To consider a report on performance monitoring by NHS Herefordshire Clinical Commissioning Group.

The chairperson said that the purpose of this item was to consider a report on performance monitoring by NHS Herefordshire Clinical Commissioning Group (CCG), as requested by the committee following consideration of ‘The future of the Herefordshire and Worcestershire Clinical Commissioning Groups consultation’ item at the 24 June 2019 meeting; minute 7 refers.  In addition, details of the One Herefordshire priorities and outcome measures had been requested by the committee following consideration of the ‘One Herefordshire and Integration Briefing’ item at the 18 October 2019 meeting; minute 17 refers.  Scott Parker, director of performance, was invited to present this report on behalf of the CCG; presentation slides had been circulated in a supplement to the agenda.

 

The principal points of the presentation included:

 

a.         The differences between Appendix 1 (CCG performance dashboard 2019/20) and Appendix 3 (presentation slides) were partly due to variations in timing and the distinction between CCG data (for services provided for the population of Herefordshire) and Wye Valley NHS Trust data (including attendances by patients from Herefordshire, Wales, and elsewhere).

 

Arrangements for performance oversight

 

b.         With the merger of the four Herefordshire and Worcestershire CCGs, assurance was provided that performance information for Herefordshire (and the other constituent areas) would still be recorded and there would be an oversight structure which would consider quality, performance and finance, overseen by the Governing Body.

 

c.         A brief overview was provided of the development of Primary Care Networks, including oversight by a local performance forum.

 

d.         It was reported that there was a Sustainability and Transformation Partnership (STP) performance forum, involving system partners with collective ownership and responsibility for the delivery of performance.

 

Presentation slides

 

Urgent care

 

e.         Accident and Emergency (A&E) four hour waits performance (c. 76%-78%) was below the national target (95%) but performance for the most severely unwell patients was stronger.

 

f.          For overall performance, Wye Valley NHS Trust was c. 14-16^th out of the 21 trusts in the West Midlands.  It was reported that there were challenges with substantive post fill but vacancies were being managed and recruitment plans were in place.

 

g.         Within national guidance, there was a 92% general and acute bed occupancy benchmark and it was one of the functions of the A&E delivery board to achieve this.

 

h.         In order to achieve 92% acute bed (general and acute) occupancy there was a projected bed gap of approximately 20 beds.  The bed gap was being closed through opening additional beds and initiatives to support reduced length of stay.  It was reported that Wye Valley NHS Trust was performing well at ‘zero day’ length of stay, i.e. working with the patient to help them to return home, avoiding the need for admission to an inpatient bed.

 

i.           Ambulance conveyance was a key challenge for the system, with Herefordshire having the highest conveyance rate for West Midlands Ambulance Service (WMAS).  The causal factors, including geographic size and population sparsity, and alternatives to conveyance were being examined for the purposes of service design.

 

Cancer waiting times

 

j.           The all cancer two week wait referrals position had improved (from c. 91% to c. 94%) and was now above the national target (93%).

 

k.         The breast symptomatic two week wait referrals position had improved significantly (from the low 30s% to high 90s%).  It was commented that this reflected the challenges for small general hospitals in running services that were reliant on small numbers of consultants.  It was reported that the STP was considering how to deliver such services across the larger footprint of the Herefordshire and Worcestershire CCG, as well as regional propositions.

 

l.           The 62 day cancer wait for receiving first definitive treatment (c. 74-75%) was below the national target (85%) and plans were in place to improve the pathways.

 

Referral to treatment (RTT) waiting times

 

m.        The RTT 18 week wait for treatment position had improved (to c. 81-82%) but was below the national target (92%) and work was ongoing to manage the waiting list and improve performance.  The potential role of the Primary Care Networks in supporting people to consider their treatment options was outlined.

 

n.         The system performed well in terms of diagnostic six week wait, and above the national target (99%).

 

o.         A lot of work had been undertaken to avoid 52 week wait breaches, with the majority of breaches occurring at providers out of county or as a consequence of patient choice.

 

Dementia diagnosis and IAPT (Improving Access to Psychological Therapies)

 

p.         It was reported that dementia diagnosis was a challenge in both Herefordshire and Worcestershire, and work had been commissioned with NHS Digital to understand how both counties compared to comparator areas; this was expected back in May / June 2020.  Mitigating factors included rising age profiles and issues specific to rural areas.

 

q.         The IAPT access rate had improved but was below the national target (22%) but there were other metrics which indicated that the service was performing well; the recovery rate was one the highest in the country.  A backlog had been cleared and it was anticipated that the target would be met towards the end of 2019/20.

 

One Herefordshire draft outcomes framework

 

r.          It was reported that the draft outcomes framework, Appendix 2 to the report, defined a range of ambitions and system level outcomes.  Reflecting the differences in constituent areas, work was being undertaken on the best measures for the different populations; it was expected that the final version would go through governance processes in April / May 2020.  The outcomes framework would provide an anchor point and an overview of the beneficial impacts.

 

The chairperson asked for clarification on Delayed Transfers of Care (DToC), as the figures provided in the report showed performance below the target (<=3.5%) but it was understood that there had been substantial improvement over the past year.  The director of performance advised that the figures for Herefordshire, unlike other areas, pooled acute hospital and community hospital numbers; for December and January the figure for the acute hospital was c. 2.3-2.4%, whereas the figure for community hospitals had risen to c. 18%.  The assistant director all ages commissioning advised that Herefordshire Council presented the figures as actual numbers rather than percentages, and a massive improvement had been achieved; with a target of 416 days of accumulated delay, this was 470 days in January 2019 but had reduced to 353 days in December 2019.  He added that this strong performance was mainly due to the work of the discharge teams, and collaborative approaches to minimise admissions to hospital and supporting people to return home as soon as possible.  The chairperson suggested that there was a need for joined up understanding and consistent presentation.

 

The chairperson asked how the cohort of Herefordshire residents accessing healthcare through NHS Wales were reflected in the performance data, especially in terms of the potential impacts on health outcomes.  The director of performance explained the escalation process to manage DToC and the assistant director all ages commissioning outlined some of the challenges for domiciliary care in the Welsh system.  The chairperson asked whether there was a way to capture data generally for this cohort and compare it to that for residents in the rest of the county.  The director of performance said that the governing bodies did recognise and consider the key differences between patients in the English and the Welsh systems.

 

Attendees were invited to ask questions and make comments, the key points included:

 

1.         In response to questions from a committee member, the director of performance advised that: a written response would be provided on mental health needs and provision for 2 to 4 year olds; assurance would be sought from Worcestershire Health and Care Trust about how the voice of the people of Herefordshire would be represented following the transfer of mental health and learning disability services from Gloucestershire Health and Care NHS Foundation Trust (formerly 2gether NHS Foundation Trust); and, in terms of cancer call-backs, it was recognised that consultant capacity was limited and it was reported that innovations used elsewhere were being explored, such as advanced nurse practitioner led clinics. 

 

The committee member expressed concern about the appropriateness of certain procedures being undertaken by less qualified or experienced health professionals.  The director of performance acknowledged the specific example but the general issue was the need to free up consultants to focus on activities that were most pertinent to their skill sets; a commitment was given to provide a further update on this.

 

2.         A committee member: expressed concern about the high number of metrics not meeting the required targets; suggested that a lean systems thinking approach should be taken to the whole A&E service; questioned whether the temporary closure of the Minor Injury Units in Leominster and Ross-on-Wye impacted upon the number of ambulance conveyances; and commented that assurances provided before the County Hospital was built that bed capacity would be sufficient had been too optimistic.

 

In response, the director of performance noted the challenges in terms of population pressures and current funding settlements.  He emphasised the work being undertaken to explore alternative services to meet the needs of the population; demand for urgent services appeared higher than expected, even taking into account the demographic shift.  It was reported that initial analysis showed that current ambulance conveyances were appropriate, so there was a need to examine as a system what could happen earlier to avoid or delay situations occurring.  It was anticipated that, with the development of Primary Care Networks and the rapid response service, more people could be supported to be safe and well in their communities.  It was reported that Herefordshire had received capital funding to support additional beds and this would have a positive impact.

 

In response to a further question, the director of performance advised that GP led triage systems worked well in certain areas with limited GP access but trials at Wye Valley NHS Trust showed that the number of patients presenting with primary care sensitive conditions were low.  Reference was made to the out of hours service provided by Taurus Healthcare and to the NHS 111 service which could book appointments for patients at GP practices.  Reference was also made to the correlation between proximity to a hospital and attendance at a hospital.

 

The assistant director all ages commissioning emphasised the importance of demand management and shifting resources into the community to reduce the number of people requiring A&E support, with references made to homecare and hospital at home services.

 

3.         The vice-chairperson considered the performance dashboard for the Worcestershire CCGs to be better than the Herefordshire dashboard; the latter using red, amber, green (RAG) ratings but with less statistical narrative.   It was questioned how the information would be presented for the Herefordshire and Worcestershire CCG from 1 April 2020, especially where there were differences in the data being collected and presented currently.

 

The director of performance advised that an integrated report was being designed, around the principles of special cause variation, and confirmed that the performance for each constituent area would be presented.

 

4.         A committee member expressed concern about the lack of consultation over the closure of ambulance stations in the county and it was questioned whether this reflected a reorganisation of the ambulance system.

 

The director of performance advised the committee that: ambulance services were commissioned on a regional basis to deliver against performance trajectories as a total organisation; in view of travel times to rural areas compared to urban areas, community first responder and defibrillator schemes could support equitable outcomes; the contract with WMAS included clear indicators for rural counties around clinical outcomes for patients; the Herefordshire Integrated Primary and Community Services Alliance Board and One Herefordshire were responsible for local response models; and, whilst he was not aware of the decision-making process around the closure of the Ross-on-Wye ambulance station, it was understood that assurances had been provided that there would not be any change in terms of crew availability.

 

In response to a further question about consultation, the director of performance reported that the regional commissioner was based in Sandwell and an impact analysis had been undertaken.

 

5.         Referring to the One Herefordshire draft outcomes framework, a committee member questioned why various metrics were blank currently.

 

The director of performance said that the framework was still in development, with consideration being given to measures and metrics that related realistically to specific NHS Long Term Plan aims or system level outcomes.

 

6.         Referring to RTT waiting times and the comment made about supporting people to consider their treatment options, a committee member questioned whether this could lead to a perception that people might be talked out of treatment.

 

The director of performance said that it was important to recognise that different procedures would have different outcomes for different people.  Therefore, conversations would be patient specific to ensure that they could arrive at an informed choice about procedures and alternative interventions.  In response to a further question, the director of performance acknowledged the need for the system to ensure that such conversations were built into its processes.

 

The chairperson commented on the value of challenge around improving performance and, in particular, welcomed the significant improvement in the breast symptomatic two week wait referrals position; adding that this demonstrated what could be achieved where there was focus and resource to address a particular issue.

 

Resolved:  In collaboration with Herefordshire Council, where appropriate, it be recommended to the clinical commissioning group:

 

(a)       That a consistent set of system figures are used going forward (e.g. Delayed Transfers of Care), including comparative data for Herefordshire and Worcestershire.

 

(b)       That it ensure that the new integrated dashboard moves away from the current RAG rating system and moves to the wider statistical narrative provided in the Worcestershire performance dashboard, with Herefordshire based performance commentaries provided.

 

(c)       The outcomes of the cohort of residents being treated under the Welsh system be included in the dashboard figures.