WELCOME AND INTRODUCTIONS. Sarah Tedford Chief Operating Officer Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT)

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1 WELCOME AND INTRODUCTIONS Sarah Tedford Chief Operating Officer Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT)

4 ABOUT US

OUR COMMUNITY Two main hospital sites King George Hospital and Queen s Hospital Services from Barking Community Hospital and clinics across outer North East London Population c.750,000 Under 5 c.

5 OUR COMMUNITY Two main hospital sites King George Hospital and Queen s Hospital Services from Barking Community Hospital and clinics across outer North East London Population c.750,000 Under 5 c.60, c.50,000 Projected growth 5 years c.8% 10 years c.15% Homerton University Hospitals NHS FT East London NHS FT City & Hackney CCG Waltham Forest CCG Tower Hamlets CCG Whipps Cross Newham CCG Newham Redbridge CCG North East London NHS FT King George Hospital Barking & Dagenham CCG Queen s Hospital Havering CCG ACO footprint The Royal London St Bartholomew s

6 SAFETY, GOVERNANCE, FINANCES, WORKFORCE Safety Incident Reporting Incidents vs Harm, risks and lessons learned Medicines (storage/prescribing) Nursing staff numbers and standards Speaking Up Governance Revised and strengthened overall governance framework Board development programme Management of SIs, incidents, risks and lessons learned systematised and clinically led by Chief Nurse Restructure of divisions monthly performance meetings

7 SAFETY, GOVERNANCE, FINANCES, WORKFORCE Finances Business planning processes refined/improved Greater control of financial management Two years control deficit delivered and on plan this year Public Sector Sustainability Award 2015 Workforce X numbers of new staff Staff Survey improvements Recruitment drives (domestic/overseas) Improve engagement with existing staff

8 OUR APPROACH THE PRIDE WAY

11 WHERE NEXT? Meeting the Constitutional Standards consistently Bridging the demand and capacity gap Working with primary care to meet patient needs Continuing to meet financial obligations Addressing workforce demand and supply gap System-wide leadership capability and capacity Involving and engaging the public in their health service Embedding safety systems and processes

12 GETTING IT RIGHT FOR PATIENTS THE RTT STANDARD FOR THE NHS Steve Russell Executive Regional Managing Director (London) NHS Improvement

13 HOW IMPORTANT IS THIS? A reminder of the history, and our present

WAITING TIMES ARE A KEY DRIVER OF PUBLIC SATISFACTION, OR DISSATISFACTION 1 50% of people were dissatisfied with the NHS in 1997; This declined and then

was 36% and 39% compared to 17% 3 55% of people who are dissatisfied say that this is due to access to a GP or hospital 4 84% of people who are dissatisfied

14 WAITING TIMES ARE A KEY DRIVER OF PUBLIC SATISFACTION, OR DISSATISFACTION 1 50% of people were dissatisfied with the NHS in 1997; This declined and then levelled off to 23% between 2010 and Between 1995 and 2010 the % of people who agreed that the time to OP appointment and surgery had got much better was 36% and 39% compared to 17% 3 55% of people who are dissatisfied say that this is due to access to a GP or hospital 4 84% of people who are dissatisfied say that this is because of a perceived lack of resources. 45% of people who are dissatisfied think there is a severe funding problem, compared to 26% who are satisfied

15 THE FOCUS FROM 2000 ON REDUCING WAITING TIMES PRE-DATED THE RTT STANDARDS (2008) to 2004 Reduce waiting times for outpatient and inpatient stages of treatment Spending review 2000 and to 2008 Move to referral to treatment waiting times Spending review to 2012 Waiting times broadly stable Prior to the 2008 standard being introduced there were 1.8m patients waiting over 18 weeks, and over 600,000 waiting more than a year

16 % >52 >18 List 9 YEARS ON, RTT PERFORMANCE IS GOING IN THE WRONG DIRECTION m 2.3m 2.3m 2.3m 2.5m 2.7m 3m 3m 3.6m 4m 824k 239k 209k 225k 146k 152k 189k 201k 301k 440k 214k 30k 19k 13k 4k % 10% 9% 10% 6% 6% 6% 7% 8% 11% 90% of patients admitted be treated in 18weeks AND 95% of non-admitted patients treated within 18w In addition 92% of patients still waiting should be waiting under 18 weeks to reverse the incentive not to treat long waits 92% of patients still waiting for treatment (surgery or outpatient) should be waiting under 18weeks 1 2 3

DECLINE STARTED IN 2012, DROPPING BELOW 92% STANDARD IN FY16 1 2 3 1

waiting list for sustainable delivery of the 92% standard is 3.

