire & The Humber (Y&TH) and is being picked up collectively, both at Chief Executive level and via Specialist Commissioning Group (SCG). There have been issues with obtaining timely and reliable information from LTHT and/or Leeds PCT and parties are working to address these. In spite of repeated assurances from LTHT there are still significant concerns about further breeches taking place in October. 1.4

18-Week Supporting Activity Measures Lead Director Carol McKenna Lead Manager Abigail Tebbs

Key Achievements GP referrals continue to reduce - work to identify causes and trends ongoing. The Issues Reported levels of GP written referrals to G&A specialties have continued to reduce in August and work to understand the nature and implications of the increase continues with main providers in order to determine if referrals are converting to elective activity and if sufficient capacity is available to meet demand and deliver 18 week /Referral To Treatment targets in December. This increase is not a local phenomenon, and similar rises are being reported across England. First outpatient attendances continue to exceed planned levels, probably in response to rises in referral rates (and additional work to sustain and deliver 18 week targets - the PCT and trusts hope that work on referral levels will identify if increased demand in sort term or ongoing and how additional capacity can best be provided. Elective ordinary activity remains below target levels, probably due, in part in August, to holidays. This is a cause for concern as plans identify levels of activity required to deliver 18 week targets, however while both local trusts report that they are unlikely to deliver the SHA September stretch 18 week target, 18 Week Project Boards report confidence in achieving December national targets. Performance continues to be measured closely by 18 week leads and contracting team and remedial actions will be taken if performance deteriorates. The Action Being Taken Referrals - a detailed analysis and investigation is underway to understand the reasons for increases in referrals. Activity - levels continue to be monitored against delivery of Referral to Treatment (RTT) targets and remedial actions will be taken if the position deteriorates. Performance Report

November 2008

Page 14 of 116


Breach Report for 2008/09 as at 30th September 2008 1.1.1. 26 Week Inpatient Breach Report Cumulative Total Breaches = 12

Month

Provider

Area / Specialty

Commentary

September 2008

LTHT

2 breaches

August 2008 July 2008 June 2008 May 2008 April 2008

LTHT LTHT LTHT LTHT LTHT

Neurosurgery Plastic Surgery Plastic Surgery Neurosurgery Neurosurgery Neurosurgery Neurosurgery

1 breaches 2 breaches 2 breaches 3 breaches 2 breaches

1.1.2. 13 Week Outpatient Breach Report Cumulative Total Breaches = 11 Month September 2008 August 2008 July 2008 June 2008 May 2008 April 2008

Provid er LTHT

Area / Specialty Neurosurgery

Commentary

LTHT

Neurosurgery

2 breaches

LTHT Neurosurgery LTHT Neurosurgery Not applicable Not applicable

3 breaches

3 breaches 3 breaches No breaches No breaches

1.1.3. Monthly Referral to first seen in 2 weeks Total Breaches = 4 Month September 2008 August 2008

July 2008 June 2008 May 2008

Performance Report

Provider

Area / Specialty

Commentary No breaches

MYHT

Upper 1 breach due to diagnostic procedure Gastrointestinal being booked outside of the 14 day cohort Not applicable No breaches Not applicable No breaches MYHT Breast 1 patient out of 334 was not seen within 14 days of standard due to patient choosing alternative hospital and no appointment being available within the 14 day target. November 2008

Page 15 of 116


April 2008

MYHT

Upper Two patients out of 385 were not seen Gastrointestinal within the 14 day standard. MYHT – one upper gastrointestinal delayed by Breast GP due to medication issues and 1 breast unable to be seen due to bomb alert at the hospital at the time of appointment.

1.1.4. Referral to Treatment 31 Days Total Breaches = 7 Month

Provider

September LTHT 2008 August LTHT 2008

July 2008 June 2008 May 2008 April 2008

LTHT

LTHT LTHT

Area / Specialty Head & Neck

Sarcoma Brain/Central Nervous System Lung Urology Not applicable Sarcoma Upper Gastrointestinal

Bradford Teaching Hospitals Trust

Commentary 1 breach due to surgeon on annual leave and paternity leave 2 breaches

2 breaches No breaches 1 breach 2 breaches

Head & Neck

1.1.5. Referral to Treatment 62 Days Total Breaches = 13 Month Provider September LTHT and 2008 MYHT

CHFT

August 2008 July 2008

LTHT and MYHT LTHT and CHFT

Performance Report

Area / Specialty Upper Gastrointestinal Lung Head & Neck Other

Lung Lung

Commentary 4 breaches in total – three apportioned between LTHT and MYHT. One patient had comorbidities that needed assessing and treating prior to operation being booked. One proved PET positive and transferred for investigations. One surgeon on annual and paternity leave. The breach at CHFT is being further investigated. 2 breaches in total apportioned between the 2 acute trusts. 7 breaches in total: one apportioned between LTHT and CHFT. Five

November 2008

Page 16 of 116


LTHT and MYHT

June 2008

May 2008

April 2008

CHFT MYHT CHFT LTHT and MYHT LTHT and CHFT LTHT and MYHT MYHT LTHT and MYHT

Performance Report

3 x Lung 1 x Upper Gastrointestinal 1 x Other Lung Lung Other Lung Upper Gastrointestinal Upper Gastrointestinal Lung Lung

apportioned between LTHT and MYHT. One at CFHT.

4 breaches in total: 1 apportioned between LTHT and MYHT and 1 apportioned between LTHT and CHFT.

3 breaches in total: one apportioned between LTHT and MYHT 1 breach apportioned 0.5 between MYHT where patient first seen and LTHT where patient first treated. Patient was referred on day 51 of the 62 day pathway.

November 2008

Page 17 of 116


2. Secondary Care Access: A & E Waiting Time Standard Lead Director: Carol McKenna and Lead Manager: Jim Barwick A & E Waits - % of patients waiting 4 hours or less – weekly data

NHS Kirklees - 2008/09 A&E 4 Hour Performance Year to Date 100% 99%

% w ith in 4 Hrs

98% 97% 96% 95% 94% 93% 92% W

W

W

W

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

W

W

W

W

W

W

W

W

W

W

W

W

W

W

W

W

W

W

W

E

E

E

W

W

W

Su

Su

Su

n-

n-

n-

22

08

22

-M ar

ar

eb

eb

-M

-F

an -J

ec

ov

ec

ov

ov

ct

ct

an -J

-D

-D

-N

-N

-N

-O

ep

ep

ug

ug

-O

-S

-S

-A

-A

ul -J

ul -J

un -J

un -J

ay

ay

un -J

-M

-F

25

11

28

14

30

16

02

19

05

21

07

24

10

27

13

29

15

01

18

08

n-

n-

n-

n-

n-

n-

n-

n-

n-

n-

n-

n-

n-

n-

n-

n-

n-

n-

n-

n-

Su

Su

Su

Su

Su

Su

Su

Su

Su

Su

Su

Su

Su

Su

Su

Su

Su

Su

Su

Su

pr

pr

-M

-A

-A

04

20

06

n-

n-

n-

Su

Su

Su

Week Ending NHS K YTD

CHFT YTD

MYHT YTD

Target %

Linear (NHS K YTD)

Linear (CHFT YTD)

Linear (MYHT YTD)

A & E Waits - % of patients waiting 4 hours or less – monthly data

98% 96% 94% 92% 90% Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Actual 96.61% 96.40% 96.62% 96.85% 97.09% 97.25% 97.37% 97.44% Profile

98%

98%

98%

98%

98%

98%

98%

98%

98%

98%

98%

98%

Key Achievements There has been a steady improvement in the overall position for NHS Kirklees. Calderdale and Huddersfield Foundation Trust (CFHT) have maintained in excess of 98% performance for several weeks. The PCT with colleagues at CHFT are working on an action plan which has influenced this improvement. Performance Report

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The performance position at Mid Yorkshire Hospital Trust (MYHT) is less favourable with performance being achieved but not sustained. This is particularly an issue at Pinderfields and less to, however still relevant for, Dewsbury Hospital. We continue to work with MYHT on the ‘Aiming for Excellence’ action plan. We have introduced a GP and nurse minors stream to A&E at Dewsbury which is supporting delivery of the 4 hour standard. Issues Concerns relate to the sustainability of the 4 hour standard at Dewsbury Hospital. The Action Being Taken All actions taken are to support and maintain the delivery of the 4 hour standard whilst improving quality of care and the experience for the people of Kirklees. We are working on our commissioning intensions in relation to the new Out of Hours contract, improved ambulance service delivery and implications of equitable access to maintain and exceed the 4 hour standard.

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3.

Primary Care Access Director Lead: Carol McKenna and Lead Manager: Mark Jenkins 3.1

Primary Care Access

Key Achievements Results of the October 2008 Primary Care Access Survey highlighted: 

Access to a GP - 100% Access to a Healthcare Professional - 100%

The next survey will take place in January 2008/09. Issues Achievement of this target is seen as an indicator of progress on the overall reform of the NHS and any under performance will impact on the PCT’s 2008/09 Performance Rating. 3.2

Primary Care Access – Supporting Measures: Extended opening hours for GP practices:-

Key Achievements 2008/09 Target 50% (37 practices), actual 76% as at 30th September 2008 (56 out of 74 practices signed up to the Local enhanced Service (LES) delivering extended hours ‘under the principles of the Directed Enhanced Service’). Issues Following the Joint Office of Deputy Prime Minister/Department of Health review there is some concern whether all practices signed up to the Local Enhanced Service (LES) can be counted towards the monthly return as they have to be delivering the hours 'under the principles of the Directed Enhanced Service (DES)'. The PCT has received confirmation from the Strategic Health Authority (SHA) which practices can be counted. A small number of practices are delivering their extended hours outside of the Directed Enhanced Service (DES) principles and therefore can't be counted. Action Being Taken The PCT has introduced a Directed Enhanced Service (DES) for extended hours. Most practices have been able to easily transfer from the LES to the DES. Current figures show 60 practices (81%) have signed up to the DES.

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4.

Access to NHS Dentistry Director Lead: Carol McKenna and Lead Manager Lead: Clare Priestley Issues Despite additional growth funding investment to reduce the NHS Kirklees dental waiting list from April 2008 and the allocation of over 10,000 patients to dental practices in Kirklees, the waiting list continues to grow beyond all expectations. The allocation of new patients to dental practices takes longer than anticipated. Patients are allocated in manageable batches, at requested times from the practices with growth funding, therefore it is unrealistic to allocate the total agreed of say 1,000 new patients from the list in, on one batch. This will delay the increase in expected access. Often patients do not complete their treatment and merely wish to be seen when they have a dental emergency. One practice being allocated 2,000 patients has had an unexpected delay in recruiting dentists. Although allocated to the practice, the patients have yet to be seen and this will delay the figures showing on the Dental Practice Board (DPB) system. The volume of patients waiting in excess of a year are in the Dewsbury and Batley areas, where capacity has been increased, but, demand exceeds this. Suggested ways to deal with this will be put forward to the Primary Care Commissioning Group in December 2008. Main reasons that people are unable to readily access an NHS dentist locally is owing to demand outstripping capacity; as part of the new dental contact practices are no longer paid for the number of patients registered and treated at their practice, they are paid for units of dental activity, so patient registration technically abolished, even though as part of the new contract there is an expectation that all patients that were registered with a practice and treated within a 36 month period prior to the 1st April 2006, would be considered to be a regular patient at that practice for all future NHS dental treatment. The reality is that if a patient has not been seen or treated within the 36 month period then dental practices have removed patients from their list for NHS treatment and the patients need to be re-assigned; patients only wanting to see a dentist when the need arises and not on a regular basis. The Action Being Taken The actions that have been taken to date include:• •

on-going discussions with existing primary care dental providers in relation to the provision of additional capacity within practices trial of an emergency dental service in a dental practice in Central Huddersfield – the majority of these patients are without a regular

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• •

dentist and the first three appointments are for patients who require further treatment following an out-of-hours appointment follow-on treatment sessions are being rolled-out across Kirklees to continue from emergency treatment received in the out-of-hours service the trial of domiciliary care is being undertaken for assessment prior to implementation across Kirklees in-hours emergency access sessions have been increased to deal with patients who only request emergency treatment and do not wish to receive continuous treatment.

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5.

A & E Ambulance Response Times Lead Director: Carol McKenna and Lead Manager: Rachel Carter Key Achievements Category ‘A’ 8 minute standard Yorkshire Ambulance Service (YAS) achieved the 75% Category A target for in-month performance in September. However, performance has deteriorated in October and it is unlikely that YAS will achieve the 75% Category A target for in-month performance in October. This is not in line with the agreed recovery plan, which predicted month-on-month achievement of 75% from September. Overall YAS performance month-to-date at 22nd October was 72.47% (year-to-date 67.84%). Performance for Kirklees patients has significantly deteriorated in October and remains the worst of all Yorkshire & The Humber PCTs. October month-to-date performance at 22nd October was 63.01% (12th of 12 PCTs). September performance was 72.3% (12th of 12 PCTs), August performance was 65.09 (11th of 12 PCTs), July performance was 65% (8th out of 12 PCTs), 61.4% in June (8th of 12 PCTs), 59% in May (12th of 12 PCTs) and 52.7% in April (12th of 12 PCTs). The Issues The target is 75% within 8 minutes from the time at which the call is connected to the ambulance service. YAS will not meet the 8 minute target for 2008/09. The Strategic Health Authority (SHA) had sought assurance from the Coordinating Commissioner (Bradford & Airedale Teaching PCT) that performance would not drop below 75% in any month for the remainder of 2008/09 - it now appears that this 75% performance will not be sustained in October. YAS is requesting additional funding in-year to maintain/re-achieve the 75% target on a monthly basis. The Consequences and Associated Risks The targets for 2008/09 are more onerous than 2007/08. The 75% and 95% targets remain, but time taken will be measured from when the emergency call is connected to the ambulance service, rather than from when three key pieces of information have been recorded. Yorkshire Ambulance Service will not achieve the new Category A target, and is unlikely to achieve the new Category B target, for 2008/09. Underperformance in 2008/09 will impact on the PCT’s 2008/09 performance rating. The Action Being Taken The deterioration in performance in October is significantly due to an increase in demand, which is being experienced nationally. Overall demand for YAS year-to-date (at 22nd October) was 0.5% down against plan, but month-to-

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date demand was up 1.3% against plan. For Kirklees the corresponding figures are Year-to-date down 1.1%, month-to-date up 4%. This largely accounts for the overall performance drop and that specific for Kirklees. The YAS Contract Board discussed the sensitivity of 75% delivery to demand increases; the Coordinating Commissioner has undertaken to gain a greater understanding of the YAS capacity/demand modelling process. Turnaround times at A&E departments have been reported by YAS as being significantly up. The target maximum turnaround time is 25 minutes, which is nominally made up of 15 minutes to clear the patient (within control of acute) and 10 minutes to clear and restock vehicle (within YAS control). Performance management of this with acute trusts has been difficult because the two elements of the turnaround time are not separately measured and therefore responsibility for "25 minute breaches" cannot be clearly associated with a specific organisation. An audit of turnaround times has been carried out by NHS Calderdale and the methodology for this will be shared with PCT Chief Executives, with a view to rolling out the audit process across Yorkshire & The Humber. Category ‘A’ 19 minute standard Category A 19 minute – Target exceeded through the year. October data not available at the time of reporting for this specific indicator, however, performance remains above the 95% target. Performance for YAS in September was 97.2% (97.4% for Kirklees) (August: YAS - 96.4%, Kirklees 98.1%) (July: YAS - 96.4%, Kirklees 97.9%), (June: YAS - 94.9%, Kirklees 96.6%), with year-to-date performance 95.4% (96.3% for Kirklees) against a target of 95%. Category ‘B’ 19 minute standard Category B performance has deteriorated in October. At 22nd October, YAS month-to-date performance was 90.61% (September 92.9%) with Kirklees month-to-date performance at 87.45% (September 90.8%). April performance for YAS against the target of 95% response within 19 minutes from call connect was 89.9% against a trajectory of 90.4%. May performance was 89.6% against a trajectory of 90.7% (year-to-date performance 89.7%) June performance was 89.6% against a trajectory of 91.0% (year-to-date performance 89.6%) July performance was 90.7% against a trajectory of 91.3% (year-to-date performance 89.9%). August performance was 92.1% against a trajectory of 92.2% (year-to-date performance 90.3). September performance was 92.9% against a trajectory of 92.2% (year-to-date performance 90.8%. Performance within Kirklees area for September was 90.8% (August 89.2%). Also refer to Category A issues and actions being taken commentary.

