1 Board Exception Report - Performance February 2010 (December 2009 data presented) Produced by...

1

Board Exception Report - Performance

February 2010(December 2009 data presented)

Produced by Business Intelligence

2

Index•Health Care Associated Infections (HCAI)

•Emergency Care

•Access

•Cancer

•Primary Care

•Cardiac

•Sexual Health

•Health Improvement

•Stroke & Transient Ischaemic Attacks (TIA)

3health and wellbeing, for life

Headline: NHS West Sussex [Nursing Homes and General Practice] had 17 cases of Clostridium difficile (C.Diff) in December ’09 which brings the total YTD to 161. Whilst this is below the community cumulative Department of Health target, it exceeds the Strategic Health Authority (SHA) stretch target by 18 cases.Current Actions: Several pieces of work have commenced to continue with efforts to reduce incidents of C.Diff, including:-

•sign up of a third of GP practices to the HCAI Local Enhanced Scheme (LES)•an information crib sheet to all the GPs re-issuing the antibiotic guidance•an HCAI newsletter.

Future Actions: The Quality Directorate are in the process of arranging 3 sessions for the prescribing leads for each practice across the patch. They will not be infection control sessions but will be learning sets with a microbiologist, a pharmacist and one of the Quality team advising lessons learnt from the Root Cause Analyses. The bid to the SHA for an antibiotic pharmacist did not receive approval but we are exploring whether there are alternative routes of funding.Other: On a positive note, MRSA cases are at 17 against a target of 19 and C.Diff for Acutes is also within DH tolerances. Overall NHS West Sussex is green against all the DH HCAI targets.

Lead: Julia Dutchman-Bailey, Director of Quality

Cleanliness and HCAI

Ap

r-0

9

Ma

y-0

9

Ju

n-0

9

Ju

l-0

9

Au

g-0

9

Se

p-0

9

Oct-

09

No

v-0

9

De

c-0

9

Ja

n-1

0

Fe

b-1

0

Ma

r-1

0

Community cumulative actual 15 33 57 70 96 115 133 144 161

Community Cumulative stretch target 12 25 39 54 71 89 106 125 143 161 183 206

Community Cumulative DH target 23 41 58 77 96 117 140 170 199 232 262 292

0

10

20

30

40

50

60

70

80

90

100

April May June July August September October November December January February March0

50

100

150

200

250

300

350

Community 2008/09 Community 2009/10

YTD DH Community trajectory YTD Actual Community 2008/09

YTD Actual Community 2009/10

West Sussex PCT Cleanliness and HCAI - Commissioner Clostridium difficile infections (Community)


Headline: Overall the NHS West Sussex position is red for the A&E 4 hour wait for December mainly due to adverse weather conditions affecting all Sussex Trusts. The position split by Trust is as follows:

•BSUH = 75 breaches•SASH = 260 breaches•WSHT = 203 breaches

Current Actions: Contract managers are aware of the reasons for the breaches and are working with the Acute Trusts to plan more effectively for winter pressures. Surrey PCT have issued a performance notice against SASH for an unacceptable level of performance for A&E 4 hour waits.Future Actions: Performance will be monitored closely on a monthly basis and any deviation from plan will be picked up by the contract managers and remedial action plans put in placeOther: The position against the target has remained steady throughout the year. The current cumulative position at December 2010 is 98.39% for

the Commissioner target so the indication is that this will be rectified by year end.Lead: Tina Wilmer, Programme Director Unscheduled care

Emergency Care - A&E 4 hour wait

2 3 4 5 6 7 8 9 10 11 12 13

Ap

r-0

9

Ma

y-0

9

Ju

n-0

9

Ju

l-0

9

Au

g-0

9

Se

p-0

9

Oct-

09

No

v-0

9

De

c-0

9

Ja

n-1

0

Fe

b-1

0

Ma

r-1

0

A&E Attendance <= 4 hours - Commissioner 18,957 22,663 19,128 23,837 18,551 18,509 23,133 19,090 18,309A&E Attendances > 4 hours - Commissioner 251 329 395 307 133 330 521 370 545% A&E attendances <= 4 hours - PCT Commissioner 98.7% 98.5% 97.9% 98.7% 99.3% 98.2% 97.7% 98.1% 97.0%% A&E attendances <= 4 hours - PCT Provider Services 99.3% 99.4% 99.7% 99.7% 99.6% 99.5% 99.5% 99.8% 100.0%

