Governing Body

27th May 2016

Quality and Performance Report – May 2016

Agenda item 13 Paper 8

Authors and Eileen Clark – Chief Nurse/Head of Quality

contributors: Mable Wu – Head of Planning and Performance

Executive Lead(s): Steve Hams, Director of Clinical Performance and Delivery

Relevant Committees Quality Committee

or forums that have
already reviewed this
issue:

Action required: To agree

Attached: Quality and Performance Report – May 2016

CCG Strategic Quality and Performance

objectives relevant to Core business: relevant to most objectives
this paper:

Risk Identified risks relating to quality and safety of commissioned services

are captured on the Surrey Downs CCG risk register and discussed at
the Quality Committee and other fora such as the local Clinical
Quality Review Groups

Compliance Finance: There continues to be a risk that the CCG will not achieve
observations: the level of performance in a number of areas of quality and that this
will impact on the potential to receive the associated quality premium
payments.

Engagement: Patient and public feedback is key to understanding

the quality and experience of commissioned services. The CCG
monitors its commissioned providers in respect of performance in this
area.

Quality impact: Quality Impact Assessments are carried out on all

service developments and improvements and monitored for future
impact.

Equality impact: Equality Impact Assessments are carried out on all

X:\NHS Surrey Downs CCG\Corporate Governance\Meetings\03 Gov Body\01 - 2016-17\02 27th May 2016\Part One\08-13 Quality and
Performance Report\2016.05.27 GB Pt1 Q & P Report Cover [Link]
 service developments and improvements and monitored for future
impact.

Privacy impact: None identified in this paper.

Legal: None identified in this paper.

EXECUTIVE SUMMARY
This report is to assure the Governing Body that the CCG reviews the performance of NHS
healthcare providers it commissions against the key performance and clinical quality and safety
indicators and that those areas of concern or risk to patients are highlighted and addressed.

Key issues to note:

Section One

A summary of the key issues for each provider is placed in the Executive Summary and again at
the end of their section in the report.

Section Two
• Incidence of Healthcare Associated Infection (HCAI): MRSA
• A&E waits within 4 hours
• Cancer urgent referral to treatment within 62 days
• Ambulance response times
• Improving Access to Psychological Therapies (IAPT)
• Dementia diagnosis

Recommendation(s):

The Governing Body is requested to:

1) Note the report

2) Discuss highlighted matters of concern
3) Agree that it has received assurance around the quality and safety of services it
Commissions and actions in place to drive further improvements.

Date of paper 18th May 2016

For further information contact: [Link]@[Link]

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Performance Report\2016.05.27 GB Pt1 Q & P Report Cover [Link]
Quality and Performance Report – May 2016

1. Introduction

1.1. Ultimate responsibility for safeguarding the quality of care provided to

patients rests with each provider organisation through its Board. However,
CCGs, as statutory organisations are required to deliver the best possible
services to and outcomes for patients within financial allocations. Therefore,
Surrey Downs CCG (SDCCG) has a statutory duty to secure continuous
improvements in the care that we commission and to seek assurance around
the quality and safety of those services. This requirement is underpinned by
national guidance and locally-determined commissioning intentions.

1.2. This report is to assure the Governing Body that the CCG monitors the
performance of NHS healthcare providers it commissions against the key
performance and clinical quality and safety indicators and, that areas of
concern or risk to patients are highlighted and addressed. The report
presents an overview of quality of care and patient safety matters, with
narrative around areas of concern, risk. A weekly performance report
covering contract performance indicators is produced and circulated to CCG
leaders. It is reviewed by the CCG Executive therefore general performance
indicators are not be covered in this report to the Governing Body.

1.3. Section One of the report provides information about Surrey Downs CCG’s
main providers based on the performance dashboard at Appendix 1 and
reports on all available data at the time of writing the report. This contains
national and local data, formal and informal, for all patients (not only Surrey
Downs). In depth review of key risk areas is contained here and, in this way,
any wider concerns around quality and safety leading to potential risk to
Surrey Downs CCG patients are addressed.

1.4. Section Two of the report summarises performance against the key areas
outlined below and forms the basis of the NHS England Area Team’s
quarterly assurance meetings:

• CCG Outcomes Indicator Set

• NHS Constitution
• CCG Operating Plan including three local priorities

1.5. The performance dashboards for Surrey Downs CCG patients (Section 2:
Appendix A) reflect the formal reporting of performance position against the
goals and core responsibilities of the CCG as outlined in ‘Everyone Counts:

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 planning and priorities for patients in 2014/15 – 2018/19’ and the ‘CCG
Assurance Framework 2014/15’. Matters of concern addressed in this
section are cross reference to Section One where necessary.

Risk Management

1.6. Each provider has its own internal governance and risk management
processes. Provider’s own risks relating to contractual requirement are
discussed at contract meetings and Clinical Quality Review Group/
Monitoring meetings.

1.7. Where inadequacies in provider performance around quality and safety are
assessed to be a risk to the CCG as a commissioner of those services, these
will be raised on the CCG’s corporate risk register or Governing Body
Assurance Framework.

2. Executive Summary of Key Areas of Concern

2.1. A summary of the key issues for each provider placed at the end of their
section on the report and in the table below.

Summary of key issues and actions

CSH Surrey

• Issue: Recruitment and vacancy management continues to be the key issue

for CSH Surrey, particularly within the nursing workforce
Action: CSH Surrey is actively recruiting and is using more innovative
schemes to try and attract staff. They continue to match staffing capacity to
demand to prioritise clinical need and maintain patient experience. The Neuro
team which has been a previous area of concern became fully staffed at the
end of March 2016.

• Issue: CSH Surrey is seeing an increase in the incidence of Pressure

damage in individuals under their care.
Action: The Tissue Viability Nurse continues to work with staff to improve the
risk assessment and management of patients who are at risk from Pressure
damage. The CSH pressure damage prevention group has been reinstated.
This will look at the workforce training requirements, the definition of CSH
care and out of CSH care, and the information given to the care agencies.

Epsom and St Helier

• Issue: Incidence of HCAI at the Trust and continued evidence of poor

compliance with the hygiene code
Action: An external review of practice is on-going but early recommendations
support a complete overhaul of teaching, practice and audit of infection
control including hand hygiene.

• Issue: Failure to achieve the A&E 4 hour standard during January and
February
Action: CCG continuing to support and monitor potential impact on patient
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 safety and experience. A remedial action plan has been sought from the
Trust and will be presented at the next available CQRG.

• Issue: The Trust has reported 2 Never Events in February 2016 – one
misplaced NG Tube (historical case discovered on further review) and one
wrong site tooth extraction
Action: Commissioners will scrutinise the Root Cause Analysis and ensure
that robust Improvement Plans are implemented and improved practice
embedded

Surrey and Borders Partnership NHS FT

• Issue – Regulation 28 Notice issued by the Surrey Coroner as a result of the

death of a patient at Epsom Hospital
Action – The Trust have made changes as a result of this. Assurance will be
sought by the CCG Quality Team through a planned walk round visit in late
April or early May

• Issue – Mazars Report and implications for SABP

Action – Review of report carried out and action plan developed. Completion
of actions will be reported through CQRG. Trust has refocused its Mortality
Review Group to ensure that all deaths are reviewed and scrutinised by
Senior Clinicians and in addition, a decision is made about the level of
investigation required.

• Potential Issue - CQC Inspection and potential actions from this

Action – Awaiting further information

Kingston Hospitals NHS FT

• Issue – Continued poor hand hygiene compliance in areas of the Trust

although there has been some improvements
Action: Trust continues to target specific service areas

• Issue: CQC inspection during January- report not yet received

Action: Await report

Surrey and Sussex Healthcare (SASH)

• Issue: The Trust has exceeded its trajectory re. Cdifficile infections for the
year
Action: The Trust is being supported by the TDA in its improvement plans

• Issue: Mazars Report has not been formally reviewed by the Trust and so
Commissioners cannot be assured on its performance against the findings
and recommendations
Action: The Trust will review the report and action plan will be discussed at
the CQRG in June 2016

South East Coast Ambulance (SECAmb)

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 • Issue – on-going concerns re service key performance indicators
Action – SDCCG following up through the lead commissioner

• Issue – Red 3 pilot investigation remedial action plan

Action – SDCCG is actively engaged in the commissioner forum to support
SECAmb and monitor the action plan.

Royal Marsden Hospital FT

• Issue – The Trust has not met the training targets for safeguarding adults
Action – The Trust has employed external trainers to deliver the levels 1 to 3
training. They expect to achieve their trajectory by the end of March 2016

St George’s Hospital

• Issue – Complaints performance

Action – continued focus on the process in targeting specific Divisions where
improvement is required

• Issue – Infection Control Performance Poor hand hygiene compliance in

areas of the Trust.
Action: Trust targeting specific service areas

• Issue: Safeguarding Children and Adult Training compliance

Action: Agreed actions for both adult and children safeguarding which are
being monitored by the respective safeguarding Committees.
• Issue: CQC inspection during January- report not yet received
Action: Awaiting publication

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Section One

1. Introduction

This section of the report provides information about Surrey Downs CCG’s main
providers based on the performance dashboard at Appendix 1 and reports on all
available data at the time of writing the report. This contains national and local data,
formal and informal, for all patients (not only Surrey Downs). Detail about key risk
areas is within the report by Provider. In this way, any wider concerns around quality
and safety within individual providers that may lead to potential risk to Surrey Downs
CCG patients are addressed. In addition, it gives an opportunity for organisational
performance against a number of quality metrics to be benchmarked against similar
providers.