17 DECLINE STARTED IN 2012, DROPPING BELOW 92% STANDARD IN FY Performance against the standard has declined as the waiting list has risen. This was passed in Q1 of FY16 2 The estimated maximum size of the waiting list for sustainable delivery of the 92% standard is 3.5m 3 The estimated maximum size of the waiting list for sustainable delivery of the 92% standard is 3.5m. For every 500k rise, performance drops by c1.3%

been treated were waiting 51 weeks or longer 2 A year later this reduced to 8% of patients waiting less than 21 weeks 3 Four years on from 2008, in

18 WHAT DOES A PERCENTAGE MEAN TO PATIENTS? Apr 2008 Apr 2012 Apr 2015 Apr 2016 Jul 2016 Dec weeks 16 weeks 16 weeks 18 weeks 19 weeks 20 weeks 1 In April % of patients who had not been treated were waiting 51 weeks or longer 2 A year later this reduced to 8% of patients waiting less than 21 weeks 3 Four years on from 2008, in April % of patients were waiting more than 16 weeks which was maintained for 7 years up to April A year later, the 92 nd percentile had increased by 2 weeks, and then by a further week in 3 months, and a further week to 20 weeks in a further 5 months

To return to the standard we need to: 1. Equalise the run rate of demand and activity 2.

19 DECLINE DRIVEN BY WAITING LIST NOT BEING IN RUN-RATE BALANCE Activity and completed pathways have risen, but at a slower rate than clock starts. The waiting list is growing because clock starts are growing faster than completed pathways. To return to the standard we need to: 1. Equalise the run rate of demand and activity 2. Clear the backlog GP referrals 3 year historic Clock Starts Clock Stops GP referrals FY16 to FY17 Clock Starts Clock Stops The 5YFV, and SR assumes much lower levels of activity growth 4.6% 5.6% 4.3% 2.9% 5.8% 3.6% -1.3% -2.2%

20 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 WITHIN A GROWING LIST, THE BACKLOG (18+ WEEK WAITERS) IS GROWING FASTEST Outpatient WL Index Outpatient Backlog Index In patient WL Index In patient WL backlog Index The outpatient waiting list is 9% higher at Dec-16 compared to October-15 (14 months) and the backlog is 42% higher 2 The inpatient waiting list is 16% higher at Dec-16 compared to October-15 (14 months) and the backlog is 57% higher The 92% standard is currently met for outpatient pathways. However, performance is dropping by 0.2% per month and will be breached in Q4 The backlog will then grow at 5k per month There are 96k too many patients waiting over 18 weeks on the inpatient waiting list to achieve the standard This backlog is growing by c3k per month Performance is dropping by 0.3% per month 77 of the 189 NHS organisations (40%) who report RTT performance do not meet the 92% standard The excess total backlog (admitted and non-admitted) in these 77 organisations is 107k

21 OUR AREAS OF FOCUS AND THE KEY LEVERS

22 1 KEY AREAS FOR ELECTIVE RECOVERY AND IMPROVEMENT Reduced reliance on hospital settings of care where clinically appropriate 2 Better use of capacity across an area 3 Best practice pathways 4 Theatre productivity

23 5 KEY AREAS FOR ELECTIVE RECOVERY AND IMPROVEMENT Much better use of technology 6 Reflecting on the required offer from the intensive support team 7 Data Quality and visibility 8 Planned care is not all about RTT

24 QUESTIONS?

25 OUR JOURNEY BHRUT and Barking, Havering and Redbridge Clinical Commissioning Group (BHR CCG)

26 CONTEXT In December 2013, the Trust migrated from Total Care Patient Administration System (PAS), to Medway PAS. This change in information system for the management of patient waiting lists, whilst large and complex, should not have affected performance. However, the migration exposed a discrepancy between current performance and historical performance and suggested that we were not compliant with Referral To Treatment (RTT) standards, as was previously thought. A reporting break was agreed in February 2014 to give us time to investigate.