0

5,000

10,000

15,000

20,000

25,000

30,000

Ap

r-0

8

Ma

y-0

8

Ju

n-0

8

Ju

l-0

8

Au

g-0

8

Se

p-0

8

Oct-

08

No

v-0

8

De

c-0

8

Ja

n-0

9

Fe

b-0

9

Ma

r-0

9

Ap

r-0

9

Ma

y-0

9

Ju

n-0

9

Ju

l-0

9

Au

g-0

9

Se

p-0

9

Oct-

09

No

v-0

9

De

c-0

9

Ja

n-1

0

Fe

b-1

0

Ma

r-1

0

No

. A

tte

nd

an

ce

s >

/< 4

hrs

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

110%

120%

% A

tte

nd

an

ce

s <

4h

r

A&E Attendance <= 4 hours - Commissioner A&E Attendances > 4 hours - Commissioner

% A&E attendances <= 4 hours - PCT Commisioner

98% target

West Sussex PCT Emergency care - A&E attendances


Headline: Performance for Cat A <8 minutes has dropped below target for the first time since July 2009, due to adverse weather conditions, combined with exceptionally high activity in emergency care, particularly during the first weekend of snow. Whilst Cat A <8 minutes was not achieved during the month, it remained above 75% for the year to date. The Cat A <19 minute target was maintained above 95% during the month, which was a significant achievement bearing in mind the weather conditions.Current Actions: No remedial action at this stage. Continued monitoring of performance by SECSCG.Future Actions: Possible application of contractual framework to be determined by SEC SCG.Other: Continued monitoring of performance to ensure compliance

Lead: Dominic Ellett, Assistant Director Acute Contracting

Emergency Care - Ambulance Response Times

% Cat A 8 minutes Apr

-09

May

-09

Jun-

09

Jul-0

9

Aug

-09

Sep

-09

Oct

-09

Nov

-09

Dec

-09

Jan-

10

Feb

-10

Mar

-10

NHS West Sussex (Monthly) 78.1% 75.3% 74.8% 74.2% 78.2% 80.1% 76.2% 75.3% 70.4%

NHS West Sussex (Cumulative) 78.1% 76.0% 75.4% 74.8% 75.3% 76.1% 76.1% 76.0% 75.7%

SECAmb (Monthly) 79.6% 77.0% 76.2% 74.5% 77.6% 78.3% 76.1% 78.1% 69.7%SECAmb (Cumulative) 79.6% 78.3% 77.6% 76.8% 77.0% 77.2% 77.0% 77.2% 76.3%

60%65%70%75%80%85%90%95%

100%

Ap

r-0

8

Ma

y-0

8

Jun

-08

Jul-

08

Au

g-0

8

Se

p-0

8

Oct

-08

No

v-0

8

De

c-0

8

Jan

-09

Fe

b-0

9

Ma

r-0

9

Ap

r-0

9

Ma

y-0

9

Jun

-09

Jul-

09

Au

g-0

9

Se

p-0

9

Oct

-09

No

v-0

9

De

c-0

9

Jan

-10

Fe

b-1

0

Ma

r-1

0

Monthly Actual performance West Sussex Monthly Actual Performance SECAMB

Ambulance Response times to Cat A - % within 8 minutes

75% target

West Sussex PCT


Headline: SECAmb continue to perform at levels below the contracted requirement for West Sussex and for South East Coast as a whole. Poor weather conditions in December have contributed to further deterioration. Overall activity is 2.5% above baseline for YTD.Current Actions: Contractual framework and penalty applied for non-performance.Future Actions: No further action at this stage. Subject to review by SECSCG.Other: The performance notice issued to SECAmb in relation to consistent underachievement against this target was removed in December as a penalty was imposed as per contracting performance criteria.