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Ambulance Response to Category A Calls within 8 Minutes

75.00% 70.00% 65.00% 60.00% 55.00% 50.00%

Apr-08 May-08 Jun-08

Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09

Actual 61.30% 62.60% 62.70% 63.90% 65.40% 67.30% 67.84% Profile

75%

75%

75%

75%

75%

75%

75%

75%

75%

75%

75%

75%

Ambulance Response to Category A Calls within 19 minutes 99.00% 98.00%

97.00% 96.00% 95.00% 94.00% Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Actual 94.60% 94.70% 94.70% 95.20% 95.40% 95.70% Profile

95%

95%

95%

95%

95%

95%

95%

95%

95%

95%

95%

95%

Ambulance Response to Category B Calls within 19 Minutes 95.00%

93.00%

91.00%

89.00% Apr-08 May-08 Jun-08

Jul-08

Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09

Actual 89.90% 89.70% 89.60% 89.90% 90.30% 90.80% 90.80% Profile

95%

Performance Report

95%

95%

95%

95%

95%

November 2008

95%

95%

95%

95%

95%

95%

Page 25 of 116


6.

Choose and Book Director Lead Carol McKenna and Lead Manager Rachel Carter Converted UBRNs as a % of GP Referrals

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Apr-08

May-08

Jun-08

Jul-08

Aug-08

Sep-08

Actual

46.0%

43%

37%

43%

41%

45%

Profile

90%

90%

90%

90%

90%

90%

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09

90%

90%

90%

90%

90%

90%

Key Achievements Performance has recovered in September after falling in August. Roll-out of Directly-Bookable Services (DBS) is progressing well at Mid Yorkshire Hospital Trust (MYHT), with all services on schedule to be directly-bookable by end of November. Proportion of DBS bookings has steadily increased since February, achieving 46% of C&B bookings in September (40% in August, 26% in July, 20% in June). The Issues September performance for Kirklees was 45% (April 46%, May 43%, June 37%, July 43%, August 41%) against a target of 90%. The Strategic Health Authority (SHA) aggregate performance has recovered to 49% but remains below the National performance of 53%. Performance relating to our two main providers was CHFT: 51% (August 48%, July 53%, June 50%), MYHT: 38% (August 34%, July 32%, June 29%). There appears to have been further slippage in the DBS programme at CHFT, although we are still being assured that DBS roll-out will be complete by March 2009. The Actions Being Taken The SHA required all PCTs with a Choose & Book (C&B) performance below the national average to provide delivery plans showing achievement of 90% Performance Report

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target by 31st March 2009. Plans for Kirklees were submitted by the due date of 24th October. The delivery plan categorised each GP practice in terms of C&B usage, and identified actions for each category as follows:We have identified four categories based on the above data:   

60+/100: Blue 40-59/100: Green 20-39/100: Pink 0-19/100: Red

We have defined a Structured Strategy of support for each range:      

RED: Weekly support visit (dedicated time slot). PINK: Alternate a weekly visit with a weekly phone call. GREEN: A weekly phone call. BLUE: A monthly phone call. Plus; Ad hoc visits for all when required. Plus; 2WW Training for BLUE practices referring to Mid Yorkshire. Introduce a Reporting system for ‘Issues’ for RED practices I.e.: - What referrals have been sent manually and why - What referrals have been rejected over CAB and why - What referrals have been cancelled on Choose and Book and Why.

Identify ‘Issues’ to be analysed and actioned: Actioned through additional training in practice and keeping PBC  updated (Identify PBC Managers)  Actioned through escalating issues to service provider (identify contacts at Mid Yorks, CHFT etc.)  Actioned through escalating issues to helpdesk/Choose and Book. Designing a ‘bespoke model’ to suit RED practices on an individual basis: Identify and document the ways that Choose and Book is administered in each of the BLUE practices.  Share this information with the RED practices during the hourly visit to see which method suits them.  Define roles and responsibilities for Managing the Activity List Monitoring Performance NHS Kirklees will be monitoring current performance against trajectory on a monthly basis. In the event of a shortfall in performance the matter will be discussed with the Practice Manager before escalation to the PBC Manager, the Director and Deputy Director of Commissioning.

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Improving Health of the Population/Reducing Health Inequalities 7.

Obesity: Director Lead: Judith Hooper and Lead Manager: Liz Messenger Kirklees Obesity Programme Obesity is the second most common preventable cause of death after smoking in Britain today and is responsible for more than 9,000 premature deaths per year in England. In Kirklees, around 1 in 5 adults are currently classified as obese (Body mass index of 30 and above) and around 1 in 3 adults are overweight (BMI of between 25 and 30). This accounts for more than half of all adults in Kirklees. Levels of adult obesity have been increasing steadily over several years and rates are expected to continue to increase in the future. Adult obesity is an issue across the whole district with no significant differences across wards. Local data gathered through the National Child Measurement Programme shows that around 1 in 10 children aged 4-5 years (reception year) and 1 in 6 aged 10-11 years (year 6) are obese. Evidence shows that children who are overweight and obese are more likely to be obese as adults. Levels of child obesity in Kirklees are similar to the national picture, although slightly lower than the England average. Nationally levels are expected continue to rise over the coming years however locally we have targets in place within Vital Signs and the Local Area Agreement that aim to halt this rise over the next three years. The Obesity Programme focuses on halting the increase in the number of children and adults in Kirklees who are obese. The programme includes those who are already overweight and gaining weight and those who are obese. The programme focuses on helping them to lose weight including medical interventions where appropriate. There are complimentary plans in place to prevent obesity through improving diet and increasing levels of physical activity. Strong links have been built between the physical activity, food and emotional well being programmes. This enables the Obesity Programme to focus on those people who are at a greater risk due to their weight. Progress • Significant progress has been made in gaining ‘insight’ into the motivations of our target group. Four pieces of qualitative insight research have been commissioned and completed. • The Obesity Programme is managing a social marketing project focussing on tackling obesity in 16-24 year olds attending further and higher education in Kirklees.

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• A good level of engagement has been achieved from a range of stakeholders through the Organisation Development Service (ODS) Model to review and redesign obesity services across Kirklees. • The National Child Measurement Programme continues to develop well. Coverage this year exceeded both local and national targets with 97% of pupils measured. Results will be available in December. • Treatment services for young people (Young PALS and MEND programmes) continue to provide physical activity, healthy eating and emotional wellbeing support for obese young people and their families. • We are developing an Obesity Network to support partnership working and information sharing amongst front line practitioners working with overweight and obese children and adults. Issues There are ongoing concerns about the low levels of recording of height and weight in GP practices. A Local Enhanced Service (LES) was developed which led to a slight increase in response however this needs to improve. There is no longer a requirement to submit this data through Vital Signs however there is still an expectation that we collect GP recorded BMI through the LDP process. Therefore work needs to continue to review and improve the collection of this data. Currently the capacity and range of weight management services presents concern. It needs to be acknowledged by partners that the commissioning process will impact on the time it takes for new services to become available to meet the likely demand. This potentially could negatively impact on stakeholder engagement. Action Being Taken • •

• •

• •

Continue to develop and implement the Obesity Programme Plan. Work towards the implementation of routine feedback to parents about their child’s weight status. This needs to be in place for school year 2009/10. Undertake further local analysis of the national child measurement programme data to identify areas with the highest prevalence of child obesity. Continue to pilot the ODS Model to review and redesign obesity services. Develop a service specification for weight management services to enable the commissioning of comprehensive weight management services for adults and children in line with the ODS process and insight research. To conduct a clinical obesity audit to gain an understanding of how general practice identify, assess, treat and refer overweight and obese patients. Identify and commission a suitable agency to develop a website for the Obesity Network to facilitate partnership working and information sharing. Continue moving towards commissioning a range of services through the social marketing demonstration with 16-24 years olds.

Performance Report

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8. Immunisation: (children who complete immunisation by recommended ages) Director Lead: Judith Hooper and Lead Manager: Jane O’Donnell Background The Health Protection Agency (HPA) Cover of Vaccination Evaluation Rapidly (COVER) collates immunisation rates in the UK from computerised Child Health Information Systems for children aged one, two and five years. Information on PCT wide coverage of uptake is in the public domain through the HPA. Vaccine uptake information from the Child Health Information Systems are reported quarterly and annually to the HPA. The data is presented in percentages against the cohort number of eligible children. Caution needs to be used when interpreting percentage vaccine uptake as low, i.e. a cohort of four with 50% uptake would mean two children were vaccinated as opposed to a cohort of six hundred with a 50% uptake. Local action to improve uptake •

The PCT immunisation coordinator initiated that GP practices in Huddersfield now receive individual vaccine uptake for all antigens. This was rolled out in north Kirklees in 2006 this triggers practices to be aware of children who default.

Children are invited twice and if they fail to attend they go into a suspension file. In Huddersfield Child Health Services send out a monthly report to all practices of children in the suspension file requesting if the practice wishes the child to be re-appointed. The Immunisation Team in north Kirklees contacts families in the suspension file to ascertain reason for failure to attend.

The PCT needs to be assured that GP practices are reporting all immunisation data. The PCT Immunisation Coordinator is exploring whether GP payments can be linked to the reports from the Child Health System to ensure coherence between payment and coverage. The PCT Immunisation Protocol reinforces the reporting to the Child Health Systems.

There is a regular ongoing programme of Immunisation and Vaccination training with good attendance from general practices.

Prior to the Department of Health’s announcement of the MMR catch up programme, Kirklees Community Healthcare Services Immunisation Team identified areas in north Kirklees where service improvements could be made and resources to improve immunisation uptake should be focused.

In June 2005 in north Kirklees the waiting list was 1901 for all

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outstanding immunisations when KCHS Immunisation Team began delivering the National Childhood Programme. The Hib campaign which commenced on 10 September 2007 and continues until 3 March 2009 added in a further 12977 children and also scheduling for the pre-school booster had to be reduced to three years four months. The waiting list for north Kirklees as of October 2008 was 306; the waiting list for Huddersfield as of October 2008 was 264. Practices in Huddersfield are informed on a weekly basis of the numbers awaiting appointments. •

Child Health Supervisors in north Kirklees have monitored waiting list levels closely and arranged extra clinics for the Immunisation Team where needed, to keep the balance of the waiting list, increasing the number of appointments produced on a weekly basis.

Future work includes: •

An audit of the PCTs immunisation protocol and Cold Chain Policy, to ensure all healthcare professionals involved in immunisation understand their roles and responsibilities.

An audit of the COVER data by The Phoenix Partnership to ensure the data is accurate.

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9.

Smoking Cessation: Director Lead: Judith Hooper and Lead Manager: Rachel Spencer Key Achievements The Stop Smoking Service has recently added extra evening groups in Huddersfield to plug gaps in provision. New staff have been recruited so the service will be up to complement beginning October 2008. Service specification has been written and performance indicators identified and shared with Kirklees Community Healthcare services. Targets have also been set with other providers. Action Being Taken •

Social Marketing insight has been completed to identify how to target routine and manual workers and increase throughput to the service, an implementation plan is currently being written to ensure services are commissioned to reflect this.

Social marketing insight with Women of Child bearing age will have an impact on referrals in this group by ensuring that services for pregnant women provide direct referral to stop smoking advisers.

• •

The Locally enhanced service in GP practices and pharmacies is currently being revised with a view to increase numbers accessing the services. Kirklees community healthcare services are following the recommendations in Healthy Ambitions and are piloting a voucher scheme for provision of nicotine replacement therapy for group members.

A Mapping exercise is underway to look at service provision against areas of high smoking prevalence.

71 health professionals have been trained in brief interventions since April 08

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10.

Sexual Health: Reduce Teenage Conception Rates Director Lead: Judith Hooper and Lead Manager: Rachel Spencer Key Achievements There were 10 factors identified in the “Deep Dive” Reviews that characterised the successful areas in England where teenage conception rates have reduced significantly. The Kirklees Strategy is working towards ensuring that all these factors, around prevention, are in place, to affect change. In one area – Communication – we initiated a Media and Communication subgroup as a joint venture between Teenage Pregnancy and Sexual Health. Effective communication is seen as central to a partnership working, access to services and informed choice. A joint strategy can tailor information to the needs of young people, parents and communities, ensuring that it is culturally sensitive as well as accurate and timely. The sub-group has developed a Terms of Reference, a Media & Communication Strategy and a supporting plan of action. The annual conception data for 2006 was released by the Office of National Statistics (ONS) on 29th February 2008. The under 18 conception rate in Kirklees has increased from 43.4% in 2005 to 43.9% in 2006. The increase is not significant, albeit, that it is heading in the wrong direction. Overall, Kirklees has achieved a reduction in its 2006 under 18 conception rate of 9.7% (since the baseline year of 1998). As the overall England rate (2006) has reduced by only 13.3% since the baseline year of 1998, it seems that Kirklees is in line with the majority of other Local authorities in achieving smaller than expected reductions in its under 18 conception rate. The identified measures for success are in the process of being fully implemented. The Teenage Pregnancy Strategy (TPS) takes a targeted approach to working with the most vulnerable groups of young people in areas identified as having a high rate of conception. Activities, health promotion/education schemes and tailored services for young people within Kirklees aim to reduce risky behaviours and to help young people to make healthy choices The Issues: It is unlikely that Kirklees will achieve the Government’s ambitious target to reduce under 18 conception rates by 50% by 2010 (year end 2011/12) in order to achieve a 50% reduction in its conception rate, Kirklees would need to reduce its rate by 10% per year (from 2006 – 2010). It is likely that the under 18-conception rate will continue to reduce in Kirklees and nationally, but not at a rate which would allow the ambitious 2010 target to be met. The challenge is in bringing partners together to tackle the underlying circumstances and to reduce inequalities and social exclusion.

Performance Report

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Consequences and associated risks National priority/key target not achieved and impact on NHS Kirklees 2008/09 performance rating. Action Being Taken •

• • • •

• •

Both prevention and support for teenage parents is of critical importance, therefore, using the toolkits from Government Office, two self-assessments have been carried out. One around prevention of teenage conceptions and the other to assess support for teenage parents. The information gathered has informed the TPS Action Plan for 2008/09. A locally enhanced service for Long Acting Reversible Contraception has been launched with training taking place in October 2008. A locally enhanced service is being written for the provision of emergency hormonal contraception in pharmacies A RSHE toolkit has been created for use in schools which is being implemented and evaluated. Actively engaging all key mainstream delivery partners who have a role in reducing teenage pregnancies – Health, Education, Social Services and Youth Support Services - and the voluntary sector Improved contraceptive and sexual health advice services so that they are more accessible and young people-centred, with a strong remit to undertake health promotion work, as well as delivering reactive services; ‘C’ card scheme is in development for condom distribution around the district. Adopted a targeted approach to working with the young people at greatest risk of teenage pregnancy, in particular with Looked After Children Ensured that the workforce involved with young people is trained to be knowledgeable, skilled and confident in R&SH matters; ensure the availability (and consistent take-up) of training (eg. R&SHE) for professionals in partner organisations working with the most vulnerable young people. Training needs to be mandatory for the key mainstream delivery partners Ensured that the Youth Service is well resourced, providing things to do and places to go for young people; ensure that it takes a clear focus on addressing social issues affecting young people, such as sexual health and substance misuse Working towards raising the aspirations of young people Working with parents to help improve the communication between young people and their parents/carers – programme to be developed and implemented Working with Children’s Centres to develop strategies to target teenage parents and their children and support teenage parents

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11.

Sexual Health – 48 hour Access to Genito Urinary Medicine (GUM Director Lead: Judith Hooper and Lead Manager: Rachel Spencer % of Patients offered an appointment to be seen within 48 hours

% of patients offered an appointment to be seen at a GUM clinic within 48 hours

100%

90%

80%

70% Mar-08

Apr-08

May-08

Jun-08

Jul-08

Aug-08

Sep-08

Actual

100.0%

100.0%

100.0%

100.0%

100.0%

100.0%

100.0%

Profile

100.0%

100.0%

100.0%

100.0%

100.0%

100.0%

100.0%

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09

100.0%

100.0%

100.0%

100.0%

100.0%

100.0%

Key Achievements Both Genito Urinary Medicine (GUM) clinics offer a mixture of drop in and booked appointments at a variety of times. The Issues The GUM clinics continue to improve its performance in relation to access. The clinics comfortably offer 100% of appointments within 48 hours of contacting the service ('offered'). The take up of those appointments ('seen') has dropped from 93% in August to 87% in September, this is due to significant staffing issues at Calderdale and Huddersfield Foundation Trust (CHFT) who have only managed to see 79% of their patients within 48 hours. Mid Yorkshire Hospital Trust (MYHT) are seeing 100% of patients within 48 hours. The SHA has agreed to performance manage PCT's against a minimum target of 80% for 'seen', and in Kirklees case this has been set to 88.54% using an average of Q1 performance. CHFT have highlighted continuing staffing issues which will continue to affect the 'seen' target. Consequences and associated risks Under-achievement against this national target will impact on the PCTs 2008/09 Performance Rating.

