TRUST BOARD Tuesday 27th February 2018 CLINICAL HARM REVIEW Richard Sunley – Deputy Chief Executive Louise Glover – Project Director

CONTENTS Introduction Background How have we got to the current position? Current position Progress Dashboard GP support Trajectories Trajectories per speciality COBRA COBRA Reporting Duty of candour Risks Next steps and Recommendations 07/11/2018 Project Director - Louise Glover

INTRODUCTION The purpose of the clinical harm review is: To identify any harm which may have arisen as a result in a delay in waiting for appointments and/or treatment. To ensure any harm is recorded and appropriate action taken in regard to any patient affected To implement change from lessons learned To minimise any risk of recurrence To mitigate any risks to patients that could occur. The main focus of the work is at the Trust, with involvement and support from the three local CCGs 07/11/2018 Project Director - Louise Glover

BACKGROUND Excessive waiting for a follow-up outpatient appointment or other elective intervention at North Lincolnshire and Goole NHS FT have been a recurring issue for the Trust for several years. To address this the current review was initiated in April 2017. The priority cohorts for review are:    1. Cancer patients waiting 104 days + 2. Pathways on an incomplete RTT pathway, who have waited more than 40 weeks for treatment. 3. Pathways which are more than 6 months past their review date for follow-up (with/without ED intervention) Project Director - Louise Glover 07/11/2018

HOW HAVE WE GOT TO THE CURRENT POSITION? The journey from initial 14518 patient pathways identified to 7359 patient pathways uploaded into COBRA Starting Point (08/08) - 14518 Removal of Duplicates -12005 Cohort Errors/Adaptions - 10486 Further Duplicate Removal - 9503 RTT Discharged after Treatment - 9070 Total added to Cobra - 7359 Total Numbers of Pathways Closed - 357 Number submitted for Clinical Review -6239 Total Left to Validate - 2 07/11/2018 Project Director - Louise Glover

CURRENT POSITION As at 19th February 2018 Completed GP Reviews 461 Awaiting DQ Validation Awaiting GP Review Awaiting Clinical Health Records Review by Consultant Awaiting Clinical Review (OPA) 2 409 3891 21 Completed GP Reviews 461 Completed Consultant Reviews at Clinical Health Record Stage 21 No harm identified at Consultant Reviews at Clinical Health Record Stage – Pathway to continue 11 07/11/2018 Project Director - Louise Glover

Full cohort uploaded for review onto COBRA – 7359 patient pathways PROGRESS Full cohort uploaded for review onto COBRA – 7359 patient pathways Current progress (as at 19th February 2018 Number of patient pathways Following DQ validation by Source (1118 + 2) awaiting validation)(= 1120) 7359 1120(a) Number submitted for clinical review 6239 Awaiting review by GPs 409(b) Submitted for review by Consultants 3891(c) Removed post Clinical review due to quality issues 1822(d) Awaiting clinical health record review by consultants 2043 Moving through stages of the review process 117(e) TOTAL (a+b+c+d+e) 07/11/2018 Project Director - Louise Glover

DASHBOARD To date no incidences of potential harm have been identified Specialty/Pathway Overall Cohort Size 1 - Validation Stage 2 - GP Review 3 - Clinical Health Records Review 4 - Clinical Review Cobra Incidents Raised Incidents of harm raised via routine governance processes Awaiting Validation DQ Reviews Completed Awaiting GP Review GP Reviews Complete Awaiting Clinical Health Records Review Clinical Health Records Review Completed Awaiting Clinical Review Clinical Reviews Completed Removed due to DQ issue Send for Further Review No Harm - Pathway Discharge No Harm - Pathway to Continue Send for face to face review Identified Low Harm Identified Moderate Harm Identified Severe Harm  Cardiology 852 217 426 46 378 2    C Rectal surgery 1684 134 1194 324 855 1 14  Ent 687 31 490 484 5  Gastro 148 11 82 6 75  General surgery 218 30 95 94  Ophth 1051 33 643 4  Resp medicine 252 138 127  T & O 193 149  Urology 264 171 135 A snapshot of the specialities with the highest number of reviews To date no incidences of potential harm have been identified 07/11/2018 Project Director - Louise Glover

GP SUPPORT A local GP piloted reviewing a list of patients at the practice who were in the priority cohorts to ascertain if this would be helpful in risk stratifying patients in order to make best use of the clinical resources available at the trust. The pilot also helped determine the time required to do the work and assess if this is a good use of GP time. The pilot demonstrated that GP notes review can identify some patients with an urgent need and some who may be suitable for discharge without further follow up. All the CCGs were asked to commission this from their GPs. This appears to have been a practical and deliverable method of rapidly triaging patients waiting to identify those with a potentially urgent need for care and to therefore minimise avoidable harm. In addition, identifying patients for discharge will release capacity and is resource saving. East Riding of Yorkshire CCG have confirmed that they were unable to support this process. GPs Reviews for colorectal, ENT, urology, Ophthalmology, Gastroenterology, Cardiology Respiratory commenced on Monday January 8th with excellent engagement from GPs within NELCCG and NLCCG 07/11/2018 Project Director - Louise Glover

