RTT Exception Report
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- Juniper Reynolds
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1 Appendix 3 RTT Exception Report 1. Purpose To provide a summary of factors impacting on 18 week RTT performance and a revised forecast of red rated performance for Quarter /16 for the admitted pathway. The planned recovery is described and supported by action plans at specialty level approved by Management Board in February and May Background a. Admitted Performance Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr % 90.5% 90.4% 90.3% 90.8% 90.5% 90.1% 67.2% 91.9% 90.6% 84.4% 63.8% 59.8% The Trust has faced significant non-elective pressure since autumn last year but held the admitted performance target at Trust level with the exception of the planned failures in November 2014 as requested by NHS England. The backlog position towards the end of Q4 2014/15 suggested that further failures of the admitted target were required to ensure the number of long waiters would be reduced. Significant focus has therefore been placed on the booking of patients by clinical priority and then longest wait. b. Non-admitted Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr % 96.1% 95.6% 95.6% 95.4% 95.6% 91.6% 92.7% 93.2% 92.1% 92.9% 93.9% 93.9% Total referrals are shown to have increased over the last 6 months by 3.1% compared to the equivalent period in 2014/15, with particular pressures across a wide range of specialties. The actual numbers vary within the specialties and % increases should therefore not be viewed in isolation. A specialty level summary is shown below: Agenda Item: 14 Page 1 of 6
2 The increase in the number of GP referrals, particularly in cancer specialties which already receive high volumes of demand, have had a significant impact on non-admitted performance and subsequently contributed to the failure against the open pathway target. Unify Specialty Name Nov14-Apr15 Nov13-Apr14 YOY Variance General Surgery (exclud % Urology % Trauma & Orthopaedics % ENT % Ophthalmology % Oral Surgery % Acute Medicine % Gastroenterology % Cardiology % Dermatology % Neurology % Geriatric Medicine % Gynaecology % X01 - Other % Total % The successful reduction in Dermatology referrals is a direct consequence of demand management through negotiation with CCGs, where 8 low risk patient conditions have been identified for treatment within the community setting rather than a referral to secondary care. The rise in Oral surgery referrals is a particular concern as predominantly linked to cancer activity. There have been constraints within specialties and sub-specialties e.g. spine, which have exacerbated the impact of the referrals and further reduced the ability of the Trust to meet the required standard. c. Open Pathway Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr % 93.5% 92.6% 92.4% 92.3% 92.6% 92.3% 92.6% 92.1% 90.6% 90.8% 92.2% 93.0% Open pathway performance measures the percentage of patients who have not received a first definitive treatment within the 18 week pathway, either as an outpatient or an inpatient. As the focus on long waiters has reduced the outpatient and inpatient backlogs, open pathway performance has improved and will continue to do so. Agenda Item: 14 Page 2 of 6
3 d. Patient waiting more than 18 weeks in the backlog The Trust level open pathway and backlog position as at 30 th April 2015 is summarised below: As the longest waiters have been treated, the overall backlog has reduced. However, the inability to deliver the level of additional activity required to reduce the backlog while maintaining capacity to off-set those graduating to >18 week position, the total number in the admitted backlog has remained relatively stagnant (698 on 19 th May 2015). However, this has generated a shift of patients from later in the pathway to shorter backlog wait times. Patients with waits over 30 weeks are monitored individually and listed for surgery as soon as fit and available. Agenda Item: 14 Page 3 of 6
4 The Specialty level open pathway and backlog position as at 30 th April 2015 is summarised below: Backlogs Apr- 15 Performance Unify Specialty Name Elective Backlog Open Pathways > 18 Weeks Proportion on Elective WL * Open Pathways > 30 Weeks Admitted Non Admitted Opens General Surgery % % 93.8% 89.7% Urology % % 90.7% 91.8% Trauma & Orthopaedics % % 90.7% 90.6% ENT % % 89.8% 93.1% Ophthalmology % % 97.9% 96.4% Oral Surgery % % 84.6% 90.8% Acute Medicine % 98.8% 96.6% 98.4% Gastroenterology % % 57.1% 86.1% Cardiology % % 97.9% 96.1% Dermatology % 95.2% Respiratory Medicine % 100.0% 95.1% 98.6% Neurology % 95.4% Rheumatology % 97.4% 99.9% Geriatric Medicine % 94.8% Gynaecology % % 95.7% 93.7% X01 - Other % % 96.7% 95.4% Total % % 93.9% 93.0% * Note - Some patients on elective WL are excluded from RTT and not in open pathways Agenda Item: 14 Page 4 of 6
5 3. The way forward A detailed RTT exception paper was presented to February Management Board, Board of Directors and Monitor where following discussion, actions to support the treatment of the longest waiting patients and reduction of backlog during the period February to June 2015 were agreed. An action plan was presented detailing specialty level plans to address short falls in elective capacity and reduction in outpatient waits. Whilst every effort has been made to increase activity levels so that the number of patients in the backlog can be further reduced, ongoing non-elective and cancer pressures have meant that the number of operations required could not be delivered. Plans to increase capacity with the support of sub-contractors have taken longer to implement than expected, but systems are now in place to step up this activity as part of the mitigation plan over the second quarter. However, improvements in admitted and non-admitted performance continue to improve open pathways which is the key target reflecting overall patients treated. Detailed specialty monitoring plans for admitted performance are now in place showing the level of activity required to deliver a range of performance measures including: Steady state Recovery plan Estimated cancellation numbers Target backlog These will be monitored via weekly PTL meetings, with actual activity versus planned tracked daily. The IMAS tool is to be rolled out across all specialties by the end of June 2015 to improve the capacity modelling and robust planning for ongoing performance delivery. The roll out plan is aimed to address the specialties at highest risk as follows: Specialty Wave 1 ENT 1 2 Gastro 1 3 General Surgery 2 4 Oral Surgery 2 5 Trauma & Orthopaedics 2 6 Urology 2 7 Cardiology 3 8 Neuro 3 9 Ophthalmology 3 10 Paediatrics 4 11 Dermatology 4 12 Other specialties 5 Agenda Item: 14 Page 5 of 6
6 4. Recommendation The specialty level action plan focusses on three key themes: Generic actions to be implemented across all specialties e.g. text reminder systems Demand and capacity work to work with CCGs in the reduction of demand where possible, and efficiency gains to maximise capacity, both internally and with partner organisations Process reviews where indicated to ensure rapid response mechanisms are in place to minimise delays within individual pathways. The action plan is overseen by the RUH internal PTL and RTT meetings to ensure issues are escalated and focus maintained. It is recognised that the admitted backlog will take longer to address than originally forecast and a planned failure is proposed for Q2. This will allow the Trust to be in a better position by the end of September with the backlog number anticipated to be in line with the RUH internal triggers (320 in total in admitted backlog). This represents the sustainable position reflecting the patient numbers that are on complex pathways, medically unfit or unavailable for admission. 5. Performance - Risk Assessment Framework Monitor caps RTT failure of all 3 measures at a score of 2. Predicted performance by month is detailed below: Performance Indicator Performing Weighting Q1 Q2 Q3 Q4 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 RTT - admitted - 90% in 18 weeks in all specialties 90% % 90.5% 82.9% 79.0% 59.8% RTT - non- admitted - 95% in 18 weeks in all specialties 95% % 95.5% 92.4% 93.0% 93.9% RTT - open pathways in 18 weeks 92% % 92.4% 92.3% 91.2% 93.0% 6. Conclusion The Board is asked to endorse Management Boards recommendation to further reduce the backlog resulting in a further quarter failure of RTT performance for admitted pathways. This will place the Trust in an improved position entering the winter of 2015/16. Agenda Item: 14 Page 6 of 6
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