1. Merton CCG Balanced Scorecard
Month 9 – 2014/15

2. Performance Summary
Are patient’s rights under the NHS Constitution being promoted?
A&E (Target 95%) – The CCG did not meet the A&E standard in M9 performing at 88.4%. This is due to St. Georges University Hospitals NHS Foundation Trust not meeting the standard (84.84%) and Epsom & St Helier University Hospital NHS Trust (92.2%).
RTT 18 weeks – ( Target Admitted patients 90% & Non- Admitted 95%) – The CCG did not meet the admitted and non-admitted standard in M9. This is expected due to the national monies allocated for backlog clearance
Cancer – Merton CCG has met 8 of the 9 Cancer Waiting times standards for M9. The CCG did not meet the 62 day Urgent referral Standard with performance of 68.8% against a threshold of 85%.
Diagnostics ( Target 99%) – The CCG did not meet the standard in M9 performing at 98.3%.
Balanced Scorecard Month /15
20 September 2018

3. Performance Summary Are health outcomes improving for local people?
IAPT (Quarterly Target 46.89%) – The CCG is below trajectory for access to IAPT in M9 performing at 32.9%
Dementia ( Target 67%) – The diagnoses rate for Merton CCG in M9 (53.5%) has increased compared to M8 (52.3%)
Winterbourne – 4 admitted patients, 1 discharge is planned for later this month.
Balanced Scorecard Month /15
20 September 2018

4. Balanced Scorecard Month 9 2014/15
Domain 1 - Are patients receiving clinically commissioned, high quality services?
Source: Monthly & Quarterly CSU Scorecard. Monthly source Open Exeter and Quarterly source: NHSE. Quarterly data will include retrospective adjustments to previous months data. YTD source: Open Exeter.
Balanced Scorecard Month /15
20 September 2018

5. Domain 1 - Are patients receiving clinically commissioned, high quality services?
Quality Issue
Provider
Description of Quality Issue
Issues
Rectifying actions
RTT 18 weeks (admitted patients) and (non admitted patients )
Epsom & St. Helier, St George's Hospital
88.7% (admitted patients
94.8% (non-admitted patients)
The main driver of underperformance is at St. Georges. All Trusts have been partaking in a backlog reduction exercise to reduce the number of patients waiting over 18 weeks and this led to an expected drop in performances.
Commissioners agreed that St. George's would fail performance until December but achieve in Q4, however, bed pressures over winter have meant there have been significant elective cancellations and the SRG is reviewing the trajectory for achieving performance.
Diagnostic tests waiting time
Kinston Hospital and Epsom and St. Helier.
98.3% against a target of 99%
Kingston hospital was marginally below the target with performance of 98%. And reported problems in Endoscopy due to unexpected long-term sickness and the departure of the admin team leader in the Endoscopy service in November. This resulted in administrative element of the service being less functional than usual, which has generated a backlog of patients waiting to be booked for diagnostic testing. Epsom & St Helier had problems with timely appointments for MRI. The trust outsourced some MRI work, however, the contracted provider did not adhere to guidelines and booked patients past breach date, resulting in underperformance.
Kingston Hospital has provided a recovery plan and indicated that the service was still affected in January. However, normal service has resumed in February and the trust anticipates meeting the target from February. ESH identified and dealt with the issue quickly. Regular meeting were scheduled with the providers to ensure no further slippage in performance. The trust has indicated that this issue will not affect performance past December.
A and E waiting times
ESH = 92.2% against a target of 95% SGH= 84.8% against a target of 95%
Epsom and St Helier reported consistently high attendances and emergency admissions , with patient activity remaining high . There were also high numbers of ambulance arrivals and patients requiring treatment in the resuscitation area of A&E. The trust continued to experience issues with bed capacity. St George’s continued to reported high attendances and admissions above predicted. The trust experienced challenging bed positions most days, with demand outstripping capacity. This was not only a result of the increased admissions, but the trust also had low discharge profiles on many days; slowing patient flow through the hospital. This ultimately impacted on the front end, resulting in large numbers of breaches. These issue culminated in what the trust reported as one of the most pressured weekends seen in recent years.
In order to mitigate the issues, St George’s put a number of actions in place; SRG wide escalation calls are taking place three times per week, with emergency escalation calls in periods of significant pressure to assess opportunities to reduce demand. All elective lists were reviewed, with only those patients identified as urgent being planned throughout the week. The trust ran in business continuity with mobilisation of all managerial and clinical staff on a number of occasions, as well as cancellation of some non- -urgent electives. In addition to this, the trust has opened further escalation with a number of off -site beds now available, with a further 6 to open by mid January.
Balanced Scorecard Month /15
20 September 2018