Lead: Dominic Ellett, Assistant Director Acute Contracting

Emergency Care - Ambulance Response Times

% Cat B 19 minutes Ap

r-0

9

Ma

y-0

9

Ju

n-0

9

Ju

l-0

9

Au

g-0

9

Se

p-0

9

Oct-

09

No

v-0

9

De

c-0

9

Ja

n-1

0

Fe

b-1

0

Ma

r-1

0

NHS West Sussex (Monthly) 93.8% 90.9% 91.9% 90.7% 92.8% 92.7% 93.3% 91.4% 87.2%

NHS West Sussex (Cumulative) 92.9% 91.5% 91.5% 91.1% 91.3% 91.6% 91.8% 91.8% 91.2%

SECAmb (Monthly) 95.5% 93.9% 93.2% 92.7% 94.0% 94.1% 93.2% 94.0% 88.4%SECAmb (Cumulative) 95.5% 94.7% 94.2% 93.8% 93.8% 93.9% 93.8% 93.8% 93.1%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Apr-

08

May-0

8

Jun-0

8

Jul-08

Aug-0

8

Sep-0

8

Oct-

08

Nov-0

8

Dec-0

8

Jan-0

9

Feb-0

9

Mar-

09

Apr-

09

May-0

9

Jun-0

9

Jul-09

Aug-0

9

Sep-0

9

Oct-

09

Nov-0

9

Dec-0

9

Jan-1

0

Feb-1

0

Mar-

10

Monthly Actual Performance West Sussex Monthly Actual Performance SECAMB

Ambulance Response times to Cat B - % within 19 minutes

95% target

West Sussex PCT


Headline: There were 206 breaches of the 6 week target in December. BSUH were responsible for 116 of these; Flexi-Sigmoidoscopy (38) and Gastroscopy (66) due to job planning and capacity issues. There has been a complete review of the entire booking process at the hospital and additional clinics have been added. Further breaches are expected at the end of January 2010 due to the size of the issue and the Board have been briefed on this. Other contributors include West Sussex Health with 55 audiology assessment breaches and Western Sussex Hospitals with 34 breaches (mostly non-obstetric ultrasound and Gastroscopy).

Current Actions: Action plans have been received and contract managers are managing the situation. We are in contact with Brighton & Hove City PCT and the provider to implement the trust remedial action plan as a matter of urgency.

Future Actions: West Sussex Health have assured the Trust that appointments are always offered when cancellations occur and communication will be improved to ensure management are able to address issues as soon as they arise and flag them up through the risk management process.

Other: Continued work with Providers has kept the breaches to a minimum throughout the year and the current issue at BSUH should be rectified by next month. Lead: Debra Wheeler, Head of Market & Capacity Management

Access – Diagnostic Test Waiting Times

Ap

r-0

9

Ma

y-0

9

Ju

n-0

9

Ju

l-0

9

Au

g-0

9

Se

p-0

9

Oct-

09

No

v-0

9

De

c-0

9

Ja

n-1

0

Fe

b-1

0

Ma

r-1

0

Patients waiting > 6 weeks for 15 key diagnostic tests (monthly data) 12 14 5 15 22 18 7 57 206Patients Waiting 6+ Weeks for all other diagnostic tests on Quarterly Census 0 0 0 0 0 0 0 0 0

Total 12 14 5 15 22 18 7 57 206Target 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

West Sussex PCTDiagnostic Tests (within 6 weeks)

0

50

100

150

200

250A

pr-0

8

Ma

y-0

8

Ju

n-0

8

Ju

l-0

8

Au

g-0

8

Se

p-0

8

Oct-

08

No

v-0

8

De

c-0

8

Ja

n-0

9

Fe

b-0

9

Ma

r-0

9

Ap

r-0

9

Ma

y-0

9

Ju

n-0

9

Ju

l-0

9

Au

g-0

9

Se

p-0

9

Oct-

09

No

v-0

9

De

c-0

9

No

pa

tie

nt

>6

we

ek

s


Headline: SASH were responsible for the two 13 week waiters (one in Ophthalmology, one in Paediatric medicine). Both patients have now been seen. The 26 week breach was at Western Sussex Hospitals in Ophthalmology due to a TCI (to come in) card being filed within a patient’s notes. Current Actions: Root Cause Analyses (RCA) and breach reports have been received and action plans are in place at both providers

Future Actions: Execution of the action plans will be monitored to ensure learning from RCAs is implemented.

Other: Indicative tolerances are set at: Achieving <=0.03%, Underachieving <=0.15% and Failing >0.15%. Overall NHS West Sussex are YTD at:•13 week at December is 0.08% underachieving in relation to numbers of patients seen overall.•26 week at December is 0.017% and therefore achieving the target in relation to numbers of patients seen overall.

