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HEAT: Access Target: By the end of December 2007 no patient will wait longer than 18 weeks from GP referral to an outpatient appointment. Performance Measure: Outpatient Waiting Times over 18 weeks A.04T 3.07.K Commentary on Progress The position at the end of June shows a small improvement on the previous month, both in a reduced number of patients waiting over 18 weeks and a smaller variance from trajectory. However there remains a significant variance from the planned performance at the end of June. Outpatients waiting >18 weeks Actual Trajectory Variance April 07 750 655 95 May 07 782 570 212 June 07 676 487 189 The 3 specialities with the most significant variances above their planned June 2007 trajectory are detailed below. These have been discussed with the National Access Support Team (NAST), and it has been agreed that revised trajectories can be submitted on the basis of robust recovery action plans. Orthopaedics Actual Trajectory Variance April 07 337 160 177 May 07 336 160 176 June 07 335 160 175 This speciality has the most significant variance from plan. This is a combination of increased referrals and a recent short-term vacancy created by a consultant retirement. The department plan to undertake an additional 16 new outpatient clinics during August to December 2007, and the replacement consultant will see an increased number of new patients. Revised LDP trajectories will be agreed with NAST and then used for future monitoring. Urology Actual Trajectory Variance April 07 50 23 27 May 07 45 18 27 June 07 58 13 45 This speciality has been under significant pressure, particularly in the delivery of cancer waiting times. Funding was allocated for a fixed term Staff grade post to provide support, but this has seen 4 staff changes in the last 18 months. A “see and treat” package has therefore been agreed with the Murrayfield Hospital in Edinburgh for 100 new outpatients. Again, revised LDP trajectories will be agreed with NAST and then used for future monitoring. Commentary on Progress Continued Orthodontics Actual Trajectory Variance April 07 78 60 18 May 07 71 50 21 June 07 78 40 38 For the past couple of months, a significant focus of the resources within this speciality have been on reducing the treatments times for patients who have already undergone consultation. This has made a significant reduction to this backlog of patients and resources will now be redirected to new outpatient appointments. We are confident that performance will now be in line with planned trajectories. HEAT: Access Target: Women who have breast cancer and need urgent treatment will get it within one month where appropriate. Performance Measure: % of patients diagnosed with breast cancer treated within 31 days. A.08T 3.11.K Commentary on Progress Breast Cancer Breast Cancer had been identified as an area which was experiencing capacity difficulties with increasing waiting times for both one stop clinics and treatment. The Highland Breast team have experienced a significant increase in the number of referrals to the service. In addition, there have been difficulties in the recruitment of a breast physician, now resolved, which had a detrimental impact on clinic capacity. A local diagnostic peer review visit was undertaken in February 2007, with the final report of the Breast Services review issued in April 2007. A Highland–wide Action Plan in response to the recommendations has been submitted to the Scottish Executive Health Department (SEHD), and a Highland-wide meeting to agree a Highland Breast Service model and the implementation detail of the high-level action plan took place 10 July 2007. Before the completion of the review, following a number of extra clinics, and temporary increase in the number of surgical sessions, the position for both the maximum wait for women who have breast cancer and require urgent treatment, and the maximum wait from GP urgent referral for breast cancer to treatment have improved significantly. Further work is required to agree a pan-Highland Breast Cancer Pathway, to ensure the timeliness of outpatient assessment and access to triple diagnosis, although it has been acknowledged that the limitations of the Highland geography may result in this not always being carried out at a single stop clinic. There is absolute agreement from all clinicians that the triple assessment diagnosis and access to treatment must not be delayed and any new pathway will be in line with the SIGN guidance. There remain delays in theatre capacity with re-modelling currently underway, which will identify the need for further sessional capacity. Progress against the recommendations will be monitored within Highland through the weekly Cancer Performance Support Team meetings. All Cancers The waiting time for urgent GP referrals to treatment had been generally disappointing across Highland. This had been due to a number of systemic problems across the patient journey which resulted in longer than 62 days for treatment in many cases. There has been detailed analysis of these common problems with resolution to a number of areas which were common to many cancers. Improvements have been significant in access to urgent outpatient appointments, diagnostic imaging and access to radiotherapy treatment. These improvements have been complimented with detailed work in each cancer site with the development of times milestone pathways for each service. The development of a comprehensive cancer tracking tool, the