2. Provider Dashboard - Quality and Safety Indicators

Appendix 1 provides an overview of Surrey Downs CCG’s main providers against

key quality and safety indicators. The narrative below addresses the Amber or Red
rated indicators.

In addition to this, the data contained in the table placed at the beginning of each
provider section is extracted from the safety section published on the NHS Choices
website. It gives an indication of how individual organisations are performing against
a range of safety indicators and also enables the committee to benchmark the
performance of providers who are commissioned by Surrey Downs CCG to deliver
services to our population.

Indicator Brief Definition

CQC national standards As the independent regulator for health and adult social care
in England, the Care Quality Commission (CQC) check
whether services are meeting their national standards of
quality and safety.
Recommended by Staff Staff survey score for satisfaction with standard of care if a
friend or relative needed treatment
Infection Control and Describes how well the organisation is performing on
Cleanliness preventing infections and cleaning
Open and honest To give an overall picture of whether the hospital has a good
reporting patient safety incident reporting culture.
Mortality Rate Whether the rate of deaths for an NHS Trust is better or
worse than expected
Food Choice & Quality Looks at the way the hospital as a whole organises its food
services, and the quality of the food it serves
Safe Staffing Shows the overall average percentage of planned day and
night hours for registered and unregistered care staff and
midwifes in hospitals which are filled. May be over 100%
which can reflect a higher need of patients on a ward
requiring 1:1 care
Patients assessed for Shows the percentage of adults admitted to hospital that
Blood Clots (VTE) NHSE were assessed for risk of blood clots, all hospitals should
Patient Safety notices assess at least 90% of patients.

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It is important to note that these ratings are at a point in time and may not align
completely to the provider dashboard at Appendix 1. Where this is the case, concern
or assurance will be included in the narrative.

Further information can be found on [Link]

Page 6 of 35
Surrey Downs CCG Main Providers

2.1. CSH Surrey

Lead Commissioner – Surrey Downs CCG

2.2. NHS Choices data

CSH Surrey does not currently receive a patient safety rating from the Care
Quality Commission in the same way that other organisations do. However, the
Quality Team continue to monitor a range of quality indicators and these are
reported within the main body of this report.

2.3. Healthcare Associated Infection (HCAI)

CSH Surrey holds a quarterly Infection Control Strategic Group meeting which
the Head of Quality is invited to attend. During the meeting, the organisation’s
annual infection control action plan and audit plans are reviewed and updated
and new areas of risk are identified and included into the plan.

Infection Prevention and Control training is delivered face to face and is based on
“Back to Basics”. Clinical staff are required to attend annually and non-clinical
staff, every 3 years. Compliance scores for the end of March 2016 are at 66% for
clinical staff and 87% for non-clinical staff. Although lower than planned, this is an
improvement on the previous year’s figures and the Specialist Nurse for Infection
Prevention and Control is focussing on improving uptake this year.

Hand hygiene audits have been carried out monthly on the Community Hospital
Wards and scores are consistently at 95-100%. Other clinical areas complete a
hand washing audit on a quarterly basis using the UV box to check technique.

2.4. MRSA Bacteraemia

At the time of writing this report, there have been no cases of MRSA Bacteraemia
acquired by patients receiving services from CSH Surrey year to date. There
were no cases identified in 2015/16

2.5. Clostridium difficile

There have been no further cases of Cdifficile reported by CSH Surrey since July
2015.

2.6. CQUINs

Achievement against Q4 and consequently the whole year’s CQUIN has been
assessed. It was agreed that the provider has achieved four out of the five
CQUINs for the year but it is unlikely that they will have completed the elements
required to achieve the local CQUIN relating to Pressure Ulcer Pathway and
Management. The CCG is awaiting confirmation of a set of figures.

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 Indicator weighting
National Indicator
(% of CQUIN scheme available)
CQUIN 1 Dementia 0.25%
Unplanned emergency
CQUIN 2 0.75%
admissions (U EC)
Local
CQUIN 1 Medicines Management 0.5%
Pressure Ulcer Pathway
CQUIN 2 0.5%
and Management
CQUIN 3 Sepsis 0.5%

There was a delay in successfully recruiting a Tissue Viability Nurse and

developing the training programme early in the year which impacted on the
training that could be provided. In addition, recognition and consequently
reporting of Pressure damage has improved over the year which has manifested
itself as increased incidence. This and the increasing frailty of patients have
affected the numbers of Pressure Ulcers that have occurred whilst under the care
of the provider. However, the quality team is assured that CSH Surrey Co-owners
are reporting appropriately and that there is a high level of engagement about this
area of practice across the organisation.

2.7. Quality Account

CSH Surrey is currently drafting its Quality Account. The draft account will be
forwarded to stakeholders for comment before its publication on the NHS
Choices Website by 30th June 2016.

2.8. Feedback from Clinical Quality Review Group – 4th March 2016

The following areas were discussed:

• The Falls Service - and the work that is in progress around establishing robust
criteria for the service going forward
• Recruitment and vacancy management - CSH Surrey is starting to see an
improvement on recruitment partly following the introduction of a Golden Hello
as an incentive for posts that are difficult to recruit to. The CSH nursing
workforce is most critical in terms of the percentage of vacancies. This issue
is on CSH Surrey’s risk register and a comprehensive report has recently
gone to the CSH board and will be reviewed by Commissioners once agreed
internally.
• New Birth Visits - The target for new birth visits under the age of 14 days by
the health visitor is now being achieved. In addition, the appointment of a new
breast feeding co-ordinator is beginning to improve breast feeding rates.
Breast feeding target rates were reached in Quarter 3 of 2015/16.
• Serious Incident Committee - There was feedback from the Serious Incident
Review Committee and a discussion around the learning from the incidents
reviewed.

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 • Patient Experience Report - The Patient Experience Report for Q1 and Q2
was discussed and agreed.
• Pressure Damage - As described in Section 2.1.4 above, the incidences of
pressure damage acquired in the care of CSH are rising for grade 2, however
grade 3 is decreasing.

Q1- grade 2 at 1.2%, Q1 - grade 3 at 0.1%

Q3 - grade 2 at 1.7%, Q3 - grade 3 at 0.05%

The CSH pressure damage prevention group has been reinstated. This will
look at the workforce training requirements, the definition of CSH care and out
of CSH care, and the information given to the care agencies. Pressure
damages within the community are being raised as safeguarding alerts
when they are graded at Stage 3 or 4.

2.9. Care Quality Commission (CQC)

CSH Surrey is currently compliant in all standards that have been inspected by
the CQC. There have been no inspections since February 2014

2.10. Serious Incidents including Never Events

CSH Surrey has not reported any Never events during this period
The Serious Incident Review Sub-Committee (SIRSC), of the Quality Committee,
is held monthly to scrutinise the investigations and subsequent action plans of
providers for whom we are lead commissioner. Areas of learning that are
identified from discussions at this meeting are shared and these also inform future
audit programmes.

A separate confidential report that gives detail around Serious Incidents affecting
Surrey Downs patients that are under investigation will be presented in Part 2 of
this meeting and will include details pertaining to incidents reported by CSH
Surrey.

2.11. CSH Surrey Board Papers

Due to commercial sensitivity CSH Surrey do not currently publish their Board
papers online, concern has been raised with the Chief Executive Officer.

Summary of key issues and actions

• Issue: Recruitment and vacancy management continues to be the key issue

for CSH Surrey, particularly within the nursing workforce
Action: CSH Surrey is actively recruiting and is using more innovative
schemes to try and attract staff. They continue to match staffing capacity to
demand to prioritise clinical need and maintain patient experience. The
Neuro team which has been a previous area of concern became fully staffed
at the end of March 2016.

• Issue: CSH Surrey is seeing an increase in the incidence of Pressure

damage in individuals under their care.

Page 9 of 35
 Action: The Tissue Viability Nurse continues to work with staff to improve
the risk assessment and management of patients who are at risk from
Pressure damage. The CSH pressure damage prevention group has been
reinstated. This will look at the workforce training requirements, the definition
of CSH care and out of CSH care, and the information given to the care
agencies.

3. Epsom and St Helier University Hospital NHS Trust (ESUHT)

Lead Commissioner – Sutton CCG. Surrey Downs CCG is an associate

commissioner and also has its own contract for services delivered at Epsom
General Hospital

3.1. NHS Choices – date extracted 19.04.16

Infection Safe Patients NHSE Patient Open and

Control and Staffing assessed Safety honest
Cleanliness for Blood notices reporting
– monthly Clots (VTE)
NHSE

95%
(Epsom)
Among the 93% (St 94.30% of Poor - Some Among
worst Helier) patients alerts not the worst
of planned assessed signed off after
level deadline.
(95% - Feb) (95.2% -Feb) (Good – Feb)

Since the report to the March Committee, performance on three of the above
indicators is down and the other two remain ‘Among the worst’. Commissioners are
aware of the issues that have already been identified regarding Infection Control and
Cleanliness including poor levels of hand hygiene compliance. Current audit figures
are 36.4% of wards achieving above 85% in Q4 with 48.8% achievement in February
2016.