Lead: Debra Wheeler, Head of Market & Capacity Management

Access – Stage of Treatment Waiting Times

Outpatient waiting >13 weeks for first appointment

0

20

40

60

80

100

120

Apr

-08

May

-08

Jun-

08

Jul-0

8

Aug

-08

Sep

-08

Oct

-08

Nov

-08

Dec

-08

Jan-

09

Feb-

09

Mar

-09

Apr

-09

May

-09

Jun-

09

Jul-0

9

Aug

-09

Sep

-09

Oct

-09

Nov

-09

Dec

-09

No

of p

atie

nt >

13 w

eeks

Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10

Patients waiting >13 weeks 1 1 0 0 3 16 45 59 84 96 109 104 43 23 2 0 0 1 1 10 2

Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10Patients waiting >26 weeks 4 5 4 3 9 8 12 9 6 3 6 5 0 1 1 1 1 1 2 1 2

Maximum wait of 13 weeks for an outpatient appointment.

Maximum wait of 26 weeks for an inpatient appointment.

Inpatient waiting >26 weeks

0

2

4

6

8

10

12

14

Apr

-08

May

-08

Jun-

08

Jul-0

8

Aug

-08

Sep

-08

Oct

-08

Nov

-08

Dec

-08

Jan-

09

Feb-

09

Mar

-09

Apr

-09

May

-09

Jun-

09

Jul-0

9

Aug

-09

Sep

-09

Oct

-09

Nov

-09

Dec

-09

Jan-

10

Feb-

10

Mar

-10

No

of p

atie

nts

>26

wee

ks


Headline: GP referrals continue to run above planned levels but decreased in month as per the seasonal trendCurrent Actions: Contract managers are working with each Acute Trust and Practice Based Commissioning (PBC) Group in order that trends are identified and understood. Peer review within PBC localities using benchmarked data is being used to inform the debate. Other referrals have decreased against previous years although still running ahead of plan. Data from Western Sussex Hospitals Trust new PAS system is being validated as activity is being double counted but not double chargedFuture Actions: The new head of planned care Debra Wheeler (Head of Market and Capacity Management) will work with PBC and Programme Manager to continually review the position.Other: 2010/11 contracts are being set at outturn.

Lead: Debra Wheeler, Head of Market & Capacity Management

Access – GP Referrals

GP Referrals 2007/08 Actuals 2008/09 Actuals 2009/10 Actuals 2009/10 PlanApr 9,454 12,485 12,606 10,052May 11,087 12,072 12,189 9,138Jun 10,872 12,658 13,557 9,595Jul 11,757 12,911 13,896 10,509Aug 11,155 11,156 11,367 9,138Sep 10,310 12,692 13,106 10,052Oct 11,141 12,986 13,323 10,509Nov 10,649 11,376 12,573 9,138Dec 8,276 10,635 11,049 9,595Jan 11,548 11,982 9,595Feb 10,914 11,630 9,138Mar 9,893 13,188 10,052YTD Total 94,701 108,971 113,666 116,510Average p/m 7,892 9,081 12,630

West Sussex PCT GP Referrals - General & Acute Specialties

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000A

pr

Ma

y

Ju

n

Ju

l

Au

g

Se

p

Oct

No

v

De

c

Ja

n

Fe

b

Ma

r

GP

Re

ferr

als

2007/08 Actuals 2008/09 Actuals 2009/10 Actuals 2009/10 Plan


Headline: Department of Health Access target for end March 2011 – 58% (465,000) of West Sussex Residents to access NHS Dental Services Current Actions: A tender exercise to consolidate and further increase general dental access throughout the county for 2010/11 is in process. Following issue of Invitation To Tender (ITT) documentation, bids have been received from twenty-five Dental Providers, covering various locations across West Sussex and are currently being evaluated. There is a timeline in place but there is currently a delay and the implications in relation to its exact effect on evaluation are not yet clarified. Future Actions: Dental contracts have been extended within 2009/10 to manage capacity. Other: Specialist Dental services; orthodontics, sedation, minor oral surgery, community dental and emergency dental being reviewed alongside

general dental access.