6. Domain 1 - continue Quality Issue Provider
Description of Quality Issue
Issues
Rectifying actions
Cancer first treatment 62 days, Includes 31 day rare standards)
SGH, RMH, ESTH, KHFT
68.8% against a threshold of 85%
The CCG did not to meet the 62 Day Urgent Referral standard with performance of 68.8% against a threshold of 85%. This was due to 10 breaches from 33 patient pathways. There were 4 internal breaches at SGH, 2 of these were attributed to delays in work up and the other two due to administrative delays. There were 2 shared breaches between SGH and RMH and both of these breaches were attributed to late Inter Trust Referrals. (Patients referred on Day 62 & 92 respectively). 1 shared between ESTH and the Royal Marsden attributed to Late Inter Trust referral; 1 internal breach at ESTH attributed to administrative delays. The final 2 were shared between KHFT and RMH and were attributed to administrative issues and Late Inter Referral.
SGH states that it will provide education on cancer waiting times for admin booking staff. Ensure OPA bookings are action in the weekly PTL meeting; expedite delays / capacity issue as soon as possible to minimize potential delays to the pathway. There is an expectation that complex patients will have an extended pathway, however a tolerance is built into the standard for such patients. St George's ensures that all patients with multiple comorbidities are worked up thoroughly in a timely manner. The trust needs to establish a closer relationship with referring trusts to identify any potential issues to enable the patient to be seen within target date. Joint PTL meetings will eliminate these issues. of the breaches are over hundred days. In view of the assurance work being undertaken on 62 day cancer waits, the expectation from commissioners now is that all RCAs on 100 day breaches are to be discussed at the Trusts relevant CQRG meetings
The Transforming Cancer Services Team (TCST) will continue to monitor SGH’s Performance over the next Quarter.
Ambulance category A (Red 1) 8 minute response Ambulance category A (Red 2) 8 minute response Ambulance category A 19 min transportation time
London Ambulance Service (LAS)
LAS Cat A performance remains a serious concern with YTD below target (75% within 8 minutes)
St Georges: St Georges had 221 thirty minute handover breaches in December. Epsom & St Helier:- LAS handover breaches increased significantly in December going from 34 to 125 thirty minute breaches. 60 minute breaches also increased from 2 to 39.
SGH has an action plan to improve flow in A&E that should improve handover performance. One of the key actions is a change in the triage process, with reduction in the number of steps and an allocated nurse to coordinate triage and ambulance handover. Despite this and as a result of the performance in December, SE CSU is seeking a meeting with SGH to discuss the significant deterioration in performance.
ESH: Despite the trust having an action plan to improve performance, with key actions including; real time review of the handover process; identification and implementation of best practice; clarifying improving administrative element of the handover process, SE CSU will discuss the drop in performance at the next SRG meeting in order to get assurance from the trust.
Mixed accommodation Breaches
ESTH
2 against a target of 0
Merton CCG has two MSA breaches in December both at Epsom & St Helier. The trust encountered issues when Endoscopy had to be used to bed patients whilst the trust tried to continue with urgent endoscopy procedures. All possible measures were taken to segregate patients but because there are no bays or cubicles in this area the breaches occurred.
 All patients were advised of the issue and no concerns or complaints were raised.
RTT 52 weeks Incomplete pathways
SGH, Royal Free.
Merton CCG had two 52 ww reported in December, one at SGH and one at Royal free. At SGH was a gyane patient. The patient is on a complex diagnostic pathway and has had a number of diagnostic appointments throughout the year.
Patient pathway is currently being reviewed. Pending this review, the patient will be discharged or an additional appointment will be scheduled for February An attempt has been made to ascertain information relating to the 52ww at Royal free; this information will be supplied as soon as it is received.

7. Domain 3 - Are CCG plans delivering better outcomes for patients
Domain 3 - Are CCG plans delivering better outcomes for patients? (April – December)
*Data Source: SWL and St Georges trust
Balanced Scorecard Month /15
20 September 2018

8. Domain 3 - Are CCG plans delivering better outcomes for patients?
Quality Issue
Provider
Description of Quality Issue
What's being done about it?
Increasing the IAPT recovery rate
SWL & St. Georges
The service is showing a downward trend this quarter in improving this outcome.
The CCG provided further investment in Q4 to increase capacity in the service. The Trust is reporting that this increase in treatment will provide an increase in recovery rates at the end of Q4 when patients have completed treatment.
Increasing the proportion of people that enter IAPT treatment against the level of need in the general population
1) Weekly performance reports are being provided by the Trust to the commissioner for assurance of weekly referrarls received. Based on this the Trust are advising that they will meet the target of 15% by Q4. 2) Weekly performance reports are being submitted to NHS England. 3) GP Practice visits have commenced to promote IAPT 4) Follow up phone calls have commenced with GP Practices that have received a visit. 5) Letter was sent to all GP Practices encouraging referrals to IAPT. 6) The Trust placed an advert for IAPT in the Wimbledon Guardian. 7) The CCG has shared the same advert with its stakeholder network.
Unplanned hospitalisation for chronic ambulatory care sensitive conditions
Merton CCG
Whilst 4 out of 9 reporting months show these admissions are to be on target, overall the level admissions in this financial year have been greater than predicted so far.
Work is continuing to implement the Better Care Fund and QIPP initiatives which impacts on a subset of these admissions. To date the Community Prevention of Admission Team (CPAT) has been extended into care homes, Integrated Locality Teams and MDT working have been introduced and in-reach nursing from Community Services at St George's was extended to also support prevention of admission in the ED and short stay wards. Additional intermediate care beds were introduced from 1st February 2015 and further beds are planned for April It is expected that the introduction of the Holistic Investigation and Rapid Investigation (HARI) service at the Nelson from April 2015 will have an impact on the reduction of these admissions. Further analysis of this data indicates that there may be value in commissioning further community support for Asthma and this is currently being worked up.
Balanced Scorecard Month /15
20 September 2018

9. Number of people accessing expert patient programmes
Domain 3 - Continue
Number of people accessing expert patient programmes
Merton CCG
The premises used for the course was unavailable and therefore was cancelled which had an impact on the number of participants.
A new venue (St Saviours Church, Raynes Park) was found. Evaluation in progress
A low number of people on our waiting list with COPD and asthma
Asking GP surgeries to arrange letters to be sent to a random selection of patients on their register.
Large drop out of course participants
In progress - Meeting with translator, and tutors to get feedback of session. Arranging a meeting with translator and participants
Delayed Transfers of Care
Kingston and St Georges Hospital
DTOC has slightly increased compared to November figures and the reasons for this are a) completion of assessment and b) public funding.
DTOC figures are reported monthly to the Merton Integration Board and the One Merton Group. As Better Care Fund schemes go live and are further embedded into operational procedures, DTOCs should continue to fall and monitoring will continue as part of the overall BCF performance management process. The majority of DTOCs are the result of awaiting assessment for continuing healthcare needs with community health and social care delays at proportionately low levels.
Increasing the proportion of people diagnosed with Dementia
Progress for this indicator is substantially below target, but improving month on month.
Improvements are thought to stem from a number of initiatives, although progress does not appear to be sufficient to meet the target of 67% by the end of the financial year. Next steps include: working with the Primary Care Support Team to ensure that all practices reap the benefits from three key list cleansing approaches; encouraging practices to deliver the recently launched care home scheme which involves conducting reviews of care home residents and giving a diagnosis where applicable; continuing to conduct focussed work with practices which have the greatest dementia ‘gaps’ (in terms of numbers of patients) and practices which are outliers as a result of having the lowest diagnosis rates.
Winterbourne
Danshell Group, CNWL Foundation Trust, and Cambian Healthcare
All 4 patients are still under the scope of Merton as reported last month. 1. Currently placed in a specialist learning disability locked rehab service. 2. Currently placed in a specialist inpatient treatment service within the NHS. 3. Currently placed in a specialist Autistic Spectrum Disorder (ASD) locked rehab service. 4. Currently placed in a specialist ASD locked rehab service.
All patients are currently detained under the Mental Health Act, for the purpose of treatment. An attempt to discharge 2 to intensively staffed community service in February unfortunately failed, with the patient needing to be returned to inpatients setting after a period of 5 days with support of police. Discharge will however be attempted later this month. In respect to 3 and 4 a plan for on going treatment in a hospital registered service has been identified as still being required. It is anticipated that 3 will be discharged to a community setting, as yet to be identified but closer to home, by September It has been confirmed however that this will not be feasible for 4 who continues to pose a significant risk to children and vulnerable females. The CTR for 1 is scheduled to take place on March 3rd.
Balanced Scorecard Month /15
20 September 2018