As of 17th March 2016, the number of staff with up to date infection Prevention and
Control training was reported at 86.88% for clinical staff.
The external review of practice is on-going and early recommendations support an
overhaul of teaching, practice and audit of infection control including hand hygiene.
Progress against these areas will be monitored and reported in future reports.

3.2. MRSA Bacteraemia

The Trust had no cases of MRSA Bacteraemia in February 2016. Their year to date
total is 4 against a zero tolerance of cases. Although the actual number of cases has
increased since the last Quality and Performance report, the long term trend is
beginning to show a decline in cases per 100,000 bed days.

Post Infection Reviews are conducted on all cases

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 3.3. Clostridium difficile

A total of 5 Cdifficile cases were reported in February 2016 of which 3 were assigned
to the Trust. 2 of these cases were at St Helier and 1 at Epsom Hospital.
There has been little D&V reported during February – none at Epsom General
Hospital

3.4. CQUINs

The CCG will be reviewing the 2015/16 against CQUINs in early May. A full report of
their achievement will be included in the July Quality and Performance report.
A shortlist of CQUINs for 2016/17 has been provisionally agreed with the Trust.

These are under the subjects of:

• NHS Staff Health and Wellbeing

• Timely identification and Treatment of sepsis
• Antimicrobial resistance and Antimicrobial Stewardship
• Medicines Optimisation (Year 2)
• Asthma Care Bundle (Year 2)
• Cancer Pathway optimisation
• Improved Mental Health awareness across the acute workforce
• Alcohol misuse, the use of brief intervention and onward referral.

Further discussions with the Trust to agree the CQUIN programme have been
scheduled for early May 2016.

3.5. Quality Account

As reported in previous Quality and Performance reports, the Trust has undertaken
an engagement exercise with a group of local stakeholders to agree their quality
priorities for 2016/17. They have circulated a short paper that outlines the agreed
priorities and rationale behind the agreement and will be sending their draft Quality
Account to the CCG for comment and agreement by the end of April to enable them
to meet the publication deadline of 30th June 2016.

3.6. Feedback from Clinical Quality Review Group

• Report in how the Trust cares for people with learning disabilities (PLD) – a
positive presentation and discussion on the initiatives in place and planned. Trust
requested to confirm their response to the Mazar’s Report.
• Maternity Dashboard – performance issues are key focus and the Trust also
advised of their intention to reconfigure services and relevant mapping and
planning required in preparation.
• Workforce Race Equality Report – the action plan following the baseline report in
July 2015 was presented. Picker Staff Survey results had been released and will
be brought to the CQRG.
• A& E – is a continuing focus for the Trust. The Epsom site had been more
challenged than the St Helier site due to limited opportunity to create additional
capacity and increase in acuity of cases.
Page 11 of 35
• Stroke – deterioration in performance largely as a result of availability of beds.
• Emergency Readmissions- highest rate for the year recorded in December.
Medicines division highest at 13.2%. Increase seen across the board. Trust
believed the current pattern is unlikely to change until the results of the
transformational work with a specific focus on the elderly population will be seen.
• Infection Control-C. Difficile - Hand hygiene remains a challenge and the
feedback from the external UCLH review has been taken through the Trust’s
internal governance process and will be brought to the CQRG.
• GP Quality Alerts - Trust confirmed the main themes from the quality alerts raised
to date relate to communication, discharge summaries and medicines
reconciliation.

3.7. Care Quality Commission (CQC)

The Trust was inspected by the CQC in November 2015 and has now received the
draft report to check for accuracy. A Quality Summit has been arranged by the CQC
and will take place on 1st June 2016 and this will be attended by Commissioners and
members of the Trust. The purpose of the Quality Summit is to develop a plan of
action and recommendations based on the inspection team’s findings as set out in
the inspection report. This plan will be developed by partners from within the health
economy and the local authority.

The inspection report sets out the findings from the announced and unannounced
visits and the CQC’s judgements and ratings, where appropriate and will be
published shortly before the Quality Summit.

3.8. Serious Incidents including Never Events

The Trust has reported two Never Events in February 2016 – one misplaced NG
Tube and one wrong site tooth extraction. Both incidents will be subject to a Root
Cause Analysis and the investigation report and associated action plans will be
scrutinised by Commissioners and improvement plans agreed.

The Sutton CCG SI Sub- Committee, which the Surrey Downs quality leads attend,
received two thematic presentations of SIs reported in 2014/15 in the Trust’s
Paediatric and Women& Children department and Maternity services at the March
meeting.

3.9. Commissioner Walk Rounds

The Director of Clinical Performance and Delivery undertook a walk round at Epsom
General Hospital during April visiting the Emergency Department, CADU, the
medical wards and HDU/ITU.

3.10. ESHUT Board Papers

The most recent set of Board papers are available to view on this weblink.
[Link]

Page 12 of 35
Summary of key issues and actions

• Issue: Incidence of HCAI at the Trust and continued evidence of poor

compliance with the hygiene code
• Action: An external review of practice is on-going but early recommendations
support a complete overhaul of teaching, practice and audit of infection
control including hand hygiene.

• Issue: Failure to achieve the A&E 4 hour standard during January and
February
Action: CCG continuing to support and monitor potential impact on patient
safety and experience

• Issue: The Trust has reported two Never Events in February 2016 – one
misplaced NG Tube and one wrong site tooth extraction
Action: Commissioners will scrutinise the Root Cause Analysis and ensure
that robust Improvement Plans are implemented and improved practice
embedded

4. Surrey and Borders Partnership NHS Foundation Trust (SABPFT)

Lead Commissioner for Surrey – NE Hants and Farnham CCG

4.1. NHS Choices

SABPFT does not receive an overall rating on NHS Choices.

4.2. Healthcare Associated Infection (HCAI)

There have been no concerns identified about the incidence of HCAI within services
provided by Surrey and Borders Partnership NHS FT.

4.3. CQUINs

Achievement against the Quarter 4 CQUINs is being reviewed and performance will
be confirmed at the CQRG meeting in May 2016. Discussions are on-going to
confirm CQUINs for 2016/17.

4.4. Feedback from Clinical Quality Review Group – 23rd March 2016

• Junior Doctors Strike – assurance was given about the actions taken by the
Trust to minimise risk and maintain patient safety.
• The Trust has been issued with a Regulation 28 Notice from the Coroner as
result of an incident at Epsom Hospital. As a result, the Quality Team will be
undertaking a Commissioner Walk Round to gain assurance around the

Page 13 of 35
 measures that the Trust has put in place to prevent future absconds by
patients.
• High Volumes of S136 – nobody has been identified as being wrongly placed
over the past 3 months however a piece of work is being undertaken to see
whether all avenues have been explored before detaining individuals under
S136
• Surrey Coroner Suicide Audit and Suicide Action Plan
o A presentation was given by Public Health England (Surrey)
o Data related to 2012/13 due to the time lag in completed coroners
inquests
o This data set was 70 suicides

Key points include:

o Correlation between money issues and suicide – demonstrated by
increases in years of economic recession
o Ratio is 28:72 (Female: Male incidence) Previous audit was 23:77 so
shift toward more females.
o Increase in suicides in age group 50-54 (most at risk group in Surrey) –
Clinical alert circulated by the Trust to raise awareness of this fact
(20% in this audit). Also increase seen in older adults – 70 +
o Increase in Females over 65 both in England and in Surrey – Social
isolation is a theme in these cases
o Less than a third (29%) of cases were known to mental health services
– 33% nationally
o The most common act is hanging – however there has been a large
increase in suicides caused by jumping or lying in front of trains – PH
Surrey are working with National Rail (Surrey) to raise awareness.

This data supports the Surrey Suicide Prevention Plan

• Mazars Report
• The Trust is looking at the numbers of deaths vs. those
reported/investigated as incidents/SIs. They have gone through a
process of benchmarking numbers of deaths, reviewing and raising SIs
as appropriate
• The Trust will be investigating all deaths of people with Learning
Disabilities
• They have mandated the need to report all deaths on any caseload
and those of patients that have received services within the previous
12 months – These are flagged up on the NHS Spine and will be
reviewed through a mortality review panel
• 121 deaths were reported in February 2016.
• The Trust will continue the revised mortality review process that was
started in February.

The CCG has requested that the lead commissioner attends a mortality review
meeting to give assurance about the robustness of the process.

• Safeguarding
• A further meeting is planned around Ashmount House
• The Large Scale Enquiry re: Derby House has concluded and is now
closed
Page 14 of 35
 4.5. Care Quality Commission (CQC)

The Trust has been inspected by the CQC during March 2016. Positive Practice was
identified by inspectors with particular services/individuals highlighted by the CQC
such as the transformation work around Fenby Ward – which has moved to Farnham
Road. The ward manager from Fenby Ward and the Designated Nurse for
Safeguarding Children were particularly mentioned amongst others.
Any issues that were escalated during the visit were dealt with by the Trust to the
apparent satisfaction of the CQC

The CQC had a particular focus on Serious Incidents and the learning that was
identified in the Mazars Report re: practice at Southern Health.