Lead: David Grant, Contract Manager Dental Services

Primary Care - Dental

Patients seen in previous 24 months

Jun-08Sep-08Dec-08

Mar-09Jun-09Sep-09Dec-09Mar-10

415,525415,525429,198440236

439,702439,702439,702439,702415,525

403,369403,603409,181

426,218

418,588422,734

92%93%95%

99%

101%102%

92%% achieved

No. Patients (Actual)

No. Patients (Target)

300,000

350,000

400,000

450,000

500,000

550,000

600,000

Jun-08 Sep-08 Dec-08 Mar-09 Jun-09 Sep-09 Dec-09 Mar-10

0%

20%

40%

60%

80%

100%

No. of Patients (Actual) No. of Patients (Target) % actual achieved

West Sussex PCT Primary Care - Dental services


Cancer - 2 week wait

Apr-

09

May-0

9

Jun-0

9

Jul-09

Aug-0

9

Sep-0

9

Oct-

09

No

v-0

9

De

c-0

9

Patients waiting < 2 weeks from urgent GP referral to first OP appointment 1,144 1,041 1,212 1,278 1,109 1,235 1,223 1,186 1,126Patients waiting > 2 weeks from urgent GP referral to first OP appointment 98 89 113 99 113 94 89 57 85% of patients waiting < 2 weeks 92.1% 92.1% 91.5% 92.8% 90.8% 92.9% 93.2% 95.4% 92.98%

Headline: The number of breaches has increased again this month and analysis of the reasons given by trusts shows that the vast majority are due to patient choice i.e. a patient has declined an offer of an appointment which was within a 2 week window as specified within policy. This was made worse by patients not wanting to attend before the Christmas period and due to the adverse weather conditions. Current Actions: Working with Cancer networks and acute trusts to ensure issues are not related to capacity. All GP practices provided with patient leaflets and information.Future Actions: Continue to monitor and work with GPs to ensure patients informed of the reasons why a 2 week appointment is being offered.

Other: National thresholds may change over time.

Lead: Alison Hempstead, Cancer Programme Director

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

Apr-

09

May-0

9

Jun-0

9

Jul-09

Aug-0

9

Sep-0

9

Oct-

09

Nov-0

9

Dec-0

9

Jan-1

0

Feb-1

0

Mar-

10 N

o.

Pati

en

ts w

ait

ing

>/<

2 w

eeks

0%

20%

40%

60%

80%

100%

120%

% w

ait

< 2

weeks

West Sussex PCT

% patients w aiting < 2 w eeks

Cancer - Two week GP referral to first OP appointment

target 93 %


Headline: Last quarter thrombolysis figures dropped dramatically. It would appear that this can largely be attributed to a decrease in data collection around the St Richard's site. The % dropped from 75% in Q2 to 20% in Q3. Overall our performance is 66% YTD.

Current Actions: The trust have plans in place to ensure data quality and data collection is improved through additional resource and will be actioned imminently.

Future Actions: NHS West Sussex will continue to review the data on a monthly basis. Overall the target has been achieved and this appears to be a data issue which should now be resolved.

Other: NHS West Sussex has now recruited to a Cardiac Programme Manager and their role will be to review and performance monitor Providers to ensure compliance

Lead: Tina Wilmer, Programme Director Unscheduled care

Cardiac - Thrombolysis

PeriodTotal Call to Needle

Call to Needle < = 60 mins Target (AHC) Actual Quarterly Actual YTD

Call to Needle > 60 mins

Jun 07 57 37 68% 65% 65% 20Sep 07 48 32 68% 67% 66% 16Dec 07 41 27 68% 66% 66% 14Mar 08 62 49 68% 79% 70% 13Jun 08 39 33 68% 85% 85% 6Sep 08 32 29 68% 91% 87% 3Dec 08 24 22 68% 92% 88% 2Mar 09 35 29 68% 83% 87% 6Jun 09 26 23 68% 88% 88% 3Sep 09 18 11 68% 61% 77% 7Dec 09 29 14 68% 48% 66% 15Mar 10 68%

0

50

100

150

200Ju

n-0

7

Se

p-0

7

De

c-0

7

Ma

r-0

8

Ju

n-0

8

Se

p-0

8

De

c-0

8

Ma

r-0

9

Ju

n-0

9

Se

p-0

9

De

c-0

9

Ma

r-1

0

Wa

itin

g >

/< 6

0 m

ins

ca

ll t

o n

ee

dle

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% w

ait

ing

< 6

0 m

ins

Actual YTD

West Sussex PCT Cardiac - Thrombolysis, 60 minute call to needle time

target 68 %


Headline: There has been a significant increase in numbers screened for Chlamydia in December 2009, almost reaching the YTD highest position which was in September.Current Actions: NHS West Sussex have issued a performance notice against West Sussex Hospitals for poor performance against chlamydia screening within the contract.Future Actions: The Local Enhanced Scheme has been through Executive Team at NHS West Sussex and approved, however funding is not yet released. Next steps are to implement plans to mail out to all 21-24 year olds about screening as there is good evidence that this will increase up-take of screening in other counties.Other: Significant improvements in numbers screened demonstrate that the work carried out by the Programme have been successful.

Lead: Paul Woodcock, Programme Manager Sexual Health

Sexual Health - Chlamydia

Apr

-09

May

-09

Jun-

09

Jul-0

9

Aug

-09

Sep

-09

Oct

-09

Nov

-09

Dec

-09

No. 15 - 24 year old persons screened or tested for Chlamydia 572 433 1,701 501 363 2,108 458 793 1,889target

1,467 1,467 1,467 1,750 1,750 1,750 2,033 2,033 2,033

Annualised Screening or testing 6,864 6,030 10,824 9,621 8,568 11,356 10,519 10,394 11,757

The population aged 15 - 24 years 87,400 87,400 87,400 87,400 87,400 87,400 87,400 87,400 87,400

Apr-0

9

May-0

9

Jun-0

9

Jul-0

9

Aug-0

9

Sep-0

9

Oct-0

9

Nov-0

9

Dec-0

9

Annualised Actual % population aged 15 - 24 screened or tested for chlamydia 7.9% 6.9% 12.4% 11.0% 9.8% 13.0% 12.0% 11.9% 13.5%

Target % population aged 15 - 24 screened or tested for chlamydia 25.0% 25.0% 25.0% 25.0% 25.0% 25.0% 25.0% 25.0% 25.0%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Apr-08

May-08

Jun-08

Jul-08

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09

Apr-09

May-09

Jun-09

Jul-09

Aug-09

Sep-09

Oct-09

Nov-09

Dec-09

Jan-10

Feb-10

Mar-10

%

P

atien

ts screen

ed

Actual % population aged 15 - 24 screened or tested for chlamydia Target % population aged 15 - 24 screened or tested for chlamydia

West Sussex PCT

Sexual Health - Screening for Chlamydia - % patients screened

25% target


Headline: The data for the recent quarter is preliminary. We have seen the expected decline in performance in Q3 owing to the additional burden of the swine flu vaccination programme in GP practices. Current Actions: DTP/IPV aged 1 - There has been a small decline in Q3 however this is very close to target and to achieve this would require 16 more children to complete their primary course. Hib/MenC at age 2 - There has been a decline in Q3, however NHS West Sussex may not achieve the target set by the end of 2009/10 as further 165 children would need to be immunised. Future Actions: Work is ongoing with the HIS to address inaccuracies in the records held by Child Health Bureau. The Director of Public Health is being approached to approve the funding (from within the PH directorate) to continue the data reconciliation exercise. This should result in improved statistics describing immunisation coverage for the cohorts in question.Others: Work by the Immunisation Co-ordinator is on-going with the Practices to encourage take-up

Lead: Nick Kendall, Consultant in Public Health

Health Improvement - Immunisations

Aged 1 immunized for DTaP/IPV/Hib Mar-09 YTD Target

Jun-08 94.4% 95.0%Sep-08 94.8% 95.0%Dec-08 94.8% 95.0%Mar-09 94.9% 95.0%Jun-09 94.8% 95.0%Sep-09 94.8% 95.0%Dec-09 94.5% 95.0%Mar-10 0.0% 0.0%

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%


Aged 1 immunized for DTaP/IPV/Hib target

West Sussex PCT

Health Improvement - Immunisation rates 2008-10Aged 1 immunized for Diphtheria/Tentus/Pertussis (DTaP) / Polio (IPV) / Haemophilos influenzae Type B (Hib)

95% target

Aged 2 immunised for Hib/MenC Mar-09 YTD Target


80%

82%

84%

86%

88%

90%

92%

94%

96%

98%


Aged 2 immunised for Hib/MenC target

West Sussex PCT

Health Improvement - Immunisation rates 2008-10Aged 2 immunised for Haemophilos influenzae Type B (Hib) / Meningococcal group C meningitis (MenC)

96% target


Headline: MMR vaccine dose 1 at age 2 - The MMR coverage has shown a very small decline this month. It is unlikely that the PCT will achieve the 92% coverage target for the year 2009/10. Another 91 children would have to be immunised by the end of March. MMR dose 2 aged 5 - This year’s target is green, although the achievement of the 95% target for 2010/11 is doubtful (representing a step change from 84% to 95% in one year).Current Actions: Children under 5 are now being called into the surgeries for their swine flu vaccines until the end of February 2010. There will be the opportunity to persuade parents who have not decided, about the safety and efficacy of other childhood vaccines (parents may prefer to come back to have their child immunised at a separate appointment). The Immunisation co-ordinator will draw this to the attention of the practice managers.Future Actions: The latest Immform data show 85% coverage of dose 1 of the school based immunisations. The current programme is set to recover and the PCT should meet this year’s target. There is a detailed project plan held by NHS West Sussex.Other: For the month of January 2010, the school based immunisations have been set back owing to the closure of schools during the bad weather.