27 In light of the issues identified, we undertook an investigation into the matter in August 2014, which identified the following issues: Training and organisational awareness of RTT and its rules were limited RTT performance was not calculated correctly Our governance processes for reporting and oversight were weak Data quality was poor Demand and capacity were not aligned

28 Other areas identified: No demand management programme in place Insufficient and inexperienced operational managers Limited operational capability of waiting list management Lack of referral management centre Disempowered clinical body

NHS Constitution Patients legal right to start nonemergency NHS consultant-led treatment within a maximum of 18 weeks from referral CQC Quality Report 2 July 2015 Improve the service planning and

29 NHS Constitution Patients legal right to start nonemergency NHS consultant-led treatment within a maximum of 18 weeks from referral CQC Quality Report 2 July 2015 Improve the service planning and capacity of outpatients by continuing to reduce the 18 week non-admitted backlog of patients Ensure no patients waiting for an appointment are coming to harm whilst they are delayed Reduce the did not attend, hospital cancellation and hospital changes rates Improve the 31 day cancer wait target

30 SCALE OF THE PROBLEM In 2013 our total incompletes waiting list size was just over 120,000 patients Through extensive validation this was reduced to 54,000 patients. (Pathways are validated on a daily basis through our central validation team)

31 Initial analysis identified that returning to meet the RTT standards in a sustainable manner would involve undertaking around 5k operations and 93k outpatient appointments over an 18-month period This was therefore not a Trust problem but a health economy problem

approximately 18,400 but we had over 1,000 patients waiting over 52 weeks We were making too slow a

32 REGULATORS Regulators had concerns over waiting list and backlogs sizes In 2013 our backlog of patients was incorrectly recorded at approximately 62,900 In April 2016 it had been validated down to approximately 18,400 but we had over 1,000 patients waiting over 52 weeks We were making too slow a progress There was significant concern around the longest waiting patients and the potential for clinical harm.

33 GOVERNANCE A Governance and Assurance Framework was developed with a clear reporting line RTT assurance and governance was managed through the RTT Programme Board External assurance was also provided through weekly meetings with NHSE and NHSI The Trust also implemented a weekly Access Board that feeds into the RTT Programme Board. This was chaired by the Chief Operating Officer/Deputy Chief Operating Officer. External Assurance Weekly Oversight NHSE/NHSI Weekly return - NHSE System-wide RTT Programme Board (weekly) RTT Director System-wide RTT PMO Operational Meeting (weekly) RTT Director Access Board (weekly) COO/DCOO Divisional PTL meetings (weekly) Div mgr/rtt lead There is also an External Clinical Harm Panel chaired by NHSE.

RECOVERY PLANS A dedicated Programme Management Office support was established for RTT across the whole health system Our RTT recovery plan covered a number of areas including: Increased clinical

34 RECOVERY PLANS A dedicated Programme Management Office support was established for RTT across the whole health system Our RTT recovery plan covered a number of areas including: Increased clinical capacity Increased productivity in both day case and theatres plus outpatients Additional weekend and evening activity Continuing to improve data quality and validation Review of RTT admin processes The use of virtual clinics Pathway redesign Outsourcing Demand management/redirection

35 Theatre Productivity: We have a Theatre Productivity Programme to increase the number of operations for our patients on the admitted pathway. There is dedicated programme support and we have profiled an increase in admitted treatments (operations performed). The programme also looks at our admissions processes and how to improve these and reduce cancellations/dnas. Outsourcing: We have a dedicated team to manage this and we have developed relationships with independent providers who can assist in referral to treatment for suitable cohorts of patients on the admitted and non-admitted pathway (including diagnostic services) We inform our patients that they will remain NHS patients and treatment is free of charge to them before we refer them to an independent provider Validation: We have developed a team of 15 validators who undertake daily validation tasks, have created data quality checks and were pivotal in our work to return to reporting for our RTT performance at the end of October 2016.

36 RTT Admin: We are reviewing the admin roles for booking and managing patient pathways This includes the development and management of clear processes and defining the roles and responsibilities of our staff in delivering the RTT standard Demand and Capacity: We have developed detailed demand and capacity plans for the specialities These models will allow services and staff to quantify weekly capacity gaps and for future planning purposes identify what are sustainable waiting lists capable of delivering the RTT standards Demand Management: A phased demand management programme has commenced which includes a series of schemes rolled out by the CCG that cover: Referral redirection Pathway redesign Referral Management

37 Communications: A system-wide communications strategy has been developed which sets out a joint communication and engagement approach between commissioners and service providers in relation to improving waiting times for elective care for Barking, Havering and Redbridge residents Communication objectives: Help drive improvement through effective communication and engagement with teams involved in elective care Provide consistent, timely and honest information to patients to help manage their expectations around waiting Provide coordinated, timely and consistent information to key stakeholders around RTT and our recovery plan Demonstrate our strategy for recovery is clear, realistic and making progress Minimise reputational risk Engage in two way communications with GPs, identify issues and reduce patient calls to GPs

38 RECOVERY PLANS CLINICAL HARM PROGRAMME Review of information on patients waiting more than 52 weeks to identify risk of harm and ensure they are appropriately and efficiently managed Phase 1 Focused on patients on admitted pathway More than 900 reviews carried out No moderate or severe harm identified. Phase 2 Focused on patients on non-admitted pathway More than 3,500 reviews carried out No moderate or severe harm identified Phase 3 Commenced 1 October 2016 Focused on patients who would have been waiting more than 52 weeks before 3rd December All 83 patients have been reviewed and no moderate or severe harm identified Phase 4 Commence 5 December 2016 Focused on a random sample of 10% of undated patients with a 35 week breach date between 4 December and 13 March patients will be reviewed for risk of deterioration all have been reviewed, no harm found.

39 FIRST PHASE OF THE RECOVERY PLAN First phase of the programme was to reduce the number of patients waiting more than a year for treatment

40 SECOND PHASE OF THE RECOVERY PLAN Detailed plan in place to achieve the 92% RTT standard by September 2017 System wide robust RTT recovery plan was submitted to NHSE in September 2016 and was signed off by NHSE February 2017.

41 At the end of February: 36,000 patients on our waiting list, (4,900 patients waiting over 18 weeks) A performance of 86% (8% ahead of plan)

42 IMPACT ON CLOCK STARTS

43 CCG S PERSPECTIVE

44 BACKGROUND CONTEXT Significant issues identified with how the Trust had historically reported RTT Reporting suspended in processes improved and data validated Unacceptable waits for some patients Massive resource and joint working challenge to mobilise at a very difficult time Increased scrutiny on both organisations as a result CCGs responsible for contract management and assurance Havering lead CCG for the BHRUT contract Directions issued by NHSE in June 2016 lifted in March 2017

45 DEMAND MANAGEMENT PROGRAMME RTT prioritised by all three BHR CCGs Delivery responsibility - avert 24k GP outpatient referrals in year Range of alternative independent sector and community providers identified and contracted New clinical pathways designed jointly with BHRUT clinicians 22,000+ patients redirected by GPs at the end of February 2017

46 BHR CCGS ROLE AS COMMISSIONER Agreed demand management programme across 10 top specialties to alleviate pressure Providing primary care clinical leadership (Chair of Havering CCG) and aligning Clinical Directors to specialty level work Two way challenge between CCGs and BHRUT on our respective delivery areas

47 DEMAND MANAGEMENT PROGRAMME

48 DEMAND MANAGEMENT Eight specialties were identified for the demand management programme: 1. Orthopaedics 2. Dermatology 3. Gynaecology 4. ENT 5. Ophthalmology 6. Gastroenterology 7. General surgery 8. Rheumatology Referral redirect contracts were established Clinical pathway redesign work also included in the programme

49 DEMAND MANAGEMENT - OUTCOMES Detailed comprehensive methods of tracking in place Weekly monitoring CCG lead identified Positive results being reported weekly

Tracking referral levels into BHRUT showed a cleared reduction

50 DEMAND MANAGEMENT - OUTCOMES Program on track to deliver planned reduction in referrals. Tracking referral levels into BHRUT showed a cleared reduction in line with plan. However this reduction was not being directly translated onto the RTT waiting list (PTL)