4.6. Serious Incidents including Never Events

The Trust has not reported any Never Events during this period

A separate confidential report that gives detail around Serious Incidents affecting
Surrey Downs patients that are currently under investigation will be presented at
Part 2 of this meeting and will include details pertaining to incidents reported by the
Trust.

4.7. Safeguarding Adults and Children

As reported above, a further safeguarding meeting is planned around Ashmount

House

The Large Scale Enquiry re: Derby House has concluded and is now closed

4.8. Commissioner Walk Rounds

As outlined in Section 2.3.6, the Quality Team will be carrying out a Quality Insight
Visit to Elgar Ward on the site of Epsom General Hospital, partly as part of the
programme of visits planned but also as a result of the Regulation 28 Notice issued
by the Surrey Coroner to the Trust. This will take place in late April or early May.

4.9. SABPFT Board Papers

The most recent set of Board papers are available on this weblink.
[Link]

Page 15 of 35
Summary of key issues and actions

• Issue – Regulation 28 Notice issued by the Surrey Coroner as a result

of the death of a patient at Epsom Hospital

Action – The Trust have made changes as a result of this. Assurance

will be sought by the CCG Quality Team through a planned walk round
visit in late April or early May

• Issue – Mazars Report and implications for SABP

Action – Review of report carried out and action plan developed.

Completion of actions will be reported through CQRG. Trust has
refocused its Mortality Review Group to ensure that all deaths are
reviewed and scrutinised by Senior Clinicians and in addition, a
decision is made about the level of investigation required.

• Potential Issue - CQC Inspection and potential actions from this

Action – Awaiting further information

5. Kingston Hospital NHS Foundation Trust (KHFT)

Lead Commissioner – Kingston CCG

5.1.1. NHS Choices – extracted on 19.04.16

Infection Safe Patients NHSE Patient Open
Control Staffing assessed Safety notices and
and for Blood honest
Cleanliness Clots (VTE) reporting
– monthly
NHSE

107%
of planned
Among the level 98.60% of Good - All alerts As
worst patients signed off where expected
(100% - assessed deadline has
Feb) (98.5% - passed
Feb)

Since the report to the March Committee, there is little change in the indicators;
increase in staffing being the key change.

Page 16 of 35
 5.2. MRSA Bacteraemia

The Trust has had no MRSA Bacteraemia infections during January and February
2016. The total number of infections attributed to the Trust is one.

5.3. Clostridium difficile

The Trust reported 3 cases of Cdifficile in February, none of which were as a result
of a lapse in care. The total number of Cdifficile infections that have been attributed
to the Trust Year to date is 18 of which 3 have been as a result of lapses in care.
Hand Hygiene audits continue to demonstrate that some areas of the Trust need to
improve however overall there has been an improvement in the poor performance of
recent months.

5.4. CQUINs

CQUINs for 2015/16 are being monitored by the lead commissioner, Kingston CCG.
Detail about agreed achievement for the year will be included in a future report.

5.5. Quality Account

A long list of potential quality priorities was developed in consultation with

stakeholders such as Healthwatch, Trust committees, commissioners and governors.

The quality priorities long list was then put to a public vote during February 2016.
Staff, volunteers, Trust members and the public was asked to vote on which priorities
to select from the long list. Three priorities were voted for from each domain: patient
safety, clinical effectiveness and patient experience. The priorities that have been
selected will be the nine Trust Quality priorities for 2016-17. A total of 304 people
completed the quality priorities survey. The next step by the Trust will be to develop
measurable objectives and goals for these priorities.

5.6. Feedback from Clinical Quality Review Group – March 2016

There was no actual meeting in March however performance papers were circulated.
Specific issue raised:

• Anticoagulation service– quality issues highlighted from the PALS report for
follow up at a subsequent CQRG. Call logs and response when messages are
left; telephone capacity during busy times process for sending yellow books;
department incident reporting and investigation process. From Board Quality
Report – February 2016
• Emergency Access - February was a difficult month with a number of days where
we were below 90%. This was for a number of reasons and also includes
Norovirus on the wards which played some part in restricting flow and bed
availability. Within ED there continued to be process issues and staffing cover
problems with a reliance on locum doctors still presenting some challenges. The
NEL length of stay was higher in February and most escalation capacity
remained open during the month.

Page 17 of 35
• Cancer Services – performance met across all of the indicators except for 31
days where the numbers where low and therefore one breach meant the target
was failed.

5.7. Care Quality Commission (CQC)

The Trust was inspected by the CQC in January 2016. The report has not yet been
made available.

5.8. Serious Incidents including Never Events

The Trust has not reported any Never Events during this period
A separate confidential report that gives detail around Serious Incidents affecting
Surrey Downs patients that are currently under investigation will be presented at
Part 2 of this meeting and will include details pertaining to incidents reported by the
Trust.

5.9. Kingston Board papers

The most recent set of Board papers are available on this weblink.
[Link]

Summary of key issues and actions

• Issue – Continued poor hand hygiene compliance in areas of the Trust

although there has been some improvements

Action: Trust continues to target specific service areas

• Issue: CQC inspection during January- report not yet received

Action: Await report

Page 18 of 35
6. Surrey and Sussex Healthcare NHS Trust (SASH)

Lead Commissioner for Surrey – East Surrey CCG

6.1.1. NHS Choices – extracted on 19.04.16

Infection Safe Patients NHSE Patient Open
Control Staffing assessed for Safety notices and
and Blood Clots honest
Cleanliness (VTE) reporting
– monthly
NHSE

97%
of
planned
Among the level 95.10% of Good - All As
best patients alerts signed
assessed off where
(95.3% - deadline has
Feb) passed

6.1.2. Since the report to the March Committee, there is little change in the
indicators.

6.2. MRSA Bacteraemia

There were no cases of MRSA Bacteraemia reported by the Trust in January or

February 2016. There has been one case attributed to the Trust in 2015/16

6.3. Clostridium difficile

The Trust reported 2 cases of Cdifficile reported in December 2015 and 1 in January
2016. As previously reported, this means that they have now exceeded the annual
trajectory set for them by the Department of Health for 2015/16. The Trust has been
supported by the TDA in improving performance around this area.

The Trust has continued to reported outbreaks of viral gastro-enteritis and this
remains a risk on the Trust’s corporate risk register scored at 15 – Likelihood 5,
consequence 3.

6.4. CQUINs

CQUINs for 2015/16 are being monitored by the lead commissioner Crawley CCG in
conjunction with East Surrey CCG. Performance against Q3 is still being agreed and
Q4 will be discussed in May 2016. Confirmed achievement will be included in a
future report.

The CCG’s have commenced work on CQUINs for 16 /17.

Page 19 of 35
 6.5. Feedback from Clinical Quality Review Group – 16th March 2016

• Falls - the Trust has a 3-month average of around 100 falls per month – 70%
of these are no harm to the patient but approximately 2% result in severe
harm. Assurance given around the falls programme in place. The Nurse
Consultant has left the Trust so a review of the model is taking place
supported by Crawley, Horsham and Mid Sussex (CHAMS) CCGs.
• Safety thermometer is at 91.2% showing an increase in patients with
catheters/UTI (at 3%). This is in line with the information from the Surrey
Infection Control lead who feels that there needs to be a renewed emphasis
on competencies around catheter care. The Trust will be taking this forward
and developing a programme to support this.
• Hand hygiene compliance is at 98%. It has not dipped below 97% since
August 2015
• Agency usage has reduced but the Trust is still adverse in its trajectory. They
are actively recruiting and have introduced a new e-rostering system which
should help them manage capacity and demand more effectively.
• Junior Doctors Strike - Assurance was given about the actions that the Trust
has taken to minimise the risk from the Junior Doctors strike. The Trust
reported that they had planned effectively and at this point had not seen an
increase in complaints as a result of the strike.
• Serious Incident (SI) – System Black Escalation - A Provider workshop was
held on 4th February to discuss the SI relating to the system pressures that
was raised. The workshop was attended by SECAmb, SaSH, Sussex
Community Trust, CSH Surrey, First Community Health & Care and the Out
Of Hours service. Discussed the issues and developed actions. Further
pathway redesign was discussed. The SI report was due to be reviewed at the
Sussex Scrutiny Panel during the week of 14th March and the action plan
taken to the local SRG. A Steering group will be formed to oversee and drive
the identified actions
• Mazars Report - The Trust has not formally reviewed this as yet. A timescale
will be identified and agreed with commissioners for doing so. Planning is for
June 2016.
• 104 day breaches - CHAMS CCGs presented a process currently used by
them to gain assurance that RCAs relating to breaches were being carried out
and acted on. The process was one that had been adapted from that used at
RSCH (Guildford). It was agreed that the principle was good but the process
needed work (i.e. very little reference to including patients in the RCA etc.).
CHAMS will review this and the process will be brought back to a future
meeting.

6.6. Care Quality Commission (CQC)

The Trust was inspected by the CQC under its new inspection regime in June 2014,
receiving a rating of “good”.