Lead: Nick Kendall, Consultant in Public Health

Health Improvement - Immunisations

Aged 2 immunised for MMR Mar-09 YTD TargetJun-08 88.7% 91.0%Sep-08 88.8% 91.0%Dec-08 88.8% 91.0%Mar-09 89.0% 91.0%Jun-09 90.8% 92.0%Sep-09 90.4% 92.0%Dec-09 89.8% 92.0%Mar-10 0.0% 0.0%

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%


Aged 2 immunised for MMR target

West Sussex PCT

Health Improvement - Immunisation rates 2008-10Aged 2 immunised for Measules / Mumps / Rubella (MMR)

92% target

Aged 5 immunised for DTaP/IPV Mar-09 YTD Target


80%

82%

84%

86%

88%

90%

92%

94%

96%

98%


Aged 5 immunised for DTaP/IPV target

Health Improvement - Immunisation rates 2008-10Aged 5 immunised for Diphtheria/Tetanus/Pertussis (DTaP) / Polio (IPV)

West Sussex PCT

96% target


Headline: The targets for prevalence and coverage have not been met

Current Actions: The backlog of data entry has now been completed and NHS West Sussex has recently submitted revised figures. An action plan is being implemented by West Sussex Health to address data cleansing issues. This will improve the achievement, however we are unlikely to meet the 2009/10 target.

Future Actions: The new manager for the Child Health Bureau is now in place and has been tasked with prioritising this indicator to improve the current systems

Other: For clarification, prevalence is the number of babies actually recorded as being breastfed against the number of babies due their 6/8 week check and coverage is the number asked. Lead: Catherine Scott, Programme Director, Health and Wellbeing

Health Improvement – Breastfeeding

The number of children recorded as being partially breastfed (receiving both breast milk and infant formula) at 6-8 weeks during quarter 4.

No.r of infants recorded as being totally breastfed at 6-8 weeks during quarter 4.

No. of infants due for a 6–8 week checks during quarter 4

Prevalence - No. of infants at 6-8 weeks who are breastfed against the no. that are due for checks during q4

The number of children being recorded as not at all breastfed at 6–8 weeks during quarter 4.

Jun-08 251 717 2,184 44.32% 813Sep-08 233 720 2211 43.10% 813Dec-08 235 700 2205 42.40% 726Mar-09 199 617 2019 40.42% 660Jun-09 221 646 2,092 41.44% 717Sep-09 251 714 2,284 42.25% 770Dec-09 232 582 2,212 36.80% 650Mar-10

Coverage: No.children with a breastfeeding status as a percentage of all infants due

for a 6–8 week check Target

Jun-08 81.55% 85.00%Sep-08 79.87% 85.00%Dec-08 75.33% 85.00%Mar-09 73.11% 85.00%Jun-09 75.72% 90.00%Sep-09 75.96% 90.00%Dec-09 66.18% 90.00%Mar-10 90.00%

Breastfeeding Initiation rates at 6-8 weeks

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Actual No. of infants at 6-8 weeks who are breastfed Target No. of infants at 6-8 weeks who are breastfed

West Sussex PCT

Coverage of breast feeding status

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Actual No.children with a breastfeeding status recorded Target No.children with a breastfeeding status recorded

West Sussex PCT

90% Target

48% Target


Headlines: Brighton & Sussex University Hospitals NHS Trust Diabetic Retinopathy Screening (DRS) service has indicated it expects to experience some capacity issues in the last quarter of 09/10, however the Programme envisages meeting the Annual Health Check (AHC) target for 2009/10. Western Sussex NHS Trust DRS service continues to perform ahead of the planned trajectory submitted in the in-year recovery plan and is confident it will meet the AHC target by the end of 2009/10.Current Actions: Western Sussex Hospitals Trust has seen dramatic increases in the uptake of screening and the trajectory is indicating that they will achieve green status by year end.Future Actions: Work is on-going with Western Sussex Hospitals Trust to ensure the continued improvements in uptake. Other: The joint working carried out by NHS and West Sussex Hospitals Trust has been a very positive step in improving the target.

Lead: Viv Mussell, Programme Manager Screening

Health Improvement - Diabetic Retinopathy

Offered screening for diabetic retinopathy

Total no. with diabetes (including those exclusions

from screening) % achievement % Target

Jun-08 25912 27,866 93% 100%Sep-08 23924 28,888 83% 100%Dec-08 22854 27,391 83% 100%Mar-09 22613 30,317 75% 100%Jun-09 26337 31,276 84% 100%Sep-09 26788 30,346 88% 100%Dec-09 27616 30,051 92% 100%

0%

20%

40%

60%

80%

100%

Jun-08 Sep-08 Dec-08 Mar-09 Jun-09 Sep-09 Dec-09

% achievement % Target

Health Improvement - Diabetic Retinopathy, % patients offerred screening for Diabetic Retinopathy

West Sussex PCT West Sussex PCT

100% target


Headline: There remains an issue with the recruitment of stroke nurses within NHS West Sussex and this has impacted on the targets.Current Actions: Patients at Surrey and Sussex NHS Healthcare Trust (SASH) are currently diverted to Guildford or Brighton out of hours. The Sussex-wide position is to implement tele-medicine which should improve the current situation. Surrey PCT have issued a performance notice against SASH in relation to stroke performance consistently falling below target. Future Actions: Western Sussex Hospitals have recently installed a new information system and are currently reviewing quarter 3 numbers as part of a data quality exercise and looking to re-submit at year end based on improved data capture.Other: The current position should improve by the next quarter due to the actions taken by the Programme stated above.

Lead: Tina Wilmer, Programme Director Unscheduled care

Stroke & TIA

Mar

-09

Jun-

09

Sep

-09

Dec

-09

Mar

-10

Jun-

10

Sep

-10

Dec

-10

Mar

-11

313 272 288 301123 132 157 148

39.3% 48.5% 54.5% 49.2% 0.0% 0.0% 0.0% 0.0% 0.0%Target % 65.0% 66.0% 68.0% 69.0% 70.0% 72.0% 75.0% 78.0% 80.0%

No. with stroke who are admitted to hospitalNo. who spend > 90% of time on a stroke unit% who spend > 90% of their time on a stroke unit

0

100

200

300

400

500

600

700

800

900

1000

Mar

-09

Jun-

09

Sep

-09

Dec

-09

Mar

-10

Jun-

10

Sep

-10

Dec

-10

Mar

-11 N

o. s

trok

e ad

mis

sion

s >/

< 90

% ti

me

on s

trok

e un

it

-200%

-150%

-100%

-50%

0%

50%

100%

% t

ime

on s

trok

e un

it

No. admitted to hospital with stroke No. who spend > 90% of time on a stroke unit

% who spend > 90% of their time on a stroke unit Target %

West Sussex PCT

Stroke - time on a stroke unit

70% 09/10 Target80% 10/11 target

Mar

-09

Jun-

09

Sep-

09

Dec-

09

Mar

-10

Jun-

10

Sep-

10

Dec-

10

Mar

-11

31 39 7510 17 26

32% 44% 34.7% 0 0 0 0 029% 35% 41% 45% 48% 52% 57% 60%Target %

No. with TIA who are high riskNo. with TIA who are scanned and treated < 24 hrs% with TIA who are scanned and treated < 24 hrs

0102030405060708090

100110120130140150160170180190200

Mar

-09

Jun-

09

Sep-

09

Dec-

09

Mar

-10

Jun-

10

Sep-

10

Dec-

10

Mar

-11

No.

at h

igh

risk

of T

IA tr

eate

d </

> 24

hrs

-200%

-150%

-100%

-50%

0%

50%

100%

% tr

eate

d <

24 h

rs

No. with TIA who are high risk No. with TIA who are scanned and treated < 24 hours

% with TIA who are scanned and treated<24 hours Target %

West Sussex PCT

Stroke - Patients at risk of TIA scanned and treated < 24 hours

45% 09/10 Target60% 10/11 target

Date post:	19-Dec-2015
Category:	Documents
View:	213 times
Download:	0 times

1 Board Exception Report - Performance February 2010 (December 2009 data presented) Produced by...

Documents