51 LUNCH AND NETWORKING 12-1pm

53 WORKSHOPS Sarah Tedford Chief Operating Officer Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT)

54 15 minute coffee break

55 HOW TO SET UP AND RUN A CLINICAL HARM REVIEW PROGRAMME FOR RTT AND LONG WAITING PATIENTS Magda will explain the background to the development of our clinical harm programme and the different stakeholders (internal and external) who were involved. This session will also cover the processes that were implemented and the different ways patients were assessed for risk. In addition the session will cover the lessons learnt, the different phases of the programme and the outputs.

56 HOW WE USED DEMAND AND CAPACITY MODELLING TO DEVELOP A ROBUST AND CREDIBLE RECOVERY PLAN Piers will take you through the work BHRUT completed on detailed specialty demand and capacity modelling and how to create a systemwide RTT recovery plan. This session will cover some of the basics and theory on demand and capacity modelling, as well as the key elements to then develop an incomplete RTT trajectory. The session will also cover the role that outsourcing of patients to the independent sector plays in a recovery plan talking through the benefits and realities.

57 HOW WE USED DEMAND AND CAPACITY MODELLING TO DEVELOP A ROBUST AND CREDIBLE RECOVERY PLAN Piers will take you through the work BHRUT completed on detailed specialty demand and capacity modelling and how to create a systemwide RTT recovery plan. This session will cover some of the basics and theory on demand and capacity modelling, as well as the key elements to then develop an incomplete RTT trajectory. The session will also cover the role that outsourcing of patients to the independent sector plays in a recovery plan talking through the benefits and realities.

58 THE ROLE OF PMO, PERFORMANCE METRICS, AND INFORMATION PACKS THAT SUPPORT IMPROVEMENT WORK One of the key parts of our RTT improvement programme has been the Programme Management Office (PMO) which has guided the work. Heylia will go through how a good PMO can help to manage and monitor RTT improvement programmes, give it structure and a governance framework to operate within. In addition the workshop will cover the weekly performance pack that was developed to outline and communicate progress to the CCGs, NHSE and NHSI.

59 HOW TO DESIGN AND IMPLEMENT AN EFFECTIVE COMMUNICATION STRATEGY FOR MANAGING RTT In this workshop, Rachel will discuss the important role an effective and comprehensive communications strategy has when treating large volumes of long waiting patients. The workshop will cover how we engaged with the different stakeholders. The session will also cover the different approaches and strategies we had when returning to reporting the national RTT standard.

60 OUR EXPERIENCES WITH IMPLEMENTING A DEMAND MANAGEMENT PROGRAMME AND REDESIGNING THE PATIENT PATHWAY Louise will run a workshop on the how to develop a demand management programme, our experiences and the results of redesigning pathways and redirecting patients. Louise will also touch on the indirect impacts of a demand management programme on RTT PTLs and how you can identify these and identify solutions.

61 OUR APPROACH TO RTT DATA QUALITY AND VALIDATION PROGRAMMES This workshop will consist of two parts. The first part will be presented by MBI Healthcare who will cover some of the context behind our need to take a reporting break for RTT. They will also cover how to identify issues with your PTL data, the changes to our PTL over time and the approach we took to resolving the problems and restoring confidence in our data. In the second part Seeni will go through what tools and data quality checks you can develop to validate pathways and provide assurance around data quality.

62 PANEL Q&A SESSION Sarah Tedford Chief Operating Officer and workshop speakers

63 THANK YOU FOR COMING ALONG TO OUR RTT CONFERENCE TODAY - WE HOPE YOU ENJOYED IT! Our presentations will shortly be downloadable from our website we will send you an with a link. If you would like to talk to us more about our RTT work then please get in touch: Piers Young Deputy Chief Operating Officer (Elective Care) piers.young@bhrhospitals.nhs.uk

DEMAND AND CAPACITY MODELLING

DEMAND AND CAPACITY MODELLING How we used demand and capacity modelling to develop a robust and credible recovery plan Piers Young Deputy Chief Operating Officer (Elective Care) CONTENTS Brief history