6.7. Serious Incidents including Never Events

The Trust has not reported any Never Events during this period.

Page 20 of 35
A separate confidential report that gives detail around Serious Incidents affecting
Surrey Downs patients that are currently under investigation will be presented at Part
2 of this meeting and will include details pertaining to incidents reported by the Trust.

6.8. SASH Board papers

The most recent set of Board papers are available on this weblink.
[Link]

Summary of key issues and actions - SASH

• Issue: The Trust has exceeded its trajectory re. Cdifficile infections for the
year
Action: The Trust is being supported by NHS Improvement in its
improvement plans

• Issue: Mazars Report has not been formally reviewed by the Trust and so
Commissioners cannot be assured on its performance against the findings
and recommendations
Action: The Trust will review the report and action plan will be discussed at
the CQRG in June 2016

7. South East Coast Ambulance Service NHS Foundation Trust (SECAmb)

Lead Commissioner for Surrey – NW Surrey CCG

SECAmb was the focus of a Quality Seminar that was held by SDCCG Quality
Committee on 8th April 2016. The aim of the seminar was to enable committee
members to discuss the risks and issues relating to the service provided by SECAmb
and to receive assurance around the actions that have been taken by
Commissioners to date. The Trust will continue to be subject to a high level of
scrutiny in future Quality Committees

7.1. NHS Choices

SECAmb does not receive an overall rating on NHS Choices.

7.2. Quality and Performance

At the time of reporting, SECAmb had not developed the requested recovery plan.
During the discussion with SECAmb at Strategic Partnership Group (SPG) it was
suggested that based on the current national standards, the Trust would aim to
deliver the agreed national standards for Red 1 and A19, 75% and 95% respectively,
but that Red 2 would be an improving picture from April with SECAmb performing at
70% for Red 2 by September and that through improvements linked to the ‘new’
Page 21 of 35
recovery plan, they would finish 2016/17 at 75%, positioning them positively for the
start of 2017/18.

Although this suggestion was acknowledged by SECAmb there was a feeling that
due to their current challenges, they may not be able to get to 70% by September,
but it was the intention to produce a detailed trajectory for NHS Improvement that
would also be shared with commissioners by w/e 8th April. It was also agreed that
SECAmb would supply commissioners with a plan for delivering the recovery plan at
the same time. SECAmb also committed to producing the recovery plan in its first
draft no later than 4-6 weeks after the date of the SPG. It was stressed that this
would be the latest point for sharing the plan.

Commissioners have also agreed to establish a focus group to monitor and manage
all elements of the plan. At this stage SECAmb will be planning against their current
operating model, although they acknowledge that the Ambulance Response
Programme (ARP) may require adjustments to some of their planning if it was to
come into effect mid-year. It should be noted that full roll out of the ARP has not
been confirmed yet and is being trialled with Yorkshire Ambulance Service and
South West Ambulance Service.

Handover delays and patient outcomes:

A Kent, Medway, Surrey and Sussex workshop that will be funded by NHSE is to
take place in May.

It has been agreed that SECAmb will implement the immediate handover policy at 45
minutes, but instigate it at 15 minutes from the end of May.

The plan is for SECAmb to

Review the Immediate Handover Policy prior to NHSE system workshop in May for
presentation

• To align policy to process (currently instigated at 45minutes)

• SECAmb is to raise any handover not completed within 45 minutes as a
Serious Incident to commissioners- this could include multiple vehicles
stacked up at hospitals as a result of no trolleys being available
• Commissioners will use SI information to flag to whole system
• SECAmb will provide data to support back on the road time to performance
and build this into their planned trajectories
• A letter will be drafted that the Accountable Officers of the Lead
Commissioning CCGs will send to Associate CCGs to inform their Acute
Trusts of the implementation of the immediate handover policy by the end of
May 2016
• Handover will take place at 45 minutes and process started at 15 minutes
• Clarify that handover must take place 15 minutes after ambulance arrives at
the hospital
• SI/Handover process will be able to be captured on the SECAmb button in
Emergency Departments
• A Task and finish group has been established to work on developing the
escalation process

Page 22 of 35
 7.3. Care Quality Commission (CQC)

The Trust is due to be inspected by the CQC during the first week of May 2016.

.
7.4. Serious Incidents including Never Events

The Trust has not reported any Never Events during this period. A separate
confidential report that gives detail around Serious Incidents affecting Surrey Downs
patients that are currently under investigation will be presented at Part 2 of this
meeting and will include details pertaining to incidents reported by the Trust.

7.5. SECAmb Board papers

The most recent set of Board papers are available on this weblink.
[Link]

Summary of key issues and actions - SECAmb

• Issue – on-going concerns re service key performance indicators

Action – SDCCG following up through the lead commissioner

• Issue – Red 3 pilot investigation remedial action plan

Action – SDCCG is actively engaged in the commissioner forum to support
SECAmb and monitor the action plan.

Page 23 of 35
8. Surrey Downs CCG as host commissioners for all Surrey CCGs

8.1. Royal Marsden NHS Foundation Trust

Lead Commissioner: Sutton CCG

Lead Commissioner for Surrey – Surrey Downs CCG

8.1.1. NHS Choices – extracted on 19.04.16

Infection Safe Patients NHSE Patient Open

Control Staffing assessed Safety notices and
and for Blood honest
Cleanliness Clots (VTE) reporting
– monthly
NHSE

96%
of planned
level
As expected 95.80% of Good - All alerts As
(97%- Feb)l patients signed off where expected
assessed deadline has
(96.6% - passed
Feb)

8.1.2. Since the report to the March Committee there is little change; a slight
drop in staffing and VTE indicators.

8.2. MRSA Bacteraemia

The Trust has reported no cases of MRSA Bacteraemia since April 2015.

8.3. Clostridium difficile

The Trust has had 37 cases of Cdifficile attributed to them between April and
February 2016. They remain confident that they will achieve their agreed trajectory of
no more than 40 cases for the year.

8.4. Feedback from Clinical Quality Review Group – 23rd February 2016 – No
meeting in March 2016

• Cancer Waiting Times - 52 week wait breaches in December – there were 4

breaches in December all of which were for plastics treatment following
benign disease. The cases were discussed in depth at the November CQRG.
• The Trust met the 18 week RTT target.
• The Trust breached the 62-day cancer target in December and in Quarter 3
but both targets were met following reallocation. There was a 100-day breach
for breast screening, which has been reported on Datix.
• Safeguarding – The Trust has not met the training targets for adults and have
subsequently employed external trainers to deliver the levels 1 to 3 training
which began at the beginning of February. The Trust expects to meet the
targets by March 2016.
Page 24 of 35
 8.5. Care Quality Commission (CQC)

The CQC visited the Trust from the 19th to 22nd April 2016 and conducted focus
groups in the week beginning 4th April 2016. Staff groups interviewed included
Admin& Clerical staff, Band 5 & 6 nurses; matrons, CNS; Consultants and
Radiography staff.

The CCG contributed to the Commissioner submission to the CQC.

8.6. Serious Incidents including Never Events

The Trust has not reported any Never Events during this period.

A separate confidential report that gives detail around Serious Incidents affecting
Surrey Downs patients that are currently under investigation will be presented at Part
2 of this meeting and will include details pertaining to incidents reported by the Trust.

8.7. Safeguarding Adults and Children

As reported above, the Trust has not met the training targets for adults and has
subsequently employed external trainers to deliver the levels 1 to 3 training which
began at the beginning of February. The Trust expects to meet the targets by March
2016.

8.8. Royal Marsden Board papers

The most recent set of Board papers are available on this weblink.
[Link]

Summary of Key Issues and Actions – Royal Marsden

• Issue – The Trust has not met the training targets for safeguarding adults
• Action – The Trust has employed external trainers to deliver the levels 1 to
3 training. They expect to achieve their trajectory by the end of March 2016

Page 25 of 35
9. St George’s Healthcare NHS Trust (SGHT)

Lead Commissioner: Wandsworth CCG

Lead Commissioner for Surrey – Surrey Downs CCG

9.1.1. NHS Choices – extracted 19.04.16

Infection Safe Patients NHSE Open and
Control Staffing assessed for Patient honest
and Blood Clots Safety reporting
Cleanliness (VTE) notices
– monthly
NHSE

94%

of planned
Among the level 96.80% of Poor - Some As
worst patients alerts not
(95% - assessed signed off
Feb) (96.6% - Feb) after deadline

9.1.2. Since the report to the March Committee there is little change; slight
drop in staffing and VTE indicators.

9.2. MRSA Bacteraemia

The Trust reported 0 cases of MRSA Bacteraemia in Quarter 4. One previously

reported Bacteraemia was de-escalated which means that their end of year total
Bacteraemia will be 3.

9.3. Clostridium difficile

The Trust reported an end of year position of 29 Cdifficile infections against a

trajectory of 31. This is an improvement from last year when they reported 38
infections. The Trust’s objective for 2016/17 remains at 31.

9.4. CQUINs

Performance against the 2015/16 is being agreed with the Trust and the lead
commissioner.

Proposals for 2016 /17 CQUINs will be shared through the quality leads and the
CQRG.