development of the cancer tracker role and the weekly review of all patients on a targeted list has resulted in a shorter wait time improvement for more patients who have, or think they may have, cancer. In addition to Breast cancer the early priority has been to target effort the other three largest cancer groups - Lung, Colorectal and Urology. Progress in Tumour specific sites Table 1 demonstrates the ISD validated performance for the 2005 Target for each tumour site for each of the reported quarters in 2006. Q2 2006 % 59.1% Q3 2006 % 63% Q4 2006 Q1 2007 (excl A & B) 63% 69% unvalidated 64.3% 47% 79.2% 87.5% unvalidated 63.6 30% 44.4% 41.7% unvalidated 100 76.2 100% 94% 66.7% 75% 100% unvalidated 72.2% unvalidated Colorectal 93.3 64% 61.1% 89.5% unvalidated Head & Neck 33.3 71% 66.7% 33.3% unvalidated Skin 100 50% 42.9% 100% unvalidated Upper GI – OG 66.7 79% 55.6% 57.1% unvalidated Upper GI – HPB 50 100% 88.9% 60% unvalidated Gynae - Ovarian 100 87.5% 100% 100% unvalidated Haematology Lymphoma 71.4 73% 83.3% Breast 2001 (31 Day Target) Breast 62-day 2005 target Urology Prostate Urology Bladder Lung 100% unvalidated Lung Cancer The Lead Clinician has led improvement initiatives as part of the multidisciplinary team which ensure that all patients are seen immediately and tracked through the system in detail. The development of a 62-day lung pathway taking account of Highland and out-of area tertiary care is agreed and in place. The implementation of a dedicated Lung Cancer Clinic has radically streamlined referral into the pathway with a timely diagnosis facilitated by direct access to CT appointments through collaboration with diagnostic imaging. This enables efficient and necessary sequencing of the CT scan ahead of the bronchoscopy tests. There is a weekly joint MDT meeting videoconferencing with the respiratory Surgeons in Grampian to support patient management. Delays in access to PET scanning prior to surgery have had a detrimental impact on performance in the last quarter, delaying the pathway for patients to definitive treatment. It is anticipated that the previous good achievement of lung cancer waiting times will be restored when the new PET capacity is commissioned in the West of Scotland. Colorectal Cancer Focused work led by the Lead Consultant has helped implement a range of improvements which have directly improved delays for patients. A comprehensive 62-day Colorectal pathway is in place with a multi-site videoconferencing weekly multi-disciplinary team meeting involving clinicians from Raigmore, Belford, Caithness Hospitals and colleagues from the Western Isles. The development of a protocol-based electronic referral, endorsed by GP Committee, will have a positive impact on the appropriateness and timeliness of referrals. There is now strict vetting criteria for identifying patients for fast tracking supported by all Consultants. Urgent cases are shared on common endoscopy lists with physicians, with the local development of the role of Nurse Endoscopist. In conjunction with the diagnostic imaging team there are now protected CT slots for rapid diagnosis. Development of the role of tracker and team leader ensure the weekly monitoring of patient delays via the cancer tracking tool with remedial action taken to expedite appointments and treatment. In order to increase consultant capacity there is more follow up now being undertaken by the clinical nurse specialists. These sustainable changes have lead to a marked improvement in access times for colorectal patients in the last quarter. Urology Cancers Improving performance in prostate cancer waiting times has been most challenging. Detailed review of the patient pathway identified significant delays being highlighted at many stages of the patient journey, which resulted in the majority of patients with prostate cancer breaching 62 days before treatment. Problems identified included delays in referral, access to rapid urgent first appointments and subsequent delays to staging and treatment. Following engagement of the whole multi-disciplinary team a detailed 62-day pathway timeline has been agreed for patients who are referred with a possibility of prostate cancer with processes to support now being implemented. Investment in the Clinical Nurse Specialist team has enabled a dedicated Nurse-led TRUS and Biopsy Clinic to allow opportunity for patients to come straight to test. Improvements in the reporting of histology and access to bone scanning have resulted in a shorter pathway to treatment for patients. A significant increase in the number of patient undergoing radical prostatectomy has had a detrimental impact on the availability of theatre capacity, but theatre modelling is currently underway to ensure that extra sessional capacity is identified. In the meantime the option to access see and treat support from outwith NHS Highland is being explored. Engagement with Primary Care clinicians via the protected learning time has provided the basis for progressing a more streamlined referral system with clear advice on referral criteria. The NOSCAN MCN for Uro-oncology has prioritised work around referral protocols which will be integrated into local pathways. There have not yet been demonstrable improvements in the waiting times for prostate cancer, but the team are confident that the initiatives agreed will have a positive impact in the next quarter. Other Cancer Sites Head and Neck A pilot is underway in conjunction with the Consultants to encourage use of Cancer Tracking Tool