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% of patients seen within 48 hours at a GUM clinic % of patients seen within 48 hours at a GUM clinic

88%

79%

70% Mar-08

Apr-08

May-08

Jun-08

Jul-08

Aug-08

Sep-08

Actual

83.8%

85.07%

89.27%

91.27%

89.72%

92.72%

87.55%

Profile

94.9%

88.54%

88.54%

88.54%

88.54%

88.54%

88.54%

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09

88.54%

88.54%

88.54%

88.54%

88.54%

88.54%

Action Being Taken •

Business Case approved in 2007/08 to enable the University Practice to provide Tier 2 STI services from 2008/09.

CaSH providing tier 2 sexual health services and potentially diverting activity away from GUM.

More frequent meetings instigated with CHFT to review the action plan to ensure achievement.

Continued roll-out of STI services within primary care,

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12.

Sexual Health – Chlamydia Screening Director Lead: Judith Hooper and Lead Manager: Rachel Spencer The percentage of 15-24 year olds screened or tested for chlamydia 18.00%

15.00%

12.00%

9.00%

6.00%

3.00%

0.00%

Apr-08

May-08

Jun-08

Jul-08

Aug-08

Sep-08

Actual

0.78%

1.39%

2.36%

3.48%

4.27%

5.53%

Profile

1.06%

2.11%

3.17%

4.23%

5.28%

7.44%

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09

8.49%

9.55%

10.33%

12.70%

14.85%

17%

Key Achievements There are 2 Chlamydia Screening Programmes that serve the Kirklees PCT population, one is a Huddersfield & Calderdale service and is hosted by Kirklees PCT and the second is a Wakefield & North Kirklees programme hosted by Wakefield District PCT. Both screening programmes have participated in ‘freshers’ weeks at Huddersfield University and colleges around the PCT area, generating significant numbers of screens. A meeting has taken place with the youth service to identify screening opportunities. In North Kirklees a call/recall system is being piloted which sends screening postal packs out to 23 and 24 year olds. Issues The PCT is not currently meeting the September trajectory of 4098 screens (7.44%). The total number of screens performed to date is 3049 (5.53%), inclusive of those screens obtained directly from the laboratory.

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Action Being Taken •

North Kirklees is the area with the least amount of screens both via the programme and via the laboratory. This may suggest reluctance in the GP’s to promote the service and a reluctance of young people taking the service up.

Social marketing work is being commissioned to identify what barriers there are to young people accepting screening.

The Locally Enhanced Service (LES) is being finalised with support from the PBC clinical lead. This will be going to the LMC in November 2008. If successful this can be continued next year or incorporated into a more comprehensive sexual health LES, which would be the preferred choice.

A LES is also being written for pharmacies to supply emergency contraception. This would include participation in the screening programme.

Screening commenced in Termination of Pregnancy (TOP) services which is producing significant numbers of screens for the service.

Screening in antenatal services is also being explored.

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13.

Infant Mortality: Smoking During Pregnancy Director Lead: Judith Hooper and Lead Manager: Rachel Spencer 13.1. % of women known to be smoking at birth in Dewsbury & Batley Issues Because of the small numbers involved, the data will be reported at the end of March 09 for the whole year. A stop smoking group has been running in the antenatal department of mid Yorkshire hospitals (MYHT); however this has not been well attended. The service is looking at the reasons why this might be to look to changing times or increase publicity. A fast track referral system is in place for all pregnant smokers and is used effectively. All midwives in MYHT have been trained in brief interventions. Action Being Taken Through the Women of Child Bearing age project, social marketing insight has suggested a pilot ‘pregnancy salon’ which will give pregnant women the opportunity to meet healthcare professionals in non healthcare settings. This will be evaluated with a view to commissioning effective services. Kirklees are looking to participate in a regional project which supports women for the duration of their pregnancy and beyond to tackle the high relapse rate in pregnancy. 13.2

Smoking During Pregnancy Percentage of Women Smoking During Pregnancy

20.0%

10.0%

0.0% Mar-08

Jun-08

Sep-08

Actual

15.4%

14.3%

14.8%

Profile

7.0%

15.4%

15.4%

Performance Report

November 2008

Dec-08

Mar-09

15.4%

15.4%

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In 2007/08 the Strategic Health Authority gave the NHS Kirklees very challenging trajectories to achieve. However, the 2008/09 trajectories have been set locally, based on 2007/08 actual activity and the PCT is actively working with all partners, to achieve the Department of Health objective of reducing the number of women known to be smoking by 1% year-on-year, over the course of 2008/09.

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14.

Infant Mortality: Breastfeeding Director Lead: Judith Hooper and Lead Manager: Julie Tolhurst 14.1 Prevalence of Breastfeeding at 6-8 weeks Key Achievements Breastfeeding plan established. Corporate approval for Baby friendly Initiative (BFI) with dedicated funding over 2 years includes upgrading quality assurance for data systems, training for staff and improved information for parents. Commissioned Baby Cafes (centres of excellence) for specialist breastfeeding support. Awareness raising campaign amongst key target groups during Breastfeeding Awareness week in May 08. Issues New target for 2008/09 onwards, still establishing accurate data recording with GP staff- training, Practice manager meetings, etc. Action Being Taken Actively working with primary care providers and KCHS to improve breastfeeding coverage and ensure accurate/robust recording of partial and total breastfeeding status with timely submission of data within each quarter. 14.2 Kirklees Breastfeeding Policy Breastfeeding represents the first vital step towards healthy nutrition for the child, adolescent and adult (WHO, 1998). Research from Public Health Collaborating Centre on Maternal and Child Nutrition demonstrates that breastfeeding has a major role to play in public health, promoting health in both short and long term for baby and mother and that breastfeeding plays a key role in addressing health inequalities in the UK. (Dyson, 2006) Kirklees PCT Breastfeeding Policy was approved June 07. The aim of the policy is to enable health care staff that has contact with breastfeeding women to provide sufficient information / support to enable women to breastfeed exclusively for six months, and then as part of their infant's diet ideally into the second year. (Department of Health, 2003) Key Achievements •

• • •

PCT approved Baby Friendly Initiative Accreditation funding for standardised process for quality breastfeeding service including improved data collection, audit, training and promotion. BFI coordinator recruited Nov 08. Improved breastfeeding initiation and continuity data recording by maternity and community staff. PCT Breastfeeding Policy approved and disseminated to staff. Parent’s policy guide produced and disseminated to health centres.

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• • •

Breastfeeding Champion training for Health Visitors completed. Breast pumps disseminated to team leaders for supporting breastfeeding mothers. Service Level Agreements agreed for breastfeeding centres of excellence (Huddersfield & Batley)- ongoing performance management. Improved attendance rates to support breastfeeding mothers. Expand provision of breastfeeding support groups across all Kirklees localities.

Breastfeeding Initiation Rates

70%

60%

50% Mar-08

Jun-08

Sep-08

Actual

70.5%

70.2%

70.3%

Profile

64.5%

66.5%

66.5%

Performance Report

November 2008

Dec-08

Mar-09

66.5%

66.5%

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15.

Infant Mortality: Early Access for Women to Maternity Services Director Lead: Carol McKenna and Lead Manager: Keith Henshall Context All women should access maternity services for a full health and social care assessment of needs, risks and choices by 12 completed weeks of their pregnancy to give them the full benefit of personalised maternity care and improve outcomes and experience for mother and baby. Reducing the percentage of women who access maternity services late through targeted outreach work for vulnerable and socially excluded groups will provide a focus on reducing the health inequalities these groups face whilst also guaranteeing choice to all pregnant women. Completion of the assessment ensures that women are supported in making well informed decisions about their care throughout pregnancy, birth and postnatal. Issues New performance indicator for 2008/09. Significant additional capacity is required across midwifery care to ensure this target is achieved. A business case has been developed and submitted. Under-performance against this indicator will impact on the NHS Kirklees 2008/09 Performance Rating Action Being Taken Work is ongoing within both acute providers to gather a manual data baseline. There remains no existing robust systems and process in place to collect the required data electronically. The NHS Kirklees is proactively working with secondary and primary care providers to develop a clear/robust baseline for this indicator to submit revised trajectories, as part of the Vital Signs Autumn refresh process, and to develop and establish robust systems and process to support delivery. In addition to extra capacity the business case identifies a new pathway of holistic care for pregnant women. This pathway will promote early access to maternity care through improved access in general practice and children centres and open access clinics as well as direct contact with community midwifery services. A significant part of delivering this vital sign will be a Communication & Marketing Strategy encouraging women to access services early, for example, at 8 weeks and / or as soon as they are aware they are pregnant

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16.

Diabetes Director Lead: Judith Hooper and Lead Manager: James Williams Diabetic Retinopathy Screening Programme Diabetic eye disease is the primary cause of blindness in the working-age population. This is due to a complication of diabetes that affects the blood vessels of the retina – a condition called retinopathy. Retinopathy can be effectively treated if detected at an early stage through retinal screening, and blindness can be prevented in 90% of those at risk with appropriate treatment. The screening programme aims to reduce blindness due to diabetic retinopathy. It does this by identifying all eligible persons with known diabetes. These diabetics are invited to attend for an annual eye screen. Appropriate follow up and treatment is provided for all those found to be affected by diabetic retinopathy. The number of patients on the Kirklees PCT diabetes register as at 31st September 2008 stands at 17,207. Key Achievements NHS Kirklees has been steadily developing capacity and improving its diabetic retinopathy screening programme during 2008. The installation of the new diabetic retinopathy software management system for the population of North Kirklees has been successfully completed. The installation of the software for South Kirklees is progressing inline with the project plan currently being managed by The Calderdale and Huddersfield Health Informatics Service. NHS Kirklees has completed the pilot Health Needs Assessment in the Huddersfield North locality. The aim of this programme was to identify how best to support hard to reach diabetics and ethnic minorities in localities where the prevalence of diabetes is high. The finding of this needs assessment will be disseminated at a stakeholder event on the 26th of November 2008. The learning from this process is being used to improve the quality of care for diabetic patients, particularly those from a South Asian ethnic minority background. Some changes have already been introduced within this locality, as a result of this needs assessment. NHS Kirklees has ensured (through changes to the commissioned screening programme) that Diabetic retinal screening is now offered to patients within this locality from a local GP practice.

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November 2008

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Next Steps The NHS Kirklees Diabetic Retinal Screening programme will be subject to external quality assurance by the National Screening Committee in due course. In preparation for this, NHS Kirklees has being reviewing key areas of practice. Working in partnership with Kirklees Council, an audit of blind and partially sited diabetics living in Kirklees has been undertaken. The audit findings are being used to improve the call and recall process and ensure appropriate failsafe mechanisms are put in place. NHS Kirklees is looking to develop and implement a social a marketing programme for diabetic patients and there families. The parameters of this programme are currently being scoped.

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Long-Term Conditions 17.

Long Term Conditions Director Lead: Sheila Dilks Lead Manager: Joanne Crewe Context The recognised outcome of improving the management of patients with chronic disease is to significantly improve their quality of life and independence by offering a personalised care plan. An informed person who knows when to self care and when to seek clinical support can control their Long Term Condition (LTC) much more effectively. Consequently, there is an imperative to progress work that reduces overall numbers of patients who develop chronic disease, timely diagnosis of patients so that appropriate management of their symptoms can be established, reduction in the overall impact of frequent hospital admissions through the provision of alternative models of care, recruitment of community matrons and specialist nurses to support patients with complex and specialist needs The aim is for everyone with a LTC to have a management strategy, supported by and developed in partnership with a clinician. This means individuals: • • •

set their own goals supported by high quality information; take personal responsibility for their own health; and are the expert for the management of their condition.

Key Achievements The NHS Kirklees is seeing reduction in admission rates for the 19 ambulatory conditions but this is reducing at a rate that is unacceptable and therefore we need to extend the reach of the commissioned services to deliver greater and more equitable coverage across Kirklees. A local trajectory will be set to reflect the benefits of the PCTs investment into the LTC programmes and meet the targets for reduction in emergency bed days for the 19 ambulatory conditions. Although progress has been slow due to recruitment training and education issues Kirklees Community Health Trust has completed the recruitment of the 25 community matrons and 2 discharge liaison nurses. Consequently we are seeing a rise in the number of Very High Intensity Users being managed within the LTC services. 3 practices in Kirklees are part of the national Year of Care pilot to develop national and local learning from the use of personalised care planning Practices have had the opportunity to take part in the Local Incentive scheme to implement personalised care planning for their patients with LTCs Performance Report

November 2008

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The next stage is:•

Allocation of Community Matrons and Case Managers to practice units with the expectation that each unit will have a GP lead ,who will mentor the Community Matron ,and will support the case management approach Kirklees LA will be appointing a further five case managers (social workers) to further develop opportunities for integration between health and social care and improve discharge pathways from the acute trusts Kirklees LA are providing generic workforce, who will provide support to patients and carers at times of crisis. This service is due to commence in December and will be widely marketed. It is expected referrals to this service will come from a wide range of sources including carers , GPs , community matrons, district nurses ambulance service and A/E . An SLA for the services of Health Dialogue has been passed to the procurement department of CHFT to take forward the contracting of the risk stratification tool. A specification is being developed for a combined health and social care single point of access.

To move further faster we need to bring together GPs from each practice units, community matrons and generic workers to agree processes for integrated working. Through the contracting process rigorously performance manage providers on the delivery of the commissioned services. Progress work to embed the use of personalised care planning within usual care for people with LTCs so that all people with LTCs have a personalised action plan for managing their LTC. Present at Business and Financial Planning Group monthly benefits realisation update. Consequences and associated risks Failure to achieve delivery of national targets will impact on the PCT’s 2008/09 performance ratings and the key performance indicators that underpin delivery of the Long Term Conditions agenda will be actively performance monitored/managed via the contract group.

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Patient/User Experience 18.

Patient Choice Lead Director: Carol McKenna and Lead Manager: Rachel Carter

% Patient Recollection of Choice

80%

70%

60%

50%

40%

30% Mar-08

May-08

Jul-08

Sep-08

Actual

44%

52%

45%

44%

Profile

80%

80%

80%

80%

Nov-08 80%

Key Achievements Kirklees performance for recollection of choice remains above the Strategic Health Authority (SHA) average (below National average). Performance has dropped from a peak in March – May 52% (coinciding with National and Local media campaigns) back to 44% for August – September (against a target of 80%). For the percentage of patients able to attend hospital of choice (or not having a preference) Kirklees performance is broadly comparable with both SHA and National performance for August – September (Kirklees: 88%, SHA: 88%, National: 89%, MYHT: 86%, CHFT: 91%). The Issues There are some inconsistencies in the data. For example the choice recollection for our main providers in August – September was 52% for CHFT and 45% for MHYT, it is hard to understand how the overall PCT performance can be below that of our two main providers given that it is more likely that our patients going elsewhere will have been offered choice.

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The Actions Being Taken National and SHA performance has also dropped since a peak in March – May. We continue to try to improve general awareness of choice amongst the population (as this significantly influences recollection of having been offered choice). The PCT is funding a local media campaign to reinforce the current national campaign. Improvements in Choose & Book usage and particularly roll-out of Direct Booking at MYHT should also improve recollection of choice.

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November 2008

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19.

Patient Safety - Infection Control/Hospital Acquired Infections Director Lead: Judith Hooper and Lead Manager: Jane O’Donnell 19.1

MRSA

Due to the timing of the November report the information on the number of MRSA bacteraemia is reported up to the end of September. The issues Receipt by the PCT of timely information continues to be an issue. Both local Acute Trust providers are unable to release their figures until after the 15th of each month due to the lockdown of the Health Protection Agency HCAI capture data system. Calderdale & Huddersfield Foundation Trust - MRSA Kirklees and Calderdale Health Economy HCAI group continues to meet fortnightly with representation from the Department of Health Improvement Team, to minimise and manage the incidence of MRSA bacteraemia and Clostridium difficile (C. difficile) infections by developing health economy wide strategies and monitor implementation. The root cause analysis (RCA) investigations are signed off by the health economy, learning is shared and action taken as required. The Health Economy of Huddersfield and Calderdale has reported a total of seven cases to date (April - 2, May - 3, June - 0, July - 1, August - 1, September - 0). The Health Economy has an agreed process in place which ensures that all MRSA bacteraemia are categorised into one of five categories following a robust RCA investigation to ensure fair management of all cases. The RCA main learning themes:• • • • •

Documentation of insertion and ongoing care of invasive devices is required. Assessment of competency of managing invasive devices. Hand hygiene compliance needs to be consistently high. Ensure MRSA is communicated to community healthcare staff on discharge. Antimicrobial prescribing guidelines should be followed.

The Health Economy action plan is continuously reviewed to ensure the nine objectives are being addressed. The Health Economy now has a quarterly newsletter which highlights the key messages and initiatives.

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The review by HCAI Department of Health Improvement Team was undertaken on 3rd July 2008, this acknowledged the progress which has been made by the Health Economy and the ongoing commitment to a zero tolerance approach to all avoidable MRSA bacteraemia. The Healthcare Commission – HCAI inspection was undertaken on 7 / 8 July 2008 in relation to the Hygiene Code, Health Act 2006 – duties 2, 3, 4 and 8, the final report is awaited. Mid Yorkshire Hospital Trust - MRSA The Kirklees and Wakefield Health Economy HCAI meeting continues to meet weekly. For the period April – September the Health Economy of Kirklees and Wakefield has reported a total of 21 cases (April - 3, May - 4, June - 2, July 5, August - 5, September - 2). The Trust breached the monthly target by one case in July and August. This is an improvement on any of the previous quarters on 2007 / 2008. To maintain this position the focus on preventing avoidable infections needs to be maintained. An appeal to the Health Protection Agency for case 05/08 and case 17/08 has been submitted and a decision on the outcome is still awaited. The Health Economy has agreed to implement categorising the cases following positive feedback from Calderdale and Huddersfield Health Economy HCAI group. Following the timely completion of the RCA investigation, the HCAI group deem the case to be avoidable or unavoidable then agree if the case can be attributed to a healthcare setting. The Main Root Cause Analysis (RCA) Themes • • •

Compliance / delay in decolonisation and screening. Variable compliance with hand hygiene practice. IV management and documentation.

The Chief Executive Officer of MYHT has circulated a letter to all band 7 sisters / charge nurses and consultants across MYHT advising that she will meet with them if any further avoidable MRSA bacteraemia occur. The health economy Health Care Associated Infection (HCAI) has developed an in depth HCAI action plan and Gantt chart to address key issues identified by the RCA investigations A score card of performance measures, compliance with practice and policy has been developed to inform the action plan. The scorecard incorporates a range of high impact intervention audits and the quality incentive measures.

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The Healthcare Commission carried out an unannounced inspection at MYHT to assess compliance with the Health Act 2006, Hygiene Code on 21 August 2008; the report is awaited. 19.2

Clostridium Difficile (C.difficile) Infections – NHS Kirklees

The C. difficile infection target for 2008/09 is based on all cases occurring in patients two years and older in Kirklees residents. The trajectory for NHS Kirklees in 2008/09 is no more than 299 cases. NHS Kirklees is working with the health economies of Calderdale and Wakefield to reduce the number of cases. The table below shows the actual number of cases reported to date: (Reference Mandatory Enhanced Surveillance System HCAI data).

Number of cases reported 26

Target 25

May

27

25

June

16

25

July

26

26

August

24

24

September

17

24

Total

136

149

Month April

Cases are attributed to the PCT through the patient’s NHS number. The table below shows a further breakdown of cases in Kirklees residents by NHS Trusts. Leeds NHS Trust

Calderdale and Huddersfield NHS Foundation Trust

Mid Yorkshire NHS Trust

SWYMHT

April

3

11

4

-

May

1

14

5

-

June

3

7

3

-

July

2

15

4

1

August

2

7

7

-

September Total to date

1

4

9

-

12

58

32

1

Month

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November 2008

Private Hospital

1

1

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The Deputy Director Infection Prevention and Control has contacted Leeds Teaching Hospitals Trust (LTHT) for assurances on measures taken to reduce the incidence of C. difficile infections. Measures being implemented include: • •

Antimicrobial prescribing control. Audits of isolation facilities, isolation compliance, antimicrobial prescribing, hand hygiene, environmental cleaning.

Of the 136 cases reported April – September 2008 to the Health Protection Agency Centre for Infections, 31 C. difficile infections have been reported from community specimens (GP requests). Specimen Location Month

Home

April

4

Nursing/Care Home 2

May

6

-

-

6

June

3

-

-

3

July

4

-

-

4

August

8

-

8

September

3

-

3

Total

28

2

32

2

Holme Valley Memorial Hospital 2

Total 8

Kirklees Infection Prevention and Control Team aims to undertake enhanced surveillance following the reporting of a community case; contacting the patients’ GP. GP – information requested • • • • •

Antibiotics prior to diagnosis Recent bowel surgery In patient within the last two months Antibiotics prescribed post diagnosis History of gastric suppressive agents

Ascertaining information from GP practices can be problematic with a number of practices refusing on the grounds of confidentiality. Two of the 32 community cases were reported at Holme Valley Memorial Hospital, the cases were unrelated but had previous admissions to Acute Trusts within the preceding month and had tested positive for infection previously. Both patients had multiple courses of antibiotics.

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Conclusion Presently the target for C. difficile rates has been achieved, but work continues to ensure NHS Kirklees achieves the year end target. 19.3

Kirklees PCT

The Infection Control Team continues to progress the focus on the areas identified from the Root Cause Analysis investigations. A Kirklees Community Healthcare Services Infection Prevention and Control action plan has been developed and agreed. The action plan will be monitored by Kirklees Infection Control Committee.

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20.

Patient and Public Involvement Director Lead: Helena Corder and Lead Manager: Dáša Farmer / Kirsty Wayman Key Achievements Every year the PCT is required to conduct a nationally prescribed patient survey that focuses on primary care. However this does not cover community nursing services although Kirklees Community Health Services is working on developing patient experience measures for service areas where this information is not yet collected. This year results from the survey will be used to measure vital sign VSB15_05. To date it is not clear what questions will be used to measure the trajectory target of 76%. This is defined by 5 key dimensions rated by patients/users are important: * Access and waiting; - this is an area that needs to be improved as patients views on their access to services are lower than the PCT’s performance on meeting its access targets. In the overall Healthcare Commission scores we achieved a score of 2/4. There are specific issues in this area such as patients wanting to see the same doctor or nurse which may not always be possible as we increase opening times. Although access is not nationally measured based on wanting to see the same doctor or nurse the fact that patients want to do this and may not be able to influences their perception that they do not have access within the 24 or 48 hour time period. * Safe, high quality coordinated care; -generally the PCT scores well in this area although there is an issue about patients feeling they are not as well informed as they feel they should be about medicines. In the overall Healthcare Commission scores we achieved 7/7 for the standard of care and 12/12 for safety and cleanliness. * Building closer relationships; * Clean, friendly comfortable place to be; -overall patients felt that practices were clean and friendly places. * Better information, more choice – this appears to be an area where the PCT needs to improve and the PCT’s Communication and Engagement Strategy covers this area of work for the future. The people are randomly selected and the sample size is small 1168 patients of which 448 (38.4%) returned the questionnaire. The survey shows that the PCT is performing around the average for PCT’s who used Picker to conduct their survey.

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This survey needs to be used as part of the totality of information the PCT collects about patient experience and not in isolation. For example the survey identifies a problem with patient’s not being offered a choice. We already are aware that this is an issue and that action is being taken to be taken to improve in this area. The Communications and PPI Teams have completed the Communications and Engagement strategy for submission as part of the World Class Commissioning assurance process. The work was underpinned by internal and external focus groups and a public survey. The Issues Feedback received from the survey undertaken showed that; •

81.7 % of those who responded (71%) felt they knew what NHS Kirklees was responsible for

The survey also gathered views on whether whether NHS Kirklees had helped to influence peoples’ views and expectations of the NHS • •

50.9% said yes 49.1% said no

Did NHS Kirklees listen to the views of local people • •

50% said yes 50% said no

The Action Being Taken The PPI Team have just completed consulting on the NHS Constitution and are currently supporting teams on involving and engaging with the public on: • • •

Holme Valley Memorial Hospital Project Calderdale and Kirklees Stroke Strategy The Redesign of Kirklees diabetes service

Additionally the PPI team are involved in the Quality Outcome Framework (QOF) assessments around GP patient surveys as well as being involved in the procurement process for both urgent care and the GP led health centre opening 8am to 8pm, 7 days a week. The Communications and Public Relations Board sub committee has been established to consider the aspects of PPI, patient experience, equality and diversity and internal communications. In addition to this, a Patient Experience group has been set up to focus on key areas of work, such as Patient Opinion.

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Discussions regarding various IT packages to underpin the work of the team and to support the delivery of PPI objectives across the organisation are being explored. A positive working relationship is being maintained with the Kirklees Local Involvement Network (LINk), the Host organisation and Local Authority LINk Management Group.

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Clinical Priority Programmes 21.

Cancer Director Lead: Carol McKenna and Lead Manager: Loraine Turner Key Achievements Leeds Teaching Hospital Trust has put additional outpatients’ sessions on and increased capacity. The Issues The above graph shows a fully validated Kirklees PCT summary position for the year, up to and including September 2008. October data is not available at the time of reporting. Monthly reports will only be included by exception. Half the breaches are at both Mid Yorkshire Hospital Trust (MYHT) and Calderdale & Huddersfield Foundation Trust (CHFT) relate to Leeds Teaching Hospital Trust (LTHT). Even though LTHT have put on additional outpatient sessions and increased clinical capacity, we are still expecting breaches due to the backlog of work. Despite the additional capacity LTHT are still forecasting breaches in the latter end of the year due to backlog of activity. The Cancer Network and the Strategic Health Authority are aware. 14 Day Target

14 Days GP Urgent Referral to First Outpatient Appointment 100.0% 99.0% 98.0% 97.0% 96.0% 95.0%

Mar-08

Apr-08

May-08

Jun-08

Jul-08

Aug-08

Sep-08

Actual

99.7%

99.48%

99.58%

99.72%

99.79%

99.78%

99.82%

Profile

100%

100%

100%

100%

100%

100%

100%

Oct-08

Nov-08

Dec-08

100%

100%

100%

Performance is slightly down at 99.82% in comparison to last year at 97.4% which was rated as achieved. Attributable to this figure are 4 breaches 2 of which were unavoidable.

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31 Day Target 31 Days Diagnosis to Treatment 100.0% 98.0% 96.0% 94.0% 92.0% 90.0%

Mar-08

Actual 98.4% Profile

98%

Apr-08 May-08 Jun-08

Jul-08

Aug-08 Sep-08

Oct-08

Nov-08

Dec-08

98%

98%

98%

98.65% 98.88% 99.23% 98.99% 98.20% 98.90% 98%

98%

98%

98%

98%

98%

Overall 2008/09 to date position is 99.27% against a target of 98% achievement, capacity issues at Mid Yorkshire Hospital Trust and Leeds Teaching Hospitals Trust (LTHT). 62 Day Target 62 Days - GP Urgent Referral to Treatment

99.0% 97.0% 95.0% 93.0% 91.0% 89.0% 87.0% 85.0%

Mar-08

Actual 91.5% Profile

Performance Report

95%

Apr-08

May-08

Jun-08

Jul-08

Aug-08 Sep-08

Oct-08

Nov-08

Dec-08

95%

95%

95%

98.44% 97.48% 95.38% 93.21% 93.51% 93.38% 95%

95%

95%

95%

November 2008

95%

95%

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Performance is down at 93.38% against a target of 95%. There has been a slight underperformance consistently for the first half of the year. The majority of the 62 day breaches are when patients have been referred locally to LTHT. These are in the main the complex pathways where diagnosis is not straightforward. There has been a lot of operational disruption for LTHT following the transfer of services from Cookridge Hospital to St James’ Hospital in December /January 2008. In addition, the Thoracic department have now appointed a further surgeon, which should see a reduction in the lung cancer surgery waiting times. The PCT continues to work collaboratively with the main cancer centres to ensure the excellent performance is maintained. The Consequences and associated risks The under performance of the 62 day target is a risk as we will be monitored against this for the whole year. Failure to achieve one of these targets is unlikely to affect the performance rating for 2008/09 on its own, but must be considered alongside performance of all existing targets performance. Underperformance will impact on the PCT’s 2008/09 performance ratings. For 2008/09 onwards, national cancer waiting time guarantees are extended to cover no-one waiting more than 31 days for a second or subsequent cancer treatment and no-one waiting more than 61 days from referral to treatment through National Screening Programmes or by hospital specialists. Robust systems and processes to collect this additional data still being developed for implementation at time of reporting. The Actions Being Taken • • •

Further work taking place working with acute trusts to get more timely information particularly on breaches. Work is also ongoing with Referrers to ensure fast track deadlines are met. Acute Trusts have in place pathway co-ordinators who track patients through from referral to treatment. There is a particular focus on ensuring patients move through the pathway seamlessly and timely, with potential breaches and breaches being dealt with. Where these occur the learning is taken and actions taken to reduce the risk of such instances re-occurring. Actively working with all providers to ensure robust data collection systems and processes in place,

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22.

Cancer – Breast Screening Director Lead: Carol McKenna and Lead Manager: Nicky Hoyle Issues The Pennine Breast Screening Programme is based in Bradford Hospitals Foundation Trust and is the breast screening service provider for the PCTs in Bradford, Calderdale, Kirklees and part of North Yorkshire. It covers an eligible population of 137,500. The Kirklees service is provided using static hospital screening facilities in Huddersfield and mobile units that are established across the district on a rolling 3 year cycle. Coverage measures the proportion of eligible women who received a screen in the previous 3 years, the national minimum standard for this being 70%. There is an aspirational target of 80%. The latest data shows that the minimum standard was exceeded for the Kirklees population in 2007/8 (source KC63 07/08), showing that the Pennine Breast Screening Service has been effective in this field. During 2007 and 2008, the 36 month round length target (i.e. 90% of eligible women invited within a three year period), has been a challenge and had declined to as low as 33% in the last quarter of 07/08. An action plan was implemented to address this and the latest report from the Quality Assurance Reference Centre (QARC) showed a recovery to 93%. The drop in round length performance was due to the introduction of 2 views of each breast instead of one, the increase in the age range of women screened from 50-64 years to 50-70 years, population growth and staffing retention and recruitment issues. There are a number of new challenges to be faced, partly due to implementation of the Cancer Reform Strategy (published November 2007) and the need to replace capital equipment over the next few years. These challenges can be summarised as: •

• • •

extension of the age range for screening from 47 – 73 years – for the Pennine Unit this means a 37% increase in the eligible population between 2007 and 2011 the introduction of digital mammography investment in new mobile units to increase capacity and replace units reaching the end of their lives providing screening for women with high risk due to family history

Key Achievements By September 2008, the implementation of the round length recovery plan led to the Programme exceeding the round length target in the quarter Jul-Sep 08 due to a sustained effort by the Unit in terms of increased levels of staffing, additional sessions to maximise use of the mobile screening units and greater throughput. Performance Report

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The overall coverage rate for Kirklees for 2007/08 exceeded the target of 70%. The Consequences and associated risks As the national coverage target was achieved for 2007/8 this will be reflected in the Healthcare Commission rating for 2008/9. The Actions Being Taken The challenge now is to maintain the current round length target, implement the Cancer Reform Strategy and address the issues relating to capital replacement of units and machines. To this end: • • •

regular meetings between Kirklees PCT, the Lead Commissioner and Pennine Breast Screening Service have been re-established. an action plan is being developed for implementation of the new Cancer Reform Strategy and related capital investment requirements collaborative meetings between all the Breast Screening Programmes in the North of the Region have been established.

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23.

Cancer - Bowel Screening Director Lead: Carol McKenna and Lead Manager: Loraine Turner National evidence suggests that implementation of a National Bowel Cancer Screening Programme should reduce cancer mortality by around 15% in those people screened and should contribute to the delivery of the PSA target for all cancers that will achieve a reduction in mortality by 2010. By December 2009 implementation of local screening programmes should have commenced. Calderdale, Kirklees & Wakefield Health Communities have agreed to be a local screening centre. A bid was put in to join the National Phase II implementation but this was unsuccessful. We are waiting for the timetable for Phase III implementation to reapply.

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24.

Substance Misuse Director Lead: Carol McKenna and Lead Manager: Tony Cooke 24.1 Drugs Misuse The Issues The PCT, through working in close partnership with social care, criminal justice and voluntary sector providers, has a strong track record in this area, with two consecutive Healthcare Commission 4* inspections. National targets have been revised via the amalgamation of the three core targets into one overall target focusing on increasing numbers in treatment and improving quality and outcomes. This target is predicated on a further 520 people accessing treatment and this is a considerable further stretch. However, if we deliver the planned improvements in retention and completion via the expansion of clinical services it is likely the overall target will be met. Without additional capacity there remains serious risk in the system in relation to both clinical governance and general capacity. The Consequences and associated risks A consequence of more people in treatment being retained for longer is improved general health and reduced wider health costs, though in the short term there is an impact via increased prescribing costs for users requiring substitute medication. There is a need to move people through the system back into primary care and other support services to prevent the system clogging up. There are some bottlenecks at present caused by a lack of clinical time and a business case has been developed to improve this and ensure that service users are assessed and reviewed according to guidance. The Actions The Drugs & Alcohol Action Team (DAAT) has committed to expanding shared care and increasing the role of primary care provision in general by reinvesting resources currently spent on specialist Tier 3 and 4 interventions. This will leave specialist services working with people with higher needs, but, it is possible that retention will reduce. However, improved pathways are already delivering improvements in retention this year, we expect this to continue. We also have a dedicated action plan to improve both the number and quality of exits from the treatment system. In addition, the Treatment Outcomes Profile will be completed on each individual. This outcome monitoring system will better enable us to tailor treatment to individual need, making it more effective. We are also undertaking a review of prescribing practice to ensure that clinicians are implementing new NICE guidance on prescribing. This should re-enforce the trend away from buprenorphine and towards methadone prescribing, exerting downward pressure on prescribing costs whilst also

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ensuring more consistent evidence based practice across the treatment system. 24.2

Alcohol Misuse

Issues Treatment provision is effective but limited and there is a need for significant expansion of provision to meet need, both via primary care (brief interventions) and treatment for dependent drinkers. Alcohol misuse remains one area of the health system that has large numbers of the potential treatment population outside services, and the costs to Kirklees are high. Initial estimates of the annual costs to Kirklees of alcohol misuse are £132m based on extrapolation from the national costs of £20bn (DoH 2007). There has also been an evidenced increase in drinking levels among under 25s and adults (Joint Strategic Needs Assessment). This has long-term implications for life expectancy, CHD, etc. The network of services recommended by Models of Care for Alcohol Misuse (this is similar to a National Service Framework) are not in place in Kirklees though a stepped care approach has been taken that outlines what should be in place at each stage of the treatment system. Treatment service provision is only touching a very small percentage of problem drinkers, and a business case has been developed to improve this. Consequences and associated risks The risk for the PCT is the inadequate levels of provision that will impact on other services. The CLIK survey shows escalating levels of alcohol misuse that if left unchecked will contribute to levels of CHD and stroke, liver disease, cancer, etc. Alcohol is also a major contributor to domestic violence, crime and accidents requiring A & E attendance. Action Being Taken Kirklees Partnership’s Alcohol Strategy was officially launched in November 2007 and is led in partnership between Kirklees PCT (Drugs & Alcohol Action Team) and Public Health, with involvement from all key partners such as Local Authority, Police, Fire, Voluntary Sector, Service Users, Licensing Industry, etc. The event was well attended and attendees made extensive contributions as to how the strategy and the actions from it need to develop. The launch of the strategy is just the start of the work to reduce alcohol related harms. The purpose of the strategy is to bring a whole host of related initiatives in Kirklees into a common framework and increase mutual understanding between services to improve outcomes A series of training events (practice protected time) have been held and the introduction of the Locally Enhanced Services has improved both the scope of interventions and accessibility in the community. However the practices Performance Report

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involved has identified large numbers of dependent drinkers and this has resulted in a 6-8 week wait for treatment provision despite the additional investment made in 2007. Next Steps I. Two Business Cases being considered in the current planning round looking at services for dependent drinkers and expansion of the Locally Enhanced Service (LES) for alcohol. II. The alcohol Health Improvement Team (HIT) has led improvements and has been effective at outlining need and making best use of existing resources. III. DAAT and Probation are investigating the possibility of developing an ‘alcohol treatment referral’ scheme for people offending as a result of their alcohol misuse. IV. A fully integrated alcohol service will be tendered that will offer interventions at all stages of need from brief interventions in primary care through to structured treatment.

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25.

Mental Health Director Lead: Carol McKenna and Lead Manager: Vicky Dutchburn Context “Services exist for the benefit of the people who use them. Service users and carers should not only be involved in shaping their care by making choices, but should be central to the provision of local services as equal partners. Service user and carer involvement must be part of everyday practice across the spectrum of mental health and social care services. Only then will service users and the public have a greater say in the way services are planned and developed, how they operate and how they can better respond to needs and expectations.” (CSCI 2005) Defining the Vision • •

The vision for NHS Kirklees is designed to enable our local population to maintain and improve their mental health and wellbeing. For those who experience mental health distress, our intention is to obtain the highest level of self-sufficiency within their communities, through the use of valued, quality support networks and services.

The Values 1. Act with integrity in the spirit of openness and true partnership 2. Encourage and empower individuals to exercise their rights to choice , respect, dignity and independence through equality, opportunity and inclusion 3. Embrace the diversity of our local population to facilitate their mental wellbeing 4. Involve and inform local people in planning and reviewing services to meet their needs 5. Implement rapidly and systematically improvements in service delivery, based on evidenced practice through effective & accountable leadership and management 6. Ensure appropriate and timely access to services 7. Value & accept feedback from Individuals and providers across Kirklees 8. Do what we say we will Mental Health services will be based on the recognition that it is the quality of the relationship between the individual and his or her social context that is important for mental health. The Joint Mental Health Commissioning Strategy (2008-2011) is based on both national guidance and local needs assessment. It should be seen as a working document to guide and support future work via agreement on specific targets, measurable outcomes and dates for achievement. The Strategy also contains targets designed to improve the Commissioning process itself. This is in recognition of the need to improve information about needs, use of Performance Report

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contracting and care management processes and managing the market effectively to improve both the range and quality of service provision. The strategy is a formal statement of plans for securing, specifying and monitoring mental health services to reasonably meet needs. It applies to all possible optimum service solutions in relation to individuals who experience mental health problems or who may be at risk of experiencing mental health problems. It sits with Joint strategic analysis work. Partnership working is central to our approach in Kirklees as we believe that it secures the best outcomes for people who experience mental health problems through the most cost-efficient use of resources. The strategy also aims to better balance services so that there is more emphasis on prevention, and earlier intervention. A key aim is to reduce the need for more complex and expensive interventions and aims to secure the best outcomes as cost effectively as possible. The strategy aims to better engage with the third sector. The breadth of provision will be expanded over the 3 years of this strategy as more effective use of the third sector is made. The intention is the lifetime of this strategy will see the creation of supportive environments, promotion of protective factors for individuals, reduction of the impact of risk, and so the improvement of well-being. This means that we will be aware of the interaction between the emotional, physical, and social aspects of our lives. The strategy will also provide a sound framework for specialist mental health service provision. Objectives •

• • •

• • •

There will be emphasis on the promotion of independence and protection of vulnerable people. We will work on reducing reliance on institutional care by creating more suitable service solutions and packages of care for people in the community. There will be an emphasis on prevention and well-being. There will be a real focus on developing capacity in primary care. There will be changes in directly provided services alongside work to grow the voluntary and independent sector that offer people more choice and control. There will be an emphasis on services that are designed to promote recovery. The personalisation of public services will assist. The development and maintenance of sustainable communities will be supported in order to address social exclusion. The partnership work underway will be further developed to deliver better outcomes, and economies of scale. The health and social wellbeing of people who live in Kirklees is a high priority. The highest standards of performance will be expected.

The Mental Health Partnership Board (MHPB) (which incorporates the function of the National Service Framework, (NSF), Local Implementation Group, (LIT)) as the key local stakeholder group for mental health services Performance Report

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will take the lead in implementing, reviewing and updating this Joint Commissioning Strategy. This forum has been instrumental in the development of local services in line with the National Service Framework for mental health policy implementation guidance. What we have achieved The PCT have developed expertise in developing and commissioning services to meet the needs of our diverse and discreet communities. We have established a history of strong partnership working and a good reputation for service user involvement and public engagement. Through the development and implementation of a robust database system, we have been able to analyse the significant spend by the PCT on Out of Area Treatment. The PCT is keen to repatriate service users to enable the provision of ‘care closer to home’, reduce costs, to ensure best value, ensure consistent quality and have effective case management. The PCT has commissioned five new, significant mental health services during 2008/09:     

Early Intervention in Psychosis; Primary Care Mental Health Services; Section 136 of the Mental Health Act (1983); Additional male Low Secure; Psychiatric Intensive Care Unit.

Also in partnership we have newly commissioned a range of services with third sector providers:        

Employment service Self help Arts Physical activity Advice and support Gender specific Carers Advocacy

What we will achieve The next phase of the PCTs strategic development is to build upon achievement to-date; to strengthen and enhance the PCT’s position in line with its Vision, Values and Objectives, providing a platform for the future which will see the PCT occupying a strong position, confident of meeting the needs of the population served in a pro-active, creative and confident way. We will continue to build on our opportunities to repatriate Out of Area Treatments (OATs), explore opportunities through policy change e.g. NHS Next Stage Review, build on developing IT infrastructure to improve business

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efficiencies, including refined demand and capacity modeling and influence the national agenda and for Payments by Results (PbR). To secure this position the PCT will focus on the following strategic priorities:  Ensure existing robust commissioning and contracting relationships are maintained with providers, influence the mental health market through enhancing relationships.  Develop the PCTs regional and national reputation to support the development of a currency and classification system for mental health, in addition to supporting service redesign and modernisation;  Establish a clear PCT profile to support and enhance the PCT’s reputation within the market and support relationships with key stakeholders;  Through an analysis of the market explore opportunities to enhance Contestability and plurality in the market  To continue to foster strong relationships with partners and local communities; Key Achievements The PCT continue to ensure partnerships are developed which help us to achieve our Mental Health vision and values within the joint commissioning strategy and bring benefits for the communities we serve. In General: Partnerships remain strong with neighbouring Primary Care Trusts, Local Authorities, Mental Health and Acute Trusts and other independent and third sector agencies. Links with Overview and Scrutiny remain strong, which is critical in terms of delivery of Mental Health and Learning Disability commissioning strategies. New service developments which have been agreed for development e.g. attention deficit disorder, primary care mental health /improving access to psychological therapies, full investment of early intervention in psychosis service, community eating disorder service, reflect positive development in line with the identified priorities of the mental health commissioning action plan. Ongoing work regarding strengthening contracting arrangements is paramount for the next ½ of the year. The advent of the model Mental Health Contract will facilitate and support the PCT commissioning expectations re new and existing services. Key areas of note in the reporting period include: Working Age Adult Services Significant progress has been made towards achieving the PCT Crisis Intensive Home Based Treatment targets by March 2009. Further work is ongoing to include additional qualifying episodes undertaken in Older Peoples services, as suggested through a revision of the Department of Health guidance. Performance Report

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The Early intervention in Psychosis service has also made significant progress towards achieving the year 2 target for March 09 and the final service target by December 09. Adult services have completed the manual audit of service users offered a copy of their care plan. The resulting action plan will include ensuring that the key Care Programme Approach (CPA) data items that will be performance managed by the Care Quality Commission in 2008/9 will be captured. The bed occupancy in the newly commissioned PICU is being maintained at a low level until some residual issues are resolved. The bed occupancy figure of 65% for September reflects that although there are now 14 commissioned beds (across Kirklees, Wakefield and Calderdale) only 10 are currently operational at this time due to a water quality issue, the remedial action plans are been monitored through routine contract meetings. Performance against the percentage of people waiting over 18 weeks (referral to treatment) in Adult Psychological Therapies has improved. Recruitment is underway for the 10 temporary posts identified for the Kirklees area. There has been a very good response and a successful outcome is anticipated. Older People’s Services Performance against Delayed Transfers of Care service target remains a risk in Older Peoples Services as there are significant issues in relation to care homes in Kirklees. Currently, in Kirklees, the position is that 4 care homes are closed to admissions and 1 care home is only allowed to admit one person per week. This situation is closely monitored by staff within the continuing care team but it is not anticipated that this will change significantly in the near future. Serious Untoward Incidents 3 new Serious Untoward Incidents (SUIs) have been reported to the Strategic Health Authority (SHA) this financial year and are now being investigated jointly by the PCT and Mental Health Trust: • •

Working age adult services = 2 Older Peoples services = 1

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26.

Learning Difficulties Director Lead: Carol McKenna and Lead Manager: Vicky Dutchburn Context The vision for NHS Kirklees is to empower and enable individuals with learning disabilities to lead a full and, as far as possible, an ordinary life as part of the community with the same hopes and aspirations as everybody else. People want to reach their potential as human beings and have a full and active role in the community. The vision is based on four main principles which mirror the DH document published in 2001, Valuing People: A New Strategy for Learning Disability for the 21st Century of: − Choice − Inclusion − Legal and civil rights − Independence Having a learning disability isn’t a need in itself. People have needs based on individual circumstances. These are very likely to be determined by social and financial circumstances and health needs. People with learning disabilities have needs that are the same as the rest of the population. They may need more support to achieve their goals. Most people want to live as independently as possible but, like us all, as part of an interdependent community. People want to achieve their full potential as human beings. This involves making lifestyle choices, working and making other valued contributions in the community. All our needs are based on individual circumstances. Some people may need more support to achieve their goals. Everybody in Kirklees is an equal citizen and has a contribution to make to the community. The aim of the vision is to set out the main areas we need to focus on to enable people with a learning disability to maximise their potential and achieve their aspirations. We also need to ensure that we include everyone as part of the vision regardless of their personal situation. We conducted three public consultation events for people with learning disabilities and carers, the feedback was analysed and incorporated in the development of the vision and commissioning strategy. Consultation is an ongoing process; we need to constantly check that the changes we make are the right ones. The Learning Disability Partnership Board has a strategic role to play and is committed to ensuring the vision is implemented. This will be achieved through working in partnership with key partners. The PCT have the lead responsibility for ensuring that a commissioning strategy is developed and implemented for both mainstream and specialist health services. As commissioners we are required to ensure that we can fulfill our statutory obligations, to commission appropriate, quality learning disability services, to meet the required and future needs of this vulnerable

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care group, within Kirklees. It is inevitable that, there will be significant impact on both Primary Care and Specialist Services. What we have achieved The PCT have developed expertise in developing and commissioning services to meet the needs of our diverse and discreet communities. We have established a history of strong partnership working and a good reputation for service user involvement and public engagement. We have worked with both our main specialist health service provider and main social care provider to improve performance in learning disability Services. Our action plans and service provision are fully integrated and show that we consider the delivery of learning disability services as a whole system pathway through a variety of services in primary and secondary care Our current and planned service models, identified within the learning disability commissioning strategy, are consistent with the recently published national guidance and recommendations;(Valuing People: A New Strategy for Learning Disability for the 21st Century (2001), Commissioning Specialist Adult Learning Disability Health Services; Good Practice Guidance (DoH November 2007), Good Practice in Learning Disability Nursing (DoH December 2007), Healthcare for all (DoH July 2008) and Valuing People Now: From Progress to Transformation(2008). Prior to developing the approved learning disability commissioning strategy we completed a benchmarking exercise, of both our current primary care and specialist health service provision. This information has been utilized to provide robust commissioning intentions for appropriate, quality learning disability services, to meet the required and future needs within Kirklees. What we will achieve The next phase of the PCTs strategic development is to build upon achievement to-date; to strengthen and enhance the PCT’s position in line with its Vision, Values and Objectives, providing a platform for the future which will see the PCT occupying a strong position, confident of meeting the needs of the population served in a pro-active, creative and confident way. To secure this position the PCT will focus on the following strategic priorities:  Ensure existing robust commissioning and contracting relationships are maintained with providers, influence the learning disability market through enhancing relationships.  Develop the PCTs regional and national reputation to support innovative approaches to service redesign and modernisation;  Establish a clear PCT profile to support and enhance the PCT’s reputation within the market and support relationships with key stakeholders;  Through an analysis of the market explore opportunities to enhance Contestability and plurality in the market, actively promoting Competition from NHS and non NHS providers Performance Report

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 To continue to foster strong relationships with partners and local communities; We will continue to build on our opportunities to repatriate Out of Area Treatments (OATs) and explore opportunities through policy change e.g. Commissioning Specialist Adult Learning Disability Health Services; Good Practice Guidance (DoH November 2007), Good Practice in Learning Disability Nursing (DoH December 2007) and Healthcare for all (DoH July 2008). We will further develop our expertise in planning and commissioning services in partnership enhancing our good reputation for service user involvement and public engagement. Key Achievements Significant progress has been made with South West Yorkshire Mental Health Trust (SWYMHT) in relation to their role on Specialist Learning Difficulties healthcare pathway. This work has been viewed as an area of best practice by the Healthcare Commission. This work is key to the development of meaningful internal and contractual key performance indicators (KPIs). The monitoring and analysis of current activity data continues to inform the pathway development, and although no formal planned activity targets exist, the data is assisting in the development of more robust targets for the future. A significant risk has been removed from the Learning Difficulties risk register, regarding possible counting of campus services, with the closure of the Fox View Annexe. The service has been re commissioned with an appropriate provider and the transition was managed with sensitivity through close partnership working. Ongoing work regarding Transfer of Learning Disability commissioning budgets to Local Authority continues, and will be completed within the Department of Health (DoH) timescales.

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27.

Physical Disabilities and Sensory Impairment Lead Director: Carol McKenna and Lead Manager: Amanda Foxley Background Patterns of physical and sensory impairment (PSI) prevalence are complex and diverse. Eighteen per cent of people over 16 years have at least one dimension of disability (equating to over 50,000 people in Kirklees) as defined by the Health Survey for England. Eighteen per cent of people over 18 years need help with at least one task of daily living which is over 50,000 people in Kirklees. A larger number of people with a range of Long Term Conditions (LTC) will come into contact with NHS Kirklees services, some of whom are jointly cared for by KC Services. The conditions which affect a lot of people aged 18 to 64 years old are visual impairments and hearing impairments, including profound hearing impairments. The conditions which affect small numbers of people aged 18 to 64 years old but have a huge impact on them and services are conditions such as cerebral palsy, acquired brain injury, multiple sclerosis, spinal injury, Parkinson’s disease, Motor Neurone disease, Huntington’s disease and dual sensory loss. There is no evidence to suggest dramatic increases in the number of people with physical and sensory impairments in future years for the 16-64 age group. However, later onset conditions such as Parkinson’s disease, sensory Impairment, arthritis and musculoskeletal conditions will rise as the population aged 45 and over rises. Disabilities linked to conditions such as diabetes and obesity are set to increase as levels of diabetes and obesity increase. Research has suggested that only half of people with complex impairments remain in their jobs. Supporting people with physical and sensory impairments into employment is critical to enabling people to remain independent. There are few accommodation options for people with more profound disabilities. Supported living and extra care housing options need to be better developed for people with more profound disabilities. Some of the pressures include: •

• • • •

a lack of supported living choices for disabled adults and families with disabled members; increasing costs for residential and nursing home placements; a growing demand for complex and costly home-based care and support packages; the need to deliver value for money in care provision whilst maintaining high quality standards and excellent outcomes for service users; the need to develop individual care planning to meet the demands of the ageing population; and a growing number of people with a long term condition (LTC).

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27.1

What We Have Achieved

We have secured joint funding to develop an Eye Clinic Liaison Officer Service (ECLO) across Kirklees and are currently working with stakeholders to develop a service specification. We have secured funding for 100 Telehealth units and have recruited a joint, 12 month post, to implement Telehealth across Kirklees so that people can monitor their own condition, in their own home, and remain as independent as possible, for as long as possible. 27.2 •

• • • •

• 27.3

What We Will Achieve We will focus on improving services for people with a sensory impairment for example via the development of the Eye Clinic Liaison Officer Service. We will improve links between eye clinics and the LA sensory impairment service. We will introduce new pathways of care for people with physical and sensory impairment. With partners, we will commission services that improve access and outcomes for people with a physical or sensory impairment. We will develop a single point of access with our partners so that the health and social care system is more easily navigated by disabled people and their carers. We will build on our approach to service user involvement and ensure this is fully integrated into how we design and commission services. How is this programme delivering the PCT’s goals?

To place the person at the centre of everything we do Partnership working with Kirklees Council is integral to the development of services, but our partnership working will not stop there. We will work with disabled people, the voluntary sector and carers to design and commission services to meet the needs of people with a physical or sensory impairment. We will use the Physical and Sensory Partnership Board, patient partnership boards and social marketing to achieve this. To improve health and reduce health inequalities The Telehealth service will enable more health services to be delivered in the community and can help prevent patients being admitted to hospital. The ECLO service will act as a bridge between Health, the Local Authority and Voluntary Sector support services for visually impaired people And ensure that people with a Visual Impairment across Kirklees have access to services which maximise their independence and well being.

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To improve quality and promote safety Continue to work with health and social care partners on delivering the quality requirements in the Long Term Conditions National Service Framework, the Stroke Strategy and Our Health Our Care Our Say recommendations. To promote choice and accessibility We will work with Kirklees Council to further develop Telehealth services to support people with long term conditions in their own home. To work well in partnership with communities, individuals and their families, staff and organisations At the heart of our work is involving people with a physical or sensory impairment, their families and carers as well as partner organisations in the commissioning and development of services so that there is a collective joint approach to well-being. To promote local sensitivity through effective commissioning Improve social and health care outcomes for people who have a stroke and their carers through commissioning services and ensuring delivery of services where people need them. Continue to develop the range of equipment available to people with visual impairment To promote strong clinical leadership to drive service re-design and innovation Develop pathways of care for people with a physical or sensory impairment that are comprehensive and inclusive.

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28.

Children Director Lead: Carol McKenna and Lead Manager: Lynne Hall-Bentley Context The National Service Framework (NSF) for Children, Young People and Maternity services is a ten year plan that is expected to be delivered by 2014. The NSF standards are split into 11 key areas:Standard 1 Standard 2 Standard 3 Standard 4 Standard 5

- Promoting Health & Wellbeing - Supporting Parenting - Child, young person and family centred services - Growing up into adulthood - Safeguarding and promoting the welfare of children and young people Standard 6 - Children and young people who are ill Standard 7 - Children and young people in hospital Standard 8 - Disabled children and young people and those with complex health needs Standard 9 - The mental health and psychological wellbeing Of children and young people Standard 10 - Not Applicable (managed via the medicines management route within the Kirklees health economy) Standard 11 - Maternity services The delivery of the standards outlined within the NSF is key to the delivery of the Every Child Matters agenda. Standards 6 and 7 focus on the delivery of care in hospital for sick children. The National service frameworks focus across all five outcomes and are not only to do with health services. Within each standard there are key targets rationale for there achievement and good practice guidance from areas that have been beacon sites, or awarded good practice or are early adopters sites for example in midwifery. Previously the Strategic Health Authority has led four networks relating to the delivery of the 11 standards 1. 2. 3. 4.

the well child the ill child child and adolescent mental health maternity services

This programme is beginning to re-emerge as the re-focusing of agendas following merger occurs. There is emerging pressure relating to the performance management of the delivery of the NSF targets. At recent national events health commissioners have been shown the medium term targets being attached to the delivery of NSF and these are Performance Report

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particularly challenging for areas such as child and adolescent mental health services which have found it difficult to achieve the first three proxy targets. Progress to date Standard 1 – promoting health and well being, identifying needs and intervening early focuses on the delivery of the child health promotion programme. The PCT is on target to delivery the child health promotion programme across all seven localities. Currently commencing the process of commissioning. Risks Current resources within localities may require moving to enable all 7 localities to delivery this universal programme Links to other work areas 

Locality working and the integration of children’s services plus links to joint commissioning in the future.

 Standard 2 – supporting parenting Progress to date There are significant gaps to being able to deliver this standard in a comprehensive and cohesive way across all areas and at all tiers. Key gaps are the involvement in the planning and delivery of services, information for parents and carers and the early intervention of evidence based care for children with learning disabilities and /or difficulties and challenging behaviours. Risks Co-ordination and clarity of support and where it is available and how to access needs to be further clarified and commissioned in a coordinated way. Links to other areas   

Parenting strategy and coordinator and development of health support provision. Delivery of a service directory Universal needs assessment

Standard 3 - child young person and family centred services

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Progress to date Further progress is required with regards to all staff working with children skilled in common core of skills, knowledge and competencies. Health Visitor Development Programme currently being written Risks Need to evidence a process delivering partnership provision to deliver coordinated care. Transition agenda Links to other work areas    

Workforce development plan Localities agendas Children’s trust arrangements Joint commissioning

Standard 4 – growing up into adulthood Progress to date There are significant gaps within this standard that require meeting prior to 2014, to deliver high quality transition processes for children growing into adulthood Risks Services address targets for the reduction of alcohol, teenage pregnancy substance misuse, sexually transmitted infections and suicide. Young people in special circumstances receive targeted or specialist services which are easily accessible and meet there needs – there are significant gaps within health provision as well as others. Transition processes are planned in partnership and focus n the needs of young people and are inclusive and meet with young people’s wishes and needs. All services for young people contribute towards assisting young people to take on increasing responsibility for there own lives. Services support parent to support there child through transition. Respecting and involving young people in their care. Links to other work streams   

Emotional health and well-being partnership group Joint commissioning Clinical networks with the acute hospital service providers.

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CAMHS Service Improvement Group Learning Disabilities Care Pathway Group ADHD pathway development.

Standard 5 – safeguarding and promoting the welfare of children and young people Progress to date Performance on target Risks Work in progress to commission and implement for the process required following a child’s death. Links to other work streams  

Integrated processes in place via safeguarding board All services and work streams should incorporate elements of this standard

Standard 6 - children and young people who are ill Progress to date Key progress required in some areas namely the development of children’s community nursing services across Kirklees. The delivery of the long terms conditions agenda for children particularly diabetes and respiratory care. The supported self care agenda for children young people and families. Links to other work streams     

Specialist assessment agenda Safeguarding Delivery of health care commission action plans The development of clinical care network across Yorkshire and the Humber region The reconfiguration of hospital services.

Standard 7 – children and young people in hospital This standard applies to every service and department that delivers care to children’s within a hospital setting Progress to date There are areas of work in place and being developed to monitor evidence against this standard

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Risk areas Areas for improvement include the public health agenda relating to the improvement of health and the reduction of inequalities. Children, young people and families offered choices in care including location and treatment and for children this choice could be about when to take medication and what form that’s in. Integration and coordination of services Links to other work streams     

Specialist assessment agenda Safeguarding Delivery of health care commission action plans The development of clinical care network across Yorkshire and the Humber region The reconfiguration of hospital services.

Standard 8 – disabled children and young people and those with complex health needs Progress to date •

Within this standard there is evidence of good practice within the children with a disability team. There needs to be further work to integrate health and education and social services and third sector to ensure families gain a coordinated service from the point of referral through identification to care delivery. A budget is available to undertake a Needs Assessment The Expert Patient Programme – a pilot programme is being commissioned for diabetes

Risk areas • • • • • • • • • • •

Multi – agency strategy within local network i.e. children’ partnership boards Accessible play and leisure supported by health as identified within the strategy. CAMHS provision to children with a disability. Access to Housing, Equipment and Assistive Technology Early identification Integrated diagnosis and intervention plan Supporting parents/strengthening families Co-ordination of healthcare Palliative care Transition into adulthood Planning and commissioning services

Standard 9 - the mental health and psychological well-being of children and young people

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Progress to date An Action Plan has been identified to deliver targets against this standard with the formation of an emotional health and well-being partnership group which will focus on three areas:1. The development and consultation through to agreement of a joint strategy for emotional; health and well-being across Kirklees 2. The delivery of a modernised service which has clear referral criteria and a significant reduction in waiting times. This element will incorporate workforce and detailed pathways 3. The prevention arm will provide a prevention strategy that will connect to Kirklees prevention strategy and deliver improved outcomes for children and young people once implemented. 4. Has been a reduction in waiting times Risks Commissioning of a tier 4 inpatient service. Inequity of provision across Kirklees Links to other work streams     

Regional and national CAMHS agenda Regional commissioning Joint commissioning Locality agenda Service improvement group

Standard 10 - Managed via the medicines management route within the Kirklees health economy. Standard 11 - maternity services. Progress to date      

Significant work required within the commissioning of services to move forward to pro-actively commissioned services across Kirklees; Work is ongoing with regards to the proposed models of delivery for example the delivery of locality midwifery services integrated into the children’s centres; Service Development Manager in post ; A Maternity Strategy is under development; Business Cases have been approved in principle and work is ongoing; A Draft Action Plan has been produced.

Risks Capacity is an issue within the commissioning agenda

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Links to other work streams    

Reconfiguration of hospital services Children’s centre agenda Practice based commissioning Improved health and well-being of mothers

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29.

Older People Lead Director: Carol McKenna and Lead Manager: Lesley Delaney Older People and Intermediate Care Background By 2025 older people will account for 1 in 5 of the population of Kirklees. As older people become an ever more significant proportion of the population, society will increasingly depend upon the contribution they can make. It is clear that there is a need to promote measures that support healthy ageing, reduce disability in old age and add quality of life for older people. We will do this through close partnerships with partners, particularly with the council and local people. Improving the interface between health and social care, bringing care closer to people’s own homes, providing dedicated case management for those with the most complex needs and supporting people to self care will all contribute to improved outcomes for older people. Our Goals 

To place the person at the centre

The National Service Framework (NSF) for Older People (DH 2001) set the strategic direction for, but moreover to securing a person centred approach to assessing a person’s needs with the patient’s and carer’s views being the key lever in commissioning a process that has a more joined up co-ordination of assessments, through the establishment of the single assessment process at local level and strives towards a more streamlined assessment approach across professional disciplines. 

To improve health and reduce health inequalities.

The older people programme is part of a more complex pathway of care that needs to be integrated, across health and social care. The Joint Strategic Needs Assessment (JSNA) identifies the current and future needs for older people: • • • •

A growing older population More illnesses associated with old age especially mental ill Isolation and lack of social networks. Improve health and reduce health inequalities through: -

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mainstream services are much more accessible

To drive up quality and promote safety.

Performance and governance measures are built into contracts for new and existing services we commission. Kirklees has a process for Safeguarding Vulnerable Adults. NHS Kirklees has dedicated staff working on identifying any development needs of local Care Homes and to raise the profile of treating people with dignity and respect. •

To promote choice and accessibility

A single point of access to intermediate care services has been established in the north of Kirklees and is being rolled out to the south of Kirklees. This will be further developed to dove-tail into the Long Term Conditions single point of access in the near future. •

To work well in partnership with communities, individual users and their families, staff, and organisations

Through the Kirklees Older People Network and the Older Peoples Partnership Board lay members are involved in panels such as tender evaluation panels to assess nursing home tender submissions for provision of intermediate care beds. Partnership commissioning is key to delivering the older peoples programme. Working closely with colleagues from the local council, we jointly set the strategic direction for older people services and joint commissioning intentions. •

To promote local sensitivity through effective commissioning

Practice Based Commissioning (PBS) consortia, local people, Kirklees Older People Network, the Older People partnership board and local professionals have played a vital role in supporting any pathway and/or service redesign for older people, that allows us an insight into what is required locally and for us to work in partnership to develop these locally. •

To promote strong clinical leadership to drive service re-design and innovation.

The aim is that our Older People / Intermediate Care Health Improvement Team (HIT) has clinical representation, not just GPs but nurses, allied health professionals, officers from the Council and independent sector. We have used clinicians extensively and particularly through PBC consortia to enable us to design and commission services for older people and intermediate care. Clinicians are fully integrated into the procurement process for Out of Hours and wider urgent care services.

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To be a visibly credible organisation, operating to the highest standards.

Through partnership commissioning and leadership, at regional level through older people regional networks such as CSIP, NIHME, Yorkshire and Humber Forum on Ageing, NHS Kirklees has well established credibility in older peoples’ services. What we have achieved Developed a Kirklees wide intermediate care pathway providing equitable, high quality services that promote faster recovery and timely discharge and to maximise independent living. Funding achieved to commission Intermediate Care services for people with mental health through recruitment of registered mental health nurses working within communities. Commissioned jointly, with the council a range of carer support services for those people caring for people with physical and mental health problems and end of life needs. The profile of the Dignity Campaign has been raised significantly, amongst PCT and Council staff, to promote treating people with dignity and respect and new ways of person centred care to people. What we will achieve To commission more services that support the intermediate care pathway such as low level preventative support services to assist people to maintain social networks and receive support and information/advice within their own communities. To implement the Kirklees Falls Pathway across the area, across disciplines and services. To provide mental health services that are ageless and provided on the basis of need rather than access dependent on a person’s age, as set out in the recently agreed Kirklees Joint Mental Health Strategy for Adults. To work on implementing the recommendations in the National Dementia Strategy (which is to be published Oct/Nov 2008). To continue to work jointly with acute trust providers, adult’s services and local people on improvements to stroke services in line with National Stroke Strategy. To continue to raise the issues and profile around dignity and respect to older people through a range of training and workshops on the issue. To review joint planning and user involvement processes and structures through reviewing membership, terms of reference and outcomes of the Older People Partnership Board, Older People/Intermediate Care HIT and links with Performance Report

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Kirklees Older Peoples Network to maintain effective links and collaborative working in light of any local needs or changes in policy. To continue to work with PBC to ensure clinical engagement and to jointly commission care pathways. To continue to work with Public Health to ensure evidence based practice and to establish effective links to locality management groups, particularly to inform future commissioning of low level preventative support services.

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30.

CVD – Cardiovascular Disease Director Lead: Sheila Dilks and Lead Manager: Joanne Crewe National Target Substantially reduce mortality rates by 2010 from Heart Disease and Stroke related diseases Vascular screening programme - Key achievements Vascular screening steering group established and active Consultation on draft GP Local Enhanced Scheme to support practices in the identification and management of people who are at risk of developing cardiovascular disease underway Related performance indicators:•

Implement the national policy 'Putting Prevention First' by: -

-

developing ‘at risk’ registers within primary care; offering those identified ‘at risk’ a personalized education package to enable them to reduce their risk factors, e.g. healthier lifestyles and treatment; increasing the number of the target population who have been risk assessed; increasing the number of the target population who have been assessed and identified as being at increased risk of developing cardiovascular disease and prescribed appropriate medication to reduce their risk; increasing the number of referrals to appropriate mainstream service, for example, stop smoking service,

Consequences and associated risks • •

Non compliance with National clinical guidelines and standards Not delivering the targets for the number of GP practices who have primary prevention registers.

Evidence based action required to deliver programme across Kirklees: •

• • •

To develop a GP Local Enhanced Scheme to support practices in the identification and management of people who are at risk of developing cardiovascular disease; Commission an outreach service which targets those hard to reach groups in the most deprived communities; To ensure effective marketing which will encourage individuals to attend opportunities for risk assessment; Work in partnership with Choosing Health programmes in Kirklees to ensure appropriate services are commissioned to support individuals to

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make changes in personal behaviours to reduce their risk of Cardiovascular disease. Cardiology Programme - Key achievements • • • •

Heart Failure service now fully operational across Kirklees; GP with Special Interest (GPwSPI) is reviewing patients with arrhythmias and/or palpitations; Primary Angioplasty available for patients across Kirklees; Rapid access chest pain clinic operational and see patients within 2 week target.

Related Performance Indicators •

• •

To ensure equitable and evidence based multidisciplinary programmes of secondary prevention and cardiac rehabilitation are available to individuals who have experienced a cardiac event; To achieve the 2 week wait standard for access to Rapid Access Chest Pain Clinics; To deliver a 10% increase per year in the proportion of people suffering a heart attack who receive thrombolysis within 60 minutes of calling for professional help; To update practice based registers so that patients with Coronary Heart Disease continue to receive appropriate advice and treatment in line with National Service Framework standards; To ensure practice based registers and systematic 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 diabetes and a BMI greater than 30; To adhere to national and local guidelines for the management of Coronary Heart Disease and related risk factors, and action is taken to reduce overall risk; Improve the management of patients with heart failure in line with NICE Clinical Guidance;

Consequences and associated risks • •

Partial non compliance with National clinical guidelines and standards Failure to achieve delivery of national targets will impact on the PCTs 2008/09 performance rating.

Evidence based action required to deliver programme across Kirklees •

Commission a comprehensive evidence based equitable programme of cardiac rehabilitation delivered by practitioners with specialist skills in cardiac rehabilitation; Continue to commission specialist stop smoking services which will enable those with established Coronary Heart Disease to access support for stopping smoking;

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• • •

Prompt primary care assessment and appropriate referral for all individuals who experience chest pain; Develop and implement an evidence based pathway and related services for the management of people with heart failure; Commission services which identify close family members at risk of those suffering sudden cardiac death.

Stroke Programme - Key achievements • •

Appointment of Stroke Programme Manager Health Improvement Team (HIT) established, and sub groups, to develop work programmes for implementation and assess compliance against Stroke Strategy quality indicators

Related Performance Indicators •

• • • •

Access is available to a hyper-acute stroke service that provides access to 24 hour brain imaging, consultant stroke specialist and thrombolysis if appropriate; Brain imaging is available within 60 minutes of request including out of hours; Those with high risk of full stroke are assessed within 24 hours; Those with lower risk of full stroke but are presenting with TIA are assessed within seven days; Adherence to national and local guidelines for the management of stroke and related risk factors including cholesterol, diabetes, obesity, hypertension and overall action is taken to reduce overall vascular risk; People who have had a stroke spend 90% of their time in hospital in a stroke unit.

Consequences and associated risks Failure to achieve delivery of national targets will impact on the PCT’s 2008/09 performance rating. Evidence based action required to deliver programme across Kirklees: •

• • • • •

A comprehensive specialist rehabilitation programme delivered by practitioners with specialist skills in stroke rehabilitation and comprising of an individualised exercise programme and education sessions which are integrated with the Expert Patient Programme and starts during admission to the stroke unit and continues after discharge in primary care; All partners to actively promote specialist stroke rehabilitation, ensure effective marketing (internal/external) and signposting to clients; A comprehensive early supported discharge service for people with stroke; Prompt primary care assessment for risk factors associated with stroke; Prompt primary care assessment and appropriate referral for all individuals who have had TIA; Identified key worker and case management for all people who have suffered a stroke, their families and carers;

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• • • •

Commission services to support hyper-acute management of stroke; Develop and commission specialist services to support and address respiratory, swallowing, dietary and communication issues; Comprehensive rollout of Gold Standards framework and Liverpool care pathway within all care settings throughout Kirklees; Incorporate care planning into routine care of people at risk or with stroke.

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Cross-Cutting Strategies 31.

Local Area Agreement (LAA) Lead Director: Judith Hooper NHS Kirklees contribution to the LAA 2008-2011 and the individual areas are further detailed within the attached LAA Report (Appendix B refers) and, where appropriate, also within the main body of the Mid-Year Report. Context Inequalities exist between people. both in avoidable gaps in health and in the factors that profoundly affect health. The Kirklees Partnership is crucial in tackling these inequalities as part of its aim to achieve the health and wellbeing of local people. We must ensure that those most at risk or in need have real equality of opportunity. The vision for health and well-being inequalities is that people across Kirklees stay as healthy as possible by: • • • • • • • • • • •

feeling more able to look after themselves, more in control of managing their problems and more able to make healthy choices; being able to easily choose and access the type of opportunities and help they need, when they need it; having opportunities for social support and being involved, so participating fully as members of their communities, as defined by them personally; ensuring those most at risk or vulnerable have opportunities available to them to help reduce their risk or vulnerability and narrow the avoidable gaps in experience; and having appropriate access to education, jobs, transport, housing, health care and a decent environment to live and work in.

The Local Area Agreement (LAA) is the main vehicle by which the Partnership will ensure delivery of local action to tackle these challenges. We must work closely with our local partner organisations in health and social care, the voluntary and private sector, to tackle the health and wellbeing challenges facing Kirklees people and we are actively involved in the leadership and activities of the Kirklees Partnership. The Kirklees Local Area Agreement (LAA) is a three year agreement between the organisations which make up the Kirklees Partnership and central government. It sets out our shared priority targets that need to be achieved to improve the quality of life in Kirklees.

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The LAA is presented in four themes: • • • •

Children and Young People Safer Stronger Communities Healthier communities and older people Economic development and the environment

In the coming years we will build on established relationships and forge new ones to ensure that our services are of the highest quality and are integrated with or align closely with those of partner organisations. This will be particularly important in ensuring that services are tailored to meet the needs of individuals.

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32.

Corporate Governance Director Lead: Helena Corder and Lead Manager: Terry Service This section of the Report covers overall governance and the review of the PCT’s committee structure and includes information governance and risk management. NHS Kirklees has reviewed its systems and processes for governance for example the development of the Provider Board and arrangements to put at arms length the PCT provider unit. Risk Management - the PCT has in place the Board Assurance Framework which is now operational within the Performance Accelerator system and risk tabs attached to all action plans within the system to support the overall PCT risk register. The PCT is currently preparing for assessment to meet the NHS Litigation Authority assessment to meet the level 1 standard for PCT’s has put action plans in place to meet level 2 requirements that will enable automatic compliance with a number of the Healthcare Commission core standards. Information Governance – the PCT has carried out a base line assessment against the requirements of the information governance toolkit and has developed an action plan to address the agreed key issues.

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33.

Equality & Diversity Director Lead: Helena Corder and Lead Manager: Kashif Ahmed Context NHS Kirklees is committed to eliminating discrimination and promoting equality of opportunity to its patients, public and its workforce. Therefore NHS Kirklees embraces its statutory requirements on the six equality legislations that cover race, disability, gender, age, sexual orientation, religion & belief. To ensure we meet compliance on the equality duties and Health care core standards C07e and C17, the following developments have taken place: 1. The recent appointment Kashif Ahmed, Equality & Diversity Manager. 2. The reforming of an Equality & Diversity Working Group, the group will take the strategic lead on implementing the Equality and Diversity Agenda. 3. The group is in the process of reviewing and refreshing the Single Equality scheme and it’s Equality & Diversity Action Plan. 4. The key priority of the group is to undertake Equality Impact Assessments on the PCT’s functions, policies, strategies and processes. 5. We have agreed with Fair Play Partnership to facilitate an organisational self assessment on Diversity. This assessment is being scheduled for late November 2008. 6. Although we applied for the National Pacesetters Programme; the programme aims to support NHS Trusts in terms of delivering change and better outcomes within equality & diversity. The application was unsuccessful because the PCT could not produce evidence of equality impact assessment which is a key priority for action.

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34.

Practice Based Commissioning Lead Director: Carol McKenna and Lead Manager: Jan Giles Key Achievements The Ipsos MORI survey of General Practices, published in September 2008, about the implementation of Practice Based Commissioning (PBC) has shown that the Kirklees position compares favourably with the national position in the following areas: • • • •

The practice considers their relationship with the PCT to be good or very good (89% Kirklees, 73% nationally) The practice has been given an indicative budget by the PCT (89% Kirklees, 59% nationally) The practice has agreed a commissioning plan with the PCT (61% Kirklees, 53% nationally) Format of information provided for PBC by the PCT classified as good (39% Kirklees, 32% nationally)

Over the past year the PCT has achieved national recognition for work in PBC, for example, the NHS Alliance selected the PCT to give a presentation on Practice Based Commissioning at the NHS Alliance annual conference in October 2008. The PCT was one of a small number invited to advise the Department of Health on the re-invigoration of PBC at an event in October 2008 The Issues The Ipsos MORI survey demonstrated concerns in the following areas:• •

Percentage (%) of practices agreeing that the PCT has a robust process for submitting business cases (22% Kirklees, 27% nationally) Quality of information provided for PBC by the PCT classified as good (39% Kirklees, 35% nationally)

The development of the Health Improvement Teams (HITs) has lead to some concern among practice based commissioners about how to engage with the broad range of agendas that they cover. The Consequences and associated risks The successful continued development of PBC requires a robust process for business cases that enables appropriate business cases to be agreed and implemented within a short timescale. While the business case process has been developed over the past year, a focus is needed on speed of response and on training for people who wish to submit business cases The provision of information in which practices have confidence is a key element of support that the PCT is expected to provide to practices

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The ability of Practice Based Commissioners to participate fully in agreeing the strategic direction with the HITs is vital to sustaining a high level of interest in PBC from practices. The Action Being Taken The process for communicating decisions on business cases has been reviewed and improvements agreed. The accreditation of providers of service redesign agreed through business cases is being taken forward by the Patient and Professions Directorate to ensure that this ties in with the timescales for the approval of business cases. Four PBC Performance Information Analysts are now in post to work with Practice Based Commissioners. Their role will further enable the provision of useful, information in a frequency and format that is of value to PBC. They will also support service improvement and priority setting of consortia through the presentation of information. The quality incentives agreed with the local acute trusts include data quality issues. Work continues to enable the engagement of Practice Based Commissioners on the work of the HITs through executive meetings, and the Kirklees Commissioning Forum. A two day conference was held at the end of October to further develop relationships and understanding of roles and responsibilities for PBC, HITs and the Professional Executive Committee.

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35.

Workforce Director Lead: Sue Ellis and Lead Manager: Laura Campbell NHS Kirklees has a role both as an employer and a strategic leader in workforce issues. A skilled, motivated workforce is critical to the delivery of our strategic goals, and to our Delivering Healthy Ambitions in Yorkshire and Humber and world class commissioning agendas. The changing demographic profile and health needs of our local population also mean that NHS Kirklees must take a lead role in workforce planning across the local health economy. Further, the 2008 / 2009 Operating Framework places a responsibility on NHS Kirklees to work with both its own workforce and that of providers to ensure that the right workforce is in place to deliver services to the local population both now and in the future. 2008 / 2009 has seen a series of developments in the area of Workforce that support NHS Kirklees’ ambitions in this area. These include: Workforce Planning Approved by the NHS Kirklees Board in April 2008, the new Workforce Planning Framework provides a coherent structure to support our workforce planning activity and meet the requirements of the 2008/2009 Operating Framework. Workforce risk assessments have been carried out with internal and partner workforces to identify areas for further action and support. To develop our workforce planning capabilities, workforce planning training is scheduled for November and December 2008. Meanwhile a major health economy workforce planning event will be held on 21 November 2008 to engage with strategic partners and progress the workforce planning agenda. Workforce Scorecard Introduced in September 2008, the new Workforce Scorecard enables NHS Kirklees to monitor and improve its performance in key workforce areas, including sickness, turnover, agency spend and staff wellbeing. Accompanied by a monthly dashboard of charts, the Scorecard is reported monthly to the Senior Management Team and Kirklees Community Healthcare Services Board, and on a quarterly basis to the NHS Kirklees Governance Committee and HR Shared Service Governance Board. Work is ongoing to develop further detailed indicators for both the Commissioning and Provider functions of the organisation.

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NHS KIRKLEES WORKFORCE SCORECARD

NHS KIRKLEES WORKFORCE SCORECARD NOVEMBER 2008 (WORKFORCE FIGURES BASED ON AUGUST 2008 INFORMATION) ▲ = improvement * indicates measurements that should be achieved by provider organisations as well as by KPCT-employed services Dimensio n

Measurement

Target

13. Absence management 13.1 PCT long term Long term sickness sickness rate at or absence rates* below 2.3% by 31 March 2009

13.2 Short term sickness absence rates*

13.3 Total sickness absence rates*

PCT short term sickness rate at or below 2.4% by 31 March 2009

Initiative

National / local target

Line manager training National on sickness absence (Better Care, management Better Value) Effective HR advice and support to line managers As above

PCT total sickness As above rate at or below national 07/08 PCT average of 4.7% by 31 March 2009

National (Better Care, Better Value)

National (Better Care, Better Value)

Measurement Frequency

Monthly

Monthly

Monthly

(PCT average based on DH FIMS data from 07/08 Q1 & Q2) High 13.4 Impact HR Financial cost of sickness absence

As above Monthly sick pay expenditure less than £132,000 on average by 31 March 2009

Local

Monthly

► = static

▼ = deterioration

Progress YTD

Trend

Forecas Forecast t Target Actual

2.1% as at 31 August 2008 The PCT remains on target to achieve less than 2.3% long term sickness absence

0.8% as at 31 August 2008 The PCT remains on target to achieve less than 2.4% short term sickness absence

As at 31 August 2008 the PCT sickness rate is 2.9% The PCT remains on target to achieve less than 4.7% total sickness absence

Monthly sickness cost for August 2008 £51765.66

(expenditure figure based on average PCT salary of spine point 31, £31,469 and "on costs" of 23%. Target based on estimated cost of target sickness rate) 14. Turnover 14.1 Turnover rate*

PCT turnover level to remain at or below 13.8% during a rolling 12 month period

As above, plus effective monitoring and action relating to exit questionnaires

National (Better Care, Better Value)

(target figure based on DH FIMS figure of 13.8% median turnover from 07/08 Q1 & Q2)

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Monthly

Turnover rate as at 31 August 2008 is 10.42% which is below the target of 13.8% for a rolling 12 month period

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NHS Kirklees PCT Workforce Dashboard

Kirklees PCT Workforce Dashboard Full Time Equivalent (FTE) Apr 08_Mar 09

Headcount Apr 08_Mar 09 1200.00

1500 Commissioning PCT

1000

Provider Services

Commissioning PCT Provider Services

600.00 400.00

Total PCT

500

1000.00 800.00

Total PCT 07/08

Tot al PCT Tot al PCT 07/ 08

200.00 0.00

0

Mar Feb Jan Dec Nov O ct Sep Aug Jul Jun May Apr

M ar Feb Jan Dec Nov Oct S ep A ug Jul Jun M ay A pr

Rolling 12 Month Turnover (%) Apr 08_Mar 09

Turnover (%) Apr 08_Mar 09 3.0% 2.5% 2.0%

Commissioning PCT

1.5%

Provider Services

1.0%

Tot al PCT 07/ 08

Tot al PCT

0.5% 0.0%

12.50% 12.00% 11.50% 11.00% 10.50% 10.00% 9.50% 9.00%

Total PCT

AprMayJun Jul AugSepOctNovDecJanFebMar

AprMayJun Jul AugSepOctNovDecJanFebMar

Sickness (%) Apr 08_Mar 09 6.0% 5.0% 4.0%

Commissioning PCT Provider Services

3.0%

Total PCT Total PCT 07/08

2.0%

PCT Target

1.0% 0.0% Apr

May

Performance Report

Jun

Jul

Aug

Sep

Oct

November 2008

Nov

Dec

Jan

Feb

Mar

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Staff Demographics Staff by Disability

Staff recorded as disabled on ESR Sep 08 PCT Total 46

1375

7

No

762 Provider 36

1033

5

Undefined

762 Commissioning PCT 10

342

2

Yes

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Staff by Gender

% Staff Full Time/ Part Time by Gender 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00%

Female Full Time Female Part Time Male Full Time Male Part Time 762 Commissioning PCT

762 Provider

PCT Total

Staff by Age

Age Profile

PCT Total

21-34 35-44

762 Provider

45-54 Over 55 Under 21

762 Commissioning PCT

0%

Performance Report

10%

20%

30%

40%

50%

November 2008

60%

70%

80%

90%

100%

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Staff by Agenda for Change Pay Band Commissioner

Staff by Agenda for Change Payband Band 9 Band 8D Band 8C Band 8B Band 8A Band 7 Band 6 Band 5 Band 4 Band 3 Band 2 Band 1 -40

-30

-20

-10

0

10

20

30

40

Provider

Staff by Agenda for Change Payband Band 9 Band 8D Band 8C Band 8B Band 8A Band 7 Band 6 Band 5 Band 4 Band 3 Band 2 Band 1 -150

-100

Performance Report

-50

0

November 2008

50

100

150

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Staff by Ethnicity Commissioner Group 762 Commissioning PCT Staff by Ethnicity

Count of Employee

Ethnic Origin A White - British B White - Irish D Mixed - White & Black Caribbean F Mixed - White & Asian H Asian or Asian British - Indian J Asian or Asian British - Pakistani K Asian or Asian British - Bangladeshi L Asian or Asian British - Any other Asian background M Black or Black British - Caribbean N Black or Black British - African S Any Other Ethnic Group Undefined Z Not Stated

Primary Assignment

Provider Group 762 Provider Staff by Ethnicity

Count of Employee

Ethnic Origin A White - British B White - Irish C White - Any other White background D Mixed - White & Black Caribbean E Mixed - White & Black African F Mixed - White & Asian G Mixed - Any other mixed background H Asian or Asian British - Indian J Asian or Asian British - Pakistani L Asian or Asian British - Any other Asian background M Black or Black British - Caribbean N Black or Black British - African R Chinese S Any Other Ethnic Group Undefined Z Not Stated

Primary Assignment

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Human Resources and Organisational Development Support The HR & OD Shared Service continues to provide a range of support in organisational development, training, people management and ensuring we meet statutory requirements and regulations in our employment of staff. The Shared Service is focused on its value added approach and is undertaking a piece of work to demonstrate its close alignment with the core business of the PCT. Introduction of the Electronic Staff Record The Electronic Staff Record (ESR) was successfully introduced in April 2008. A data validation exercise is scheduled for winter 2008 to validate and improve the detailed information held on the system.

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36.

Clinical Governance Director Lead: Sheila Dilks and Lead Manager: Sue Smith Context Quality and clinical governance remains high on the agenda of healthcare services with a particular focus on driving continuous quality improvements within the context of world class commissioning. The creation of a new regulatory body the Care Quality Commission (CQC) will provide independent scrutiny of the decisions made by primary care trusts as to what service they purchase on behalf of their communities. In the meantime the Healthcare Commission (HC) has issued new assessment criteria for commissioner and provider services to assess their compliance against the Standards for Better Health as part of the quality component of the Annual Health Check (AHC). Trusts will need to demonstrate that they have given greater priority to patient experience, safety and the quality of care. Achievements and challenges Last year the Quality and Clinical Governance Strategic Framework and accompanying action plan was endorsed by the Professional Executive Committee (PEC) and Governance Committee. The action plan includes 14 key objectives with measurable outcomes that aim to drive quality improvements and enable us to comply with local and national objectives and requirements. Significant progress with the action plan has been achieved. Those achievements, outstanding actions and challenges are routinely reported to the Governance Committee and via that the Trust Board. The Quality and Clinical Governance Strategic Framework action plan has been recently loaded onto our performance management system Performance Accelerator to enable us risk rate each action, collate evidence and assurances and track progress against each action. The following highlights just a few of the key actions and achievements: We establish “fit for purpose� clinical governance arrangements for commissioner and provider services: We have worked with KCHS to review our clinical governance arrangements and have made significant progress during 2008. This work is aligned to the overall Governance review currently being undertaken. Quality Indicators are embedded in commissioning and contracting: Significant progress has been made at regional and local level through the Clinical Quality Board to develop patient focussed outcome indicators and build those into contracts. We have worked with colleagues across the region

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to agree priorities and develop metrics with the expectation that a range of quality Indicators will go into 2008/2009 contracts. A tool is designed (the Quality Matrix) that brings together data and information on independent contractor and provider performance to drive quality improvements: The Quality Matrix has been piloted and is supported by the PEC and Governance Committee. Further work is required during 2008/2009 to develop the systems to support this work e.g. Performance Accelerator. We are compliant with the Standards for Better Health and systems are in place to adapt to the new national regulatory framework: Actions to prepare for our 2008/09 Standards for Better Health (SfBH) assessment and improve on our fair/fair Annual Health Check rating are being coordinated by the SfBH steering group. A full report on actions, risk mitigation and processes to support this work has been developed. As last year progress against the action plan will be reported on performance accelerator and to the Governance Committee and via to the Trust Board. We have reviewed our framework to support clinical audit, effectiveness and research to increase engagement, ensure demonstrable benefits for patients, meet requirements and are value for money: We have conducted a full review of each function. Proposals to strengthen these functions will be presented to the November Governance Committee We are strengthening our capability and capacity to enable training and education to be delivered in the most innovative and flexible way: Progress with our cross directorate action plan to build learning capability and capacity with proposals for the future will be presented to the December Governance Committee and Senior Management Team (SMT). Other actions include: • A full review of all aspects of the mandatory training programme to ensure it is “fit for purpose” for the commissioner and provider arms of the PCT. • With clinicians and the support of the PEC and LMC we reviewed Practice Protected Time (PPT). Proposals to for future PPT will be presented to the November Governance Committee and SMT for approval.

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37.

Information Management & Technology (IM&T) Director Lead: Peter Flynn and Lead Manager: Ian Wightman IM&T: The National Programme for Information Technology (NPfIT) in the NHS is a key strategic programme to provide the essential information infrastructure to help realise the Government’s vision first set out in the NHS Plan, of a health service focused on the needs and wishes of patients and their carers. Its aim is to support the NHS to deliver better, safer care to patients, via new computer systems, services and infrastructure that, in primary care, link GPs and community services to hospitals. It aims to improve patient care by enabling clinicians and other NHS staff to increase their efficiency and effectiveness by giving them access to patient information safely, securely and easily. A key element of the programme is creating a NHS Care Records Service to improve the sharing of patients' records across the NHS with their consent. All healthcare organizations’ use effective and integrated information technology and information systems which support and enhance the quality and safety of patient care, choice and service planning and commissioning. 1.

IT Infrastructure and Hardware To ensure that IT equipment is appropriate, in place and meets the PCT and dependant partners IT requirements for:a. Provider Services b. GP Practices c. Corporate Services

Actions required are; . Objective Actions to date Establish A complete and Manual and dynamic Asset register electronic collection of IT assets Completed in provider corporate services and GP practices Establish an effective replacement and repair solutions process

Performance Report

Evaluation of current replacement and repair solutions process completed. New clear guidance documented and agreed December November 2008

Further Actions Validation and dynamic testing required in all three spaces

Status

Evaluation and monitoring required of new system Procurement process needs modification due by March 2009.

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Ensure IT kit is of NPfIT specification and/or the kit is functioning at the required level.

2008. Procurement process requires evaluation electronic collection of IT assets is available in provider corporate services and GP space proactive non compliant IT kit being replaced

Ensure IT infrastructure and back office functions are appropriate for PCT functions/requirements

Management of the HIS relationship. Merger of Staff IT accounts. Identification of back office requirements

2.

Completed replacement of non compliant IT kit in all three areas by April 09,

On going work continuing to ensure solutions appropriate for all back office requirements.

Clinical Applications a. Provider Services b. GP Practices Actions required are;

Objective h Deployment of CfH LSP TPP System 1 to provider services in PCT.

Actions to date All community deployed With the exception of CasH and Chlamydia screening who are reliant on new version of software due 09

Support and maintenance of non-LSP clinical systems

Walk in centre Clinical application in place. Dental software identified and procured, deployment commenced. All practices on GPSoC scheme

Implementation of GPSoC scheme (GP Clinical systems meeting national IT requirements).

Performance Report

November 2008

Further Actions Roll out new software version when available and deploy solution to CasH and Chlamydia screening who are reliant on new version of software due 09 Community Dental services deployment of new clinical application occurring excepted date Jan 09.

Status P

P

One practice to sign PCT/Practice agreement

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3.

Benefits Realisation

Objective Establish Use IT as an enabler to support the realisation of benefits to the Organisation,

Actions to date Financial benefits; PCT savings on existing maintenance contracts (Epex3) and GP signed up to GPSoC scheme and savings on maintenance contracts. GPSoC Safer systems; better security of the system and data by hosting the server in Category 1 secure building:

Further Actions Support practice based commissioning reporting

Status

Increase Provider functionality on IT applications to further enhance performance, clinical safety and financial issue. Support GP practice to migrate if requested to other GPSoC systems

Application meets the NPfIT vision and aims full audit trail of IT system IT system now supporting the 18 weeks agenda.

Use IT as an enabler to support the realisation of benefits for patients; clinical safety, patient choice and confidentiality

appropriate patient and clinical data to be shared between clinicians across community and primary care settings (60% of clinicians to date) The ability to utilise remote booking and internet appointments now available

Work closely with the SHA benefits realisation team fully and provider service improvement team to realise benefits Further enhancement and deployment of new functionality.

Paper light clinical recording reduces the need for storing physical records active in a number of provider departments/services

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Use of National clinical templates validated by expert clinical reference groups Pilots to evaluate the appropriate use of new technology to support new ways of working in provider services IT kit in place to support patient choice. KPCT report completed and returned to SHA

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38.

Prescribing Director Lead: Sheila Dilks and Lead Manager: Neill MacDonald Medicines Management and Prescribing Prescribing budgets As at August 2008 prescribing data, GP practice prescribing budgets are projected to under spend by approximately £2.4 million. This position may change as predictions can be unreliable up to month 8 (November prescribing data). One confounding factor which may actually increase the under spend is that the expected increase in category M drug prices as of October 2008 did not occur, in fact prices decreased, and may have an additional impact of £0.5 million reduction on prescribing costs. This was due to a change in funding for the community pharmacy contract (see community pharmacy below) GP practice support Vacant posts within the medicines management team have been recruited to over the last few months. All posts will be filled by January 2008. This has meant that we have been able to allocate support to all GP practices in respect to medicines management and prescribing activities. The practice support team continue to work with practices to implement areas of prescribing identified with individual practices at the annual prescribing review meetings held in the first quarter of 2008/9. A number of potential cost improvement areas in respect to prescribing have not been implemented due to lack of support from secondary care consultants. These areas will be reviewed to assess if these should be pursued further, and if they should be specified within secondary care contracts. Quality Outcomes Framework (QoF) and Incentive schemes (GP practices) Priority areas for practices have been identified through the QoF packs developed by the medicines management team, and incorporate a number of audits designed to improve the quality and cost-effectiveness of prescribing, and to improve patient outcomes. These are monitored regularly by the medicines management team. All Department of Health “Better Care Better Value” indicators are incorporated into the QoF work areas or the PBC incentive schemes, and are monitored on a regular basis. Revised indicators are expected imminently from the Department of Health.

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Medicines Management Campaigns The Medicines Management team undertook:•

A waste medicines campaign across the PCT in September and October. The campaign involved all local GP practices and Pharmacies including audit of returned medicines to pharmacies. Initial estimates indicate that approximately £1million of unused drugs is returned to pharmacies for destruction across Kirklees, this equates to just under 2% of the overall prescribing budget. A number of public awareness events in supermarkets and other high profile public areas were undertaken by the medicines management team, advertising in the local press, and bus advertising for a 4 week period. The outcome of the campaign will be evaluated over the last quarter of the financial year. Antibiotics campaign – This is planned for January 2009.

Community Pharmacy The Department of Health and Pharmaceutical Services Negotiating Committee (PSNC) have negotiated a change to the remuneration of community pharmacies for NHS Pharmaceutical Services, which was announced at the end of September 2008. The impact of these changes equates to an increase in funding by the PCT of £1.65 million from October 08 to March 09, and £1.8 million for 2009/10. These negotiations and the changes to funding were discussed behind closed doors, with no information on the anticipated changes being provided to PCTs prior to the agreements. The increase in remuneration to pharmacies had been anticipated to be addressed through increases to category M generic drug prices. It may be that following further discussions with finance that prescribing budgets may be reduced, bearing in mind the large projected under spend, to take account of the changes to community pharmacy remuneration. A business case has been approved to implement a minor ailments scheme pilot in the Fartown area of the PCT involving 7 GP practices and 10 community pharmacies. It is anticipated this will be ready to commence in December 2008. Community Pharmacy contract monitoring visits for 2008/9 have commenced, and will be completed by January 2009. Controlled Drugs The Controlled Drugs Local Intelligence Network is now fully operational, and meets regularly every 3 months. Controlled Drugs Incidents are reported via the network into a central point for all organisations across the Calderdale, Wakefield and Kirklees areas, and is co-ordinated via Kirklees PCT. An information sharing agreement has been approved by all organisations, which Performance Report

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provides an operating framework for the Intelligence network to work more effectively. Inspection visits for a selection of GP practices are planned for the last quarter 2008/9. Practices not inspected will be required to complete a self assessment questionnaire. Now that the Network is in place and operating, quarterly Controlled Drug reports will be provided to the board as suggested in the recent Healthcare Commission Annual report. Further work needs to be undertaken to improve the speed of communication in respect to controlled drugs incidents to the CD Accountable Officer, and to raise the profile of controlled drugs across the Kirklees area. Patient Group Directions There has been significant activity in updating existing patient Group Directions (PGDs), and developing new ones for the HPV vaccination programme to support Kirklees Community Health Service staff in various work areas, including the Immunisation and vaccination team, The Walk in Centre, Contraception and Sexual Health Services. Many of these PGDs have also been distributed to GP Practices to enable them to work more efficiently, particularly in respect to Immunisation and vaccination. PCT premises inspections Medicines Management inspection of PCT premises will commence in January 2009. These are conducted on a 2 year rolling programme to ensure compliance with the PCT medicines code and national legislation in respect to the safe and secure handling of medicines. Area Prescribing Committee (APC) The APC continues to work across primary and secondary care, and has developed a number of formularies / guidelines for use across the primary/secondary care interface. These include: • • • • •

Antimicrobial prescribing formulary / guidelines Wound management formulary & guidelines Grey list drugs (drugs less suitable for prescribing) Update to the Red / Amber list of drugs (red = hospital only, Amber = suitable for shared care). Development of new and review of existing shared care guidelines to help to assure patient safety, and patient outcomes.

Practice Based Commissioning (PBC) Medicines management has been incorporated into PBC business plans, and has been identified as a key area for PBCs to work on. Action plans have Performance Report

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been agreed between the PCT medicines management team representatives and PBC prescribing leads / PBC boards, with work progressing on all areas identified. Training and Education The medicines management team will be developing training packages for the 2008/9 PCT mandatory training programme for PCT clinical staff, and addresses areas highlighted in the recent CNST assessment. Additional training is being planned to support Local Authority and private care home staff as significant concerns have been identified in respect to medicines and medicines management in care home environments. A business case to support this will be presented in December. Newsletters The medicines management team have been continued to produce and circulate a number of newsletters and include information on current topical issues, alerts, recommendations, updates to best practice guidance, plus much more. There are now three newsletters produced on a regular basis by the team: • • •

PCT Medicines Management Newsletter (produced 2 monthly for GP practices and pharmacies) Bitz – a new newsletter looking at drug availability, licence changes etc (2 monthly) Community Pharmacy Newsletter – (2 – 3 monthly) – providing guidance and advice to pharmacies.

Medicines Management Policies The PCT Medicines Code has been revised, and is currently out to consultation. It is anticipated this will be approved by the Governance Committee in December. A completely new Controlled Drugs policy, and supporting guidance document is in progress, and will be going to consultation soon. It is anticipated this will be approved in December / January. National Patient Safety Agency Alerts (NPSA) There have been a significant number of work areas identified by the NPSA over the last 18 months. The majority of actions in relation to PCT services have been completed. There are however a number of outstanding actions which are currently being addressed. Most relate to policy revisions to incorporate recommended changes. These policy changes are anticipated to have been completed by December 2008. The greatest area of concern in respect is in respect to implementation of NPSA alerts (relating to medicines / medicines management issues) by Performance Report

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primary care contractors. This has been highlighted as a major issue by PCTs nationally, with Kirklees being no different. The issue of how to encourage GP practices, and other primary care contractors to implement the required actions. To help to identify the issues, and to improve the situation locally, one of the medicines management team will be undertaking a project to assess how NPSA alerts are managed within GP practices.

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http://www.kirklees.nhs.uk/fileadmin/documents/About_Us/Mid-Year_20Performance_20Report_1_  

http://www.kirklees.nhs.uk/fileadmin/documents/About_Us/Mid-Year_20Performance_20Report_1_.pdf

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