9.5. Feedback from Clinical Quality Review Group – 16th March 2016

• Staff Feedback Survey – The Trust was disappointed on the result of the
survey, with below average scores. The Board recognised that change is
required. Action was being taken on staff morale and it is on the Board risk
register. Key areas of concern for staff were noted to be, IT/ Estate issues,
pressure due to vacancies, acting up arrangements. CQUIN funding was key
opportunity to work on improvements for staff, it was stressed that this is on-

Page 26 of 35
 top of what is already offered now. As this is a non-recurrent value it must be
used to maximise the impact of the funding.
• Workforce – nurse staffing – Trust not currently achieving framework. 8
breaches with agency staff last month, mainly understood to be issues in
Paediatrics. Total Cap on agency spend should be 10% however trust is
reporting 11.2% spend. In April the cap reduces to 8% and would cover
agency staff for all professions, including medical.
• Cancer 100 day breaches root cause analysis – not fit for purpose.
Documented process has since been agreed with commissioners.
• Safeguarding Adults compliance for training - remains a key area of focus.
The Trust is now demonstrating a compliance of 71% for adult training.
• Safeguarding Children compliance for training - Following validation of the
Safeguarding Children data the compliance for the Trust is now 75% at level
3, with Surgery an outlier in relation to Training performance. There are
agreed actions for both adult and children safeguarding which are being
monitored by the respective safeguarding Committees.
• Complaints – performance remains a challenge. A workshop took place on 7
March 2016 to review how the complaints process is working from beginning
to end and the governance/reporting/performance management. Participating
will be the Deputy Chief Nurse, Divisional Directors of Nursing and
Governance, Heads of Nursing, General Managers, Divisional Governance
Managers and the corporate complaints and PALS teams.

9.6. Care Quality Commission (CQC)

The Trust was inspected by the CQC under its new inspection regime in April
2014, receiving a rating of “good”.

9.7. Serious Incidents including Never Events

The Trust reported 8 SIs in February which brings the YTD total to 120.
The Trust had not reported any Never Events during this period. The YTD position at
February 2016 is 8.

A separate confidential report that gives detail around Serious Incidents affecting
Surrey Downs patients that are currently under investigation will be presented at Part
2 of this meeting and will include details pertaining to incidents reported by the Trust.

9.8. St George’s Board papers

The most recent set of Board papers are available on this weblink.
[Link]

Page 27 of 35
Summary of Key Issues and Actions – St George’s Hospital

• Issue – Complaints performance

Action – continued focus on the process in targeting specific Divisions where
improvement is required

• Issue – Infection Control Performance Poor hand hygiene compliance in

areas of the Trust.
Action: Trust targeting specific service areas

• Issue: Safeguarding Children and Adult Training compliance

Action: Agreed actions for both adult and children safeguarding which are
being monitored by the respective safeguarding Committees.

• Issue: CQC inspection during January- report not yet received

Action: TBC

Page 28 of 35
10. Surrey Downs CCG – other providers

Surrey Downs CCG also commissions care from the following providers:

• Ashford and St Peters NHS Foundation Trust

• Frimley Park Hospital NHS Trust
• Royal Surrey County Hospital NHS Trust
• Virgin Care - Surrey
• Guys and St Thomas’ Hospitals NHS Trust
• Moorfields Hospital NHD Trust
• Royal National Orthopaedic Hospital NHS Trust
• Princess Alice Hospice

Information about these providers will be included on an exception basis and any
concerns of a confidential nature will be raised in Part 2 of this meeting.

5.1.1 Ashford and St Peters NHS Foundation Trust

Lead Commissioner: North West Surrey CCG

As reported in previous Quality reports, Ashford and St Peters continues to be under

investigation by NHS Improvement (Formerly Monitor) regarding their A&E
performance, Breaches in the Cancer targets and financial performance. No further
information is available at this time. The Trust currently has a rating of 3.

5.1.2 Royal Surrey County Hospital NHS Trust

Lead Commissioner: Guildford and Waverley CCG

Guildford and Waverley CCG has issued a performance notice to RSCH for their
declining performance in A&E, Stroke, Cancer 62 days, Workforce and Diagnostics.
This is the second notice issued (the first one was issued in November 2015).
The CCG has also escalated concerns to CQC and NHS Improvement via the notice
letter.
They have received a remedial action plan and are working with the Trust to ensure
improvements are achieved and sustained.

Page 29 of 35
11. Surrey Downs CCG – Any Qualified Providers

11.1. Dorking Healthcare (DHC)

11.2. NHS Choices

Dorking Healthcare does not receive an overall rating on NHS Choices.

11.3. Feedback from Contract /Clinical Quality Review Group

The next CQRG is due to be held with Dorking Healthcare on 9th May 2016. DHC
has recently appointed a new Governance Manager following the retirement of the
previous post holder. The SDCCG Head of Quality has met with her to talk through
the Quality reporting process, the latest report and to gain additional assurance in a
number of areas. There are no concerns that need to be escalated at this time.

11.4. Care Quality Commission (CQC)

Dorking Healthcare is currently compliant in all standards that have been assessed
by the CQC. The last inspection was reported in October 2013.

11.5. Serious Incidents including Never Events

A separate confidential report that gives detail around Serious Incidents affecting
Surrey Downs patients that are currently under investigation will be presented at Part
2 of this meeting and will include details pertaining to incidents reported by Dorking
Healthcare.

11.6. Epsomedical (EM)

11.7. NHS Choices

Epsomedical does not receive an overall rating on NHS Choices.

11.8. Feedback from Contract /Clinical Quality Review Group

The next CQRG is due to be held on the 19th May 2016. In the interim quarter, the
Quality Team has continued to monitor the organisations quality report and no
concerns need to be escalated at this time.

11.9. Care Quality Commission (CQC)

Epsomedical is currently compliant in all standards that have been inspected by the
CQC. The last inspection of Cobham Day Surgery took place in August 2013 and
Epsom Day Surgery in February 2014.

11.10. Serious Incidents including Never Events.

There have been no Never Events or Serious Incidents reported by Epsomedical

since the last Quality and Performance report in March 2016.

Page 30 of 35
12. Quality issues arising within services hosted by Surrey Downs CCG for
CCGs in the Collaborative

12.1. Medicines Management

Progress on reducing antimicrobial prescribing in primary care – Helen Marlow,

Lead Primary Care Pharmacist and NICE Medicines and Prescribing Associate
The CCG Medicines Management team have been working with GP practices in
Surrey Downs on an on-going basis to reduce prescribing of antimicrobials.
Specific actions that have been taken:

In 2014/15:

• Education of GP practice prescribing leads on antimicrobial resistance (using

RCGP TARGET resources), review of current prescribing data and promotion
of tools to reduce antibiotic prescribing
• Promotion of the Surrey Primary Care Antibiotic prescribing guidelines
• Inclusion of messages to promote responsible antibiotic prescribing in
ScriptSwitch (our prescribing decision support software)

In 2015/16:

• Inclusion of a requirement to develop practice action plan to improve practice

antibiotic prescribing within the level 1 prescribing primary care standard for
2015/16. All practices produced an action plan by end of July 2015.
• Continuing promotion of the RCGP TARGET resources
• Purchase and distribution of “When should I worry leaflet?” to GP practices.
The leaflet provides information for parents about the management of
respiratory tract infections in children and has been designed to be used in
primary care consultations.

Achievement of Quality Premium Targets

The patient safety Quality Premium in 2015/16 and in 2016/17 includes some
measures around improved antibiotic prescribing in primary care. These are
reduction in the number of antibiotics prescribed in primary care and reduction in the
proportion of broad spectrum antibiotics prescribed in primary care. The CCG has
achieved both of the national Quality Premium targets for antibiotic prescribing set
for 2015/16. The trajectory for the number of antibiotics prescribed continues to be
downward; however we are making less good progress on the proportion of broad
spectrum antibiotics prescribing in primary care despite achieving our 2015/16
target. See attached graphs for CCG trends and individual practice performance.

How to further reduce the use of broad spectrum antibiotics in primary care will be
discussed at the GP prescribing leads meeting in April 2016. The CCG practice
pharmacists have already identified that laboratory testing and reporting may be
contributing to inappropriate use of broad spectrum antibiotics.

Page 31 of 35
Antimicrobial stewardship

In August 2015, NICE published guideline (NG15) Antimicrobial stewardship:

systems and processes for effective antimicrobial medicine use. The guideline
includes recommendations for CCGs on improving antimicrobial stewardship. A key
recommendation from the guideline is for commissioners to ensure that antimicrobial
stewardship operates across all care settings as part of an antimicrobial stewardship
programme.

Recommendation to the Quality Committee

The Quality Committee is asked to consider advising the Executive Team of the
benefit of appointing a clinical lead for antimicrobial stewardship to lead the
implementation of recommendations from the NICE guideline on antimicrobial
stewardship.

13. Quality issues arising within ‘other’ services

13.1. Care Homes

CAS Alert: Patient Safety Alert - Risk of death from failure to prioritise home visits in
general practice

This alert was cascaded to SDCCG practices through the national system and, as
commissioner with responsibility for ensuring practices comply, NHSE will be
following up to obtain assurance from individual practices around the systems that
they have put in place to manage to risks identified. However, with the CCG’s
increasing role around quality and safety in practices, the Quality Team asked for
further assurance that this particular alert had been discussed and that the four
actions were being addressed across localities.