TRAJECTORIES Based upon proposed methodology of 15 minutes per set of case notes, 4 to be reviews completed per hour using 1 SPA per week by each Consultant, the reviews for the current cohort would be completed by end April except for Colorectal which due to high numbers would complete by September 30th 2018 Total number of SPAs per speciality divided by number of Consultants gives the total number of weeks for completion of the reviews. The use of SPAs can be aligned with local governance activities as described in “A Guide to Consultant Job Planning (BMA – 2011)” Assumptions: The specialities reviewed by GPs may reduce numbers for consultant review by 10% based upon the pilot phase. The number of consultants per speciality is accurate 07/11/2018 Project Director - Louise Glover

Trajectories per Speciality 5/2/18 12/2/18 19/2/18 26/2/18 5/3/18 12/3/18 19/3/18 26/3/18 2/4/18 9/4/18 16/4/18 23/4/18 30/4/18 7/5/18 14/5/18 21/5/18 28/5/18 4/6/18 11/6/18 18/6/18 25/6/18 2/7/18 9/7/18 16/7/18 23/7/18 30/7/18 6/8/18 13/8/18 20/8/18 27/8/18 3/9/18 10/9/18 17/9/18 24/9/18 Surgery and Critical Care Anaesthetics   Breast surgery Colorectal Ent General surgery Ophthalmology Oral surgery Orthodontics Plastic surgery T&O Upper GI Urology Medicine Cardiology Diabetic medicine Endocrinology Gastroenterology General medicine Medical oncology Neurology Respiratory Rheumatology Other Specialities Paediatrics Pain management Orthoptics Obstetrics 07/11/2018 Project Director - Louise Glover

All patients identified within cohorts are uploaded onto the system COBRA COBRA is the electronic recording system designed in – house by members of the Information Team All patients identified within cohorts are uploaded onto the system The progress of each individual patient record can be tracked at each stage Clinicians have described it as an intuitive system. Patient details are pre –populated so the reviewer needs to only add their outcome Training has been offered and rolled out across the trust in group or individual sessions for managers and clinicians NHSI have invited the Team to present COBRA at their National Conference in April 24th 07/11/2018 Project Director - Louise Glover

HARM Cancer Prospective HARM Cancer Retrospective COBRA REPORTING A snapshot of the level of detail recording all cohorts in COBRA. The current cohorts of patient records being reviewed by Trust Consultants are HARM Cancer Prospective HARM Cancer Retrospective HARM Retrospective 07/11/2018 Project Director - Louise Glover

DUTY OF CANDOUR The Duty of Candour is a legal duty on hospital, community and mental health trusts to inform and apologise to patients if there have been mistakes in their care that have led to significant harm Communications to the public about the Clinical Harm Review has to date been minimal. This current approach has been agreed with Dr. David Black, NHSE Regional Medical Director Progress is being made within the Clinical Harm Review, however, the degree of risk and extent of harm to patients that may have arisen due to excessive waiting is not yet clear. Therefore we do not wish to cause patients unnecessary worry at this point in time, and monitor the situation continually. Position statement finalised and with Head of Communications as a standby statement ready to be used depending on specific inquiries, should the Trust receive any. Should moderate or severe harm be identified the Serious Incident process will automatically be initiated 07/11/2018 Project Director - Louise Glover

RISKS Lack of clinical engagement enabling the Clinical Harm Review to be completed at pace A major risk is that the number of patients needing face to face clinical review and the degree of urgency for this to take place is not compatible with the clinical resources available at the Trust. There are several specialties where there is a serious shortfall of capacity to meet the needs of patients currently in the care of the Trust and prevent the Trust being in this position in the future. This will require the Trust and 3 CCGs to work together to identify and implement solutions. 07/11/2018 Project Director - Louise Glover

NEXT STEPS and RECOMMENDATION The Trust needs to continue to minimise unnecessary patient follow up and agree with commissioners how this is managed and communicated. Ensure that electronic referral is in place and used from October 2018 Clear communications on the reasons for follow-up / discharge; patient initiated follow-up and clarifying reasonable expectations of GPs in monitoring and managing patients according to advice from Trust clinicians, through the use of advice and guidance arrangements. Working on commissioning priorities – Clear referral thresholds and follow up criteria in many specialties, poorly commissioned pathways (for example the MSK pathway), some ‘one consultant’ services which need re-commissioning and examples (such as the commissioning of optometrist to provide care to some patient groups who otherwise need to use ophthalmology services) where progress would both improve access to care, quality of care and save money. Working with Commissioners to implement RightCare methodology www.england.nhs.uk/rightcare Getting It Right First Time (GIRFT) www.gettingitrightfirsttime.co.uk, Procedures of Low Clinical Value (PLCV) www.nice.org.uk Recommendation Trust Board are asked: To Note progress to date 07/11/2018 Project Director - Louise Glover