information, and timely response to identified delays at key milestones eg time to first appointment, time to diagnosis. Lymphoma A 62-day pathway is agreed and being implemented. Haematology is one of the core services managed by the new SSU Cancer Services Manager, and a range of priorities around clinic facilities, access to inpatient beds, cancer audit coverage will inform, and be informed by, the oncology initiatives discussed earlier. Oesophageal/Gastric A 62-day pathway is in draft, formal sign off pending. Joint initiatives with the Colorectal Team have enabled implementation of a range of improvements which have directly improved delays for patients. These include refinement on the criteria for identifying patients for fast tracking and shared Endoscopy lists with surgeons and a specialist Nurse Endoscopist. Further initiatives include the development of Nurseled sessions for patients with oesophageal stents. Skin Cancer – Melanoma Diagnosis and treatment is often completed at patient’s first appointment either with GP or consultant. Ovarian Cancer Weekly joint-MDT in place with Grampian Gynaecology-oncology team. Key role in place from the Gynaecology CNS to the pre-diagnostic and diagnostic stages of the pathway. Recruitment to current Consultant vacancies within the Specialism across the NOSCAN are being addressed. Other Support Services Diagnostics The work driven by the National Diagnostic Collaborative has shown dramatic improvements in the time patients wait to access tests. Detailed capacity and demand analysis resulting in the appointment to two new Radiology Consultant posts, radical redesign of the pathways and dedicated access to procedures will provide sustainability to these imaging improvements. The Cancer Network and the Diagnostic Project have worked together to shape and embed fast-track referral routes for patients with suspected cancer. Oncology A fundamental review of Oncology Services has integrated the work of a number of ongoing initiatives. A dedicated Cancer Services Manager has been appointed to provide more focused and integrated management of the Oncology Department, Haematology and Breast services. The review of Chemotherapy Services has resulted in agreement of the minimum standards of care and treatment across Highland, and which will guide the safe ongoing delivery of Chemotherapy Services, and the appropriate development of new remote chemotherapy services. A comprehensive review of current Radiotherapy access, in advance of the commissioning of a second linear accelerator, has prompted streamlining of patient pathways for patients requiring consultation, and treatment planning, radical or palliative treatment. A recent Demand and Capacity analysis has resulted in the implementation of a number of key recommendations around patient flow, prioritised professional workloads and the redesign of roles and responsibilities. In addition, extra capacity has been developed locally by the co-operation of radiographic and physics staff to ensure that there is no delay to patient treatment. The review of utilisation of Oncology acute inpatient beds has highlighted the need to tighten criteria for admission, set minimum standards of care and treatment, and whole system solutions involving GPs and the CNS specialists in the community. Laboratories The majority of patients who have cancer are diagnosed by way of Pathology (approximately 90%), therefore, timely access to reports is an essential part of the pathway. The Pathology Consultants have a key role as members of the cancer multi-disciplinary team. Significant efforts have been made to ensure that timely reports are available to aid or confirm diagnosis, with the electronic Results Reporting System operational from July, via SCI Store. The procurement of a replacement electronic system has been delayed and recent focussed effort has accelerated this with implementation planned in quarter 2 of 2008/2009. Equipment to improve tissue-processing have been prioritised in the recent submission to NOSCAN Capital allocation, currently awaiting formal sign-off by the SEHD. Theatres The lack of a day surgery unit in the main acute hospital puts significant pressure on the main theatres which are currently working at full capacity. The development of a dedicated day surgery unit has been agreed, but will not be commissioned until early 2010. The experience and learning from the theatre-modelling approach taken to achieve the 18 week target has now been applied to take account of projected cancer surgery with the development of early rota of theatre capacity to ensure the correct balance of specialty access. Any additional weekly sessions are being released in main theatre suite with a detailed review of current usage. There is a plan for the visiting Vanguard mobile theatre unit to assist with this capacity problem. Information Access to robust and ‘real time’ data collection and analysis has been vital, and NHS Highland has developed an electronic patient management system to facilitate the clinical pathway for patients who have, or might have, cancer. This intranet-based multi-user Cancer Tracking Tool (CTT) captures waiting times information in a realtime basis, and informs action to help proactively manage patients through to timely diagnosis and/or treatment across the whole of Highland. Workforce Planning Close monitoring, review and necessary redesign of current diagnostic and tumour specific pathways, will continue. Directed effort in robust Workforce Planning will begin to future proof cancer services in Highland, and the already evident need to exploit opportunities for role enhancement of non medical staff continues to be reinforced. Patient Involvement Cancer patients, carers and lay representatives influence services through their direct involvement at the Cancer steering group, local meetings, through feedback to clinical services, and in local community forums. Intensive Support NHS Highland has been receiving intensive support from the Scottish Executive’s Cancer Performance Support team (CPST) and undertake a weekly monitoring meeting with the Executive Lead for Cancer, Cancer Network Manager, and SSU General Manager and Cancer Services Manager. Most of the CPST recommendations in the high-level Action Plan have now been achieved. Out of Area Protocols have been agreed with NHS Grampian and with NHS Western Isles. A protocol with NHS Greater Glasgow & Clyde has yet to be progressed. The SEHD have made capital resources available to NHS Highland to assist in the local teams managing each of the nine tumour sites making improvements in eg, time to first appointment and time to diagnosis. Summary All cancer pathways span a range of departments and NHS Highland are ensuring that any improvements take account of the complex interface of the various systems. Detailed review of all patient pathways and changes in the delivery of support services has had an immediate impact. The provision of clinicians and management teams with accurate, real-time information, and their continued engagement in the regular scrutiny of that information, has facilitated immediate remedial action for many patients across all pathways. Whilst improvements have been initially slow, weekly review of evidence now shows an increasing number of GP urgent referral patients who are being treated for cancer within 62 days. It is expected that this improvement will be sustained and improved, with increasing confidence in the delivery of the 31 and 62 day targets across all cancer sites. Target: By the end of 2007 patients will wait no more than 9 weeks for any MRI or CT scans and other key diagnostic tests Performance Measure: Waiting Times For Diagnostic Scopes A.12T 3.26.K Commentary on Progress The draft position for the end of June 2007 is that 48 patients will be waiting over 9 weeks. We had planned that by this stage no patients would be waiting, and we are required to have no patients waiting by the earlier target date of 1 August 2007. The distribution of the 48 patients is detailed below. No of patients SSU waiting > 9 weeks 0 Upper GI 3 Lower GI 2 Colonoscopy 5 Cystoscopy 10 Total Mid CHP 6 North CHP 14 Total 2 0 6 14 3 7 0 24 5 9 11 48 23 Mid Highland CHP scored red for Lower GI because, although there are only 2 patients waiting over 9 weeks, the longest wait is 17 weeks. The table above shows the actual number of patients waiting over 9 weeks by test. North CHP has the most significant pressures which have arisen due to a consultant vacancy. The new appointment takes up post in August and plans are in place to ensure that no patient will be waiting over 9 weeks at the end of July. These plans include retraining of one of the existing consultants, pooled waiting lists and additional capacity. Across Highland there are now only 6 patients left to book in order to meet the end of July deadline, and plans are being put in place to ensure these patients are seen by the end of the month. HEAT: Treatment National Targets: For 2007/2008 To reduce to zero patients delayed over 6 weeks To reduce to zero those delayed in short stay beds Performance Measure: Patients experiencing a delay in discharge where the delay was 6 weeks or more. T.01T 4.01.K Commentary on Progress The NHS Highland target is proving challenging but achievable. Within the Highland Partnership several factors are emerging, these are limited care home availability, the option of choice being exercised (5 patients) and the lack of specialist beds (3 patients) is impacting on progress. Whilst in Argyll and Bute there has been a slight increase in numbers reflecting a demand peak rather than a trend. Examples of issues coming together to cause this are an increase in emergency admissions from the community into care homes reducing availability for those leaving hospital, self-funders reaching thresholds and requiring LA funding and the failure of an appeal which means a return of that case to the list. It is anticipated that this figure will now decrease again. SOUTH EAST CHP HEAT: Efficiency Target: 80% of complaints responded to within 4 weeks Local Performance Measure: Completed Complaints – % of completed complaints resolved within 4 weeks Commentary on Progress Compliance was not achieve in the following operating units: SE CHP - 50% A number of measures are currently being put in place to improve performance and ensure compliance against the target of 80% of complaints being responded to within 20 days. These measures are: All complaints letters are to be sent to investigating officers on the day of receipt and if not possible, certainly within three working days. Ensuring that Complaints Officers follow up all investigations at 15 days to ensure that progress is being made. Holding letters are being send out as soon as it is apparent that the 20 day target is not going to be achieved Weekly meetings with the Complaints Officers and the Head of Clinical Governance and Risk Management to review all complaints at 15 days and to agree course of action.