It was confirmed by the Primary Care Manager that this alert had been discussed as
an agenda item by all 3 localities in April 2016. A number of practices highlighted
that they had already created or revised their procedures as a result of this alert and
were happy to share these with other practices.

Surrey Quality Assurance Steering Group

Throughout 2015, a Surrey multi-agency task and finish working group was formed
to review multi-agency Quality Assurance (QA) models (for commissioners) and to
identify opportunities for improvement.

As a result of this, a number of further work streams have been identified and task
and finish groups have been formed to take this work forward. They are:

• Public Point of Contact

• Communications
• QA information sharing
• Support offers for providers
• Early warning systems and response
• Resources
Page 32 of 35
 • Training and support for health and social care professionals

This work will apply to all independent providers. The first meeting of the steering
group that will oversee these work streams took place on 26th April and will in future
meet bi-monthly to monitor and assure progress.

Page 33 of 35
Appendix 1 Provider Dashboard – Quality and Safety Indicators
Provider dashboard (Trust level data)
2014/15 Epsom and St Surrey and
Indicator Source Source Frequency Period Kingston SASH SECAMB Royal Marsden St George's
Target Helier Borders
Patient Reported Outcome Measures (PROMS)

1.1 Health gain (EQ-5D index) – groin hernia surgery 0.15 0.13 0.00

1.2 Health gain (EQ-5D index) – varicose vein surgery 0.10 0.10
PROMS HSCIC website Annual FY 2013/14
1.3 Health gain (EQ-5D index) – hip replacement surgery
0.39 0.47 0.47
(primary)
1.4 Health gain (EQ-5D index) – knee replacement surgery
0.31 0.36 0.36
(primary)
Friends and Family Test (FFT)

2.1 Friends and Family Test response rate - A&E 8.5% 1.6% 28.1% 26.0%

2.2 Friends and Family Test response rate - Inpatients 15% 29.7% 30.0% 19.3% 19.5%

2.3 Friends and Family Test response rate - Maternity 16.1% 16.7% 29.3% 100.0%
Friends and Family
NHSE website Monthly Feb-16
2.4 Friends and Family Test % recommend - A&E Test (FFT) 87.4% 94.3% 96.3% 80.7%

2.5 Friends and Family Test % recommend - Inpatients 95.1% 95.8% 95.4% 93.1%

2.6 Friends and Family Test % recommend - Maternity 98.3% 98.6% 97.1% 5.9%

Mixed Sex Accommodation breaches

3.1 Mixed Sex Accommodation breaches UNIFY CSU portal Monthly 0 Mar-16 0 0 0 0 0 0
Patient Safety
4.1 Patients admitted to hospital who were risk assessed
UNIFY NHSE website Quarterly 95% Dec-15 93.6% 98.3% 95.3% 95.0% 96.5%
for venous thromboeombolism (VTE)

HSCIC
4.2 Rate of patient safety incidents per 1000 bed days National Reporting 33.12 31.78 28.56 22.58 57.93 34.08
portal//[Link] 01/10/14-
and Learning Service Bi-Annually
ources/- look for organisation patient 31/03/15
4.3 Percentage of patient safety incidents resulting in (NRLS)
safety incident reports-data workbooks 0.56% 0.61% 0.50% 4.68% 0.06% 0.31%
severe harm or death
4.3 Incidence of Healthcare Associated Infection (HCAI):
0 0 0 0 0 0
MRSA
PHE CSU portal Monthly Feb-16
4.4 Incidence of Healthcare Associated Infection (HCAI):
3 3 1 7 3
Clostridium difficile

4.5 Never Events (provisional data) STEIS/NHSE NHSE search for Never Events Data Monthly 0 Feb-16 0 0 0 0 0 0 0

Hospital Mortality
Quarterly
Jul-14 to Jun-
5.1 Summary Hospital-Level Mortality Indicator (SHMI) HES HSCIC portal// Dr Foster (rolling 12 0.98 0.92 0.96 0.90
15
months)
Unscheduled Care
6.1 A&E waits within 4 hours 95% Feb-16 93.0% 90.8% 91.4% 83.2%
6.2 Unplanned re-attendance rate at A&E within 7 days of
UNIFY SCSU dashboard Monthly 5% Dec-14 7.1% 7.0% 5.8% 2.9%
original attendance
6.3 Left A&E department without being seen rate 5% Dec-14 2.5% 2.8% 2.3% 2.7%
Category A ambulance calls
7.1 Life threatening (defibrillator required): Category A
75% 63.0%
calls within 8 minutes - Red 1
7.2 Life threatening (defibrillator NOT required): Category
SECAMB SECAMB report Monthly 75% Mar-16 51.3%
A calls within 8 minutes - Red 2
7.3 All life threatening: Category A calls within 19 minutes 95% 89.4%

Page 34 of 35
 2014/15 Epsom and St Surrey and
Indicator Source LS Source Frequency Period Kingston SASH SECAMB Royal Marsden St George's
Target Helier Borders
Mental Health

8.1 Proportion of patients on Care Programme Approach

NHSE website//Mental Health
(CPA) followed up within 7 days of discharge from UNIFY Quarterly 95% Dec-15 96.3%
Community Teams Activity
psychiatric inpatient care (also 1.2)

Cancelled Operations
9.1 Number of last minute elective operations cancelled
163 15 170 6 149
for non clinical reasons
UNIFY NHSE website Quarterly Dec-15
9.2 Number of patients not treated within 28 days of last
2 0 0 0 35
minute elective cancellation
Referral To Treatment (RTT) waiting times for non-urgent consultant-led treatment
10.1 Referral to treatment times (RTT): % of admitted
90% 79.3% 80.8% 86.8% 92.0% 75.6%
patients who waited 18 weeks or less
10.2 Referral to treatment times (RTT): % of non-admitted
95% 91.4% 96.9% 88.3% 99.4% 86.8%
patients who waited 18 weeks or less
UNIFY CSU portal Monthly Feb-16
10.3 Referral to treatment times (RTT): % of incomplete
92% 94.5% 97.0% 93.6% 94.7% 88.4%
patients waiting 18 weeks or less
10.4 Referral to treatment times (RTT): number of
0 0 0 0 0 0
incomplete patients waiting 52 weeks or more
Diagnostic test waiting times

11.1 % Patients waiting over 6 weeks for a diagnostic test 1% 0.1% 0.1% 0.0% 0.5%
UNIFY CSU portal Monthly Feb-16
11.2 Number of patients waiting over 6 weeks for a
8 2 0 35
diagnostic test
Cancer waits
12.1 (CB_B6) Cancer patients seen within 14 days after
93% 96.6% 95.9% 93.0% 96.9% 88.2%
urgent GP referral
12.2 (CB_B7) Breast Cancer Referrals Seen within 2 weeks 93% 0.0% 96.3% 94.4% 95.4% 93.8%

12.3 (CB_B8) Cancer diagnosis to treatment within 31 days 96% 99.1% 95.7% 96.9% 98.8% 97.8%

12.4 (CB_B9) Cancer Patients receiving subsequent surgery

94% 100.0% 100.0% 100.0% 96.4% 97.9%
within 31 days
12.5 (CB_B10) Cancer Patients receiving subsequent
Open Exeter NHSE website Quarterly 98% Dec-15 100.0% 100.0% 100.0% 100.0% 100.0%
Chemo/Drug within 31 days
12.6 (CB_B11) Cancer Patients receiving subsequent
94% 0.0% 0.0% 100.0% 98.5% 0.0%
radiotherapy within 31 days
12.7 (CB_B12) Cancer urgent referral to treatment within
85% 86.1% 90.2% 87.1% 79.0% 85.4%
62 days
12.8 (CB_B13) Cancer Patients treated after screening
90% 100.0% 100.0% 93.8% 90.8% 94.3%
referral within 62 days
12.9 (CB_B14) Cancer Patients treated after consultant
86% 95.1% 85.7% 100.0% 83.3% 90.9%
upgrade within 62 days

Page 35 of 35
Surrey Downs CCG Performance Report 2015/16
April 2016
This report reflects the current CCG performance position against the goals and core
responsibilities of CCGs as outlined in the NHS England documents of “Everyone
Counts: Planning for Patients 2014/15 to 2018/19” and “CCG Assurance Framework
2015/16”.

The report summarises performance against the key areas outlined below and forms
the basis of the NHS England South regional team’s quarterly assurance meetings:

• CCG Outcomes Indicator Set

• NHS Constitution
• CCG Operating Plan

The report
Figure is domains
1: Five set out under the five
of the NHS domains
Outcomes of the NHS Outcomes Framework:
Framework

1
1 Executive Summary
The key risks that have been identified are:
• Emergency admissions for alcohol related liver disease (February data)

Year to date there have been 52 admissions compared to 60 during the same period
last year. This equates to a rate of 23.40 admissions per 100,000 population
compared to 27.00 last year. At the Local Joint Commissioning Group (LJCG) in
May, the Public Health Prevention Plan will be reviewed with Surrey County Council.

• Maternal smoking at delivery (March data)

During Quarter 4 2015/16, 29 women out of 660 maternities were smokers at the
time of delivery. This equates to a rate of 4.4%, which is 0.1% higher than the same
period last year (4.3%). The smoking rate has been falling from a high of 5.7% in
Quarter 2 2015/16.

• Breast feeding prevalence at 6-8 weeks (June data)

There is no change from last report as validated data from Q2 is not available

• Incidence of Healthcare Associated Infection (HCAI): MRSA (February data)

There have been no new reported cases of MRSA since last report.

• A&E waits within four hours (February data)

Year to date, Surrey Downs CCG has failed to achieve the 95% target, with
performance of 94.1%. The CCG has not met the national standard since
September 2015.

Q4 activity has continued to offer challenges to the local systems but regular,
planned communication calls have assisted in preventing systems failure. The CCG
continues to participate in ensuring the operational efficiency in the urgent care
system and, from a long term strategic standpoint, is working towards implementing
an integrated model of care.
• Cancer urgent referral to treatment within 62 days (February data)

81.5% of patients referred were treated within 62 days year to date. This represents
134 breaches out of 725 patients, 26 breaches over the 85% target.
Epsom & St. Helier has an action plan which is being monitored by the monthly
Planned Care Working Group and also at the Clinical Quality Reference Group.
• Ambulance response times (March data)

2
 Over the last year, South East Coast Ambulance Service NHS Foundation Trust
(SECAmb) performance has fluctuated around the 75% target for Red 1 and Red 2
responses within 8 minutes.
In 2015/16, trust wide performance was below target for Red 1 with 72.6% and Red
2 with 70.8%.

SECAmb continues to struggle with meeting National Targets and will produce a
detailed recover trajectory for Monitor and a Recover Action Plan which will be
shared with commissioners by w/e 8th April. Commissioners have agreed a focus
group to monitor and manage all elements of the plan.
SECAmb are due to have a CQC inspection at the beginning of May and the CCG
has fed into the Surrey Collaborative feedback letter. In the letter, key areas of
concern have been highlighted to the CQC inspectors/
• Improving Access to Psychological Therapies (IAPT) (February data)

The national access target for 2015/16 is that 15% of people with depression and
anxiety disorders enter treatment. This equates to a monthly rate of 1.25%, or 334
people per month. 10.3% of the CCG’s prevalence figure entered treatment from
April 2015 to February 2016, a shortfall of 930 people.

The CCG introduced a self-referral pathway to IAPT services in order to improve

access to services which has resulted in an increase in referrals to the services and
the trend is expected to continue into 2016/17.

• Dementia Diagnosis

The CCG’s current performance is 62.8% which is below the National Target of
66.7%. The CCG continues to work with practices and nursing homes to improve the
diagnosis rate by education workshops and also by improving identification through
supporting GP practices with coding. The CCG will be co-producing a dementia
strategy with Surrey County Council and will embed memory assessment services
into community hubs
The Quality Committee is asked to:
1. Review the report and note the CCG’s performance;

3
2 Key concerns
Based on the most recent data the quality and performance risks highlighted in this
report are:
• Emergency admissions for alcohol related liver disease
• Maternal smoking at delivery
• Breast feeding prevalence at 6-8 weeks
• Incidence of Healthcare Associated Infection (HCAI): MRSA
• A&E waits within 4 hours
• Cancer urgent referral to treatment within 62 days
• Ambulance response times
• Improving Access to Psychological Therapies (IAPT)
• Dementia Diagnosis
Table 1 below shows the number of indicators in each domain of the NHS Outcomes
Framework, and the NHS Constitution, rated Red/Green based on latest year to date
performance.
Red Green
CCG Outcomes Framework:
1. Preventing people from dying prematurely 3 0
2. Improving quality of life for people with long 0 1
term conditions
3. Helping people to recover from episodes of ill 1 0
health or following injury
4. Ensuring that people have a positive Data not yet released
experience of care
5. Treating and caring for people in a safe
environment and protecting them from 1 1
avoidable harm
NHS Constitution 4 14

Table 1: RAG ratings for performance indicators

4
3 CCG Outcomes Indicators (Full dashboard is at Appendix A)
3.1 Preventing people from dying prematurely
3.1.1 Emergency admissions for alcohol related liver disease (February data)
This measure is a proxy indicator for the mortality rate from liver disease, which is part
of the CCG Outcomes Indicator Set. The number of admissions is directly age and sex
standardised per 100,000 population.
Year to date, there have been 52 admissions compared to 60 during the same period
last year. This equates to a rate of 23.40 admissions per 100,000 population compared
to 27.00 last year.
Looking at the monthly data February showed an increase in admissions rate following
some low volumes of fluctuation (Table 2).
Month Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar FY
2014/15 volume 3 5 4 4 8 5 6 8 8 5 4 4 64
2015/16 volume 3 7 4 3 4 5 5 4 8 3 6 52
2014/15 rate per
1.35 2.25 1.80 1.80 3.60 2.25 2.70 3.60 3.60 2.25 1.80 1.80 28.80
100,000 population
2015/16 rate per
1.35 3.15 1.80 1.35 1.80 2.25 2.25 1.80 3.60 1.35 2.70
100,000 population

Table 2: Surrey Downs CCG emergency admissions for alcohol related liver
disease

Figure 2:Rolling year Surrey Downs CCG emergency admissions for alcohol related liver disease
At the Local Joint Commissioning Group (LJCG) in May, the Public Health Prevention
Plan will be reviewed with Surrey County Council. The Sustainable Transformation
Programme aims to support a common and shared prevention plan and is currently
under development

5
3.1.2 Maternal smoking at delivery (March data)
This indicator forms part of the CCG Outcomes Indicator Set. It measures the
percentage of women who were smokers at the time of delivery, out of the number of
maternities.

During Quarter 4 2015/16, 29 women out of 660 maternities were smokers at the time
of delivery. This equates to a rate of 4.4%, which is 0.1% higher than the same period
last year (4.3%).

3.2
FigureTreating
3: Rolling and caringDowns
year Surrey for people in a safe
CCG emergency environment
admissions andrelated
for alcohol protecting them
liver disease
from avoidable harm

3.2.1 Incidence of Healthcare associated infection (HCAI)

[Link] MRSA
There was no case reported in February.

6
4 NHS Constitution Metrics (Full dashboard is at Appendix A)
4.1 A&E waits within four hours (February data)
A&E wait times are measured within the NHS Constitution and form part of the Quality
Premium calculation for CCGs in 2015/16. The full year target is that at least 95% of
patients are admitted, transferred or discharged within four hours of their arrival at an
A&E department. If the target is not achieved then 30% of the eligible funding will be
removed.
In the most up to date National figures for the CCG, Surrey Downs CCG has failed to
achieve the 95% target, with performance of 94.1%.

The CCG actively monitors the A&E status of its key trusts on a daily basis. The
performance is disseminated on a daily basis to senior management, reviewed at
Finance and Performance Subcommittees monthly and by the Executive Management
Team biweekly. Surrey Downs CCG actively engages with all key stakeholders via the
System Resilience Group (SRG) and shares the information to ensure actions are taken
to mitigate risks.

Throughout February, Epsom struggled to cope with surges in activity, admissions and
continual demand for Majors and Resus. The hospital also struggled with bed capacity
during the month due to admissions routinely exceeding discharges which often led to a
number of unplaced points in ED. To mitigate the pressures, the Trust continued to
have medical outliers in the hospital’s planned care and private wards.

Figure 4: Trust wide weekly A&E 4 hour waits

The CCG continues to participate in the 7 day LOS meeting at its key acute site with
community and social care colleagues, the aim of this meeting is to discuss and
‘unblock’ patients who have been in an acute bed for more than 7 days

SDCCG SRG also has in place an operational framework for Nursing Home
Assessment CHC beds. In addition, there is an evolving integration strategy alongside
aimed at providing an enhanced level of support for older people in the community

7
4.2 Cancer waiting times
The nine national cancer waiting times measures form part of the NHS Constitution and
are based on data within the Open Exeter system.
Cancer waiting times performance at South West London NHS trusts is monitored by
the Transforming Cancer Services Team (TCST). All trusts that do not achieve the
required standards on a monthly basis are asked to provide the TCST with exception
and breach reports. The team work in conjunction with providers to formulate action
plans and monitor performance going forward.

4.2.1 Patients receiving first definitive treatment for cancer within 62 days of an
urgent GP referral (February data)
The target is that 85% of patients receive first definitive treatment within 62 days of an
urgent GP referral for suspected cancer. This also includes 31 day waits for children’s
cancer, testicular cancer and acute leukaemia.
81.5% of patients referred were treated within 62 days year to date. This represents
134 breaches out of 725 patients, 26 breaches over the 85% target limit. This also
includes a 22-day delay on the pathway of one patient at Epsom and St Helier due to
the patient being unattainable to arrange MRI.
Year to date the breaches occurred at Epsom and St Helier (34), The Royal Marsden
(58), St George’s Healthcare (16), Surrey and Sussex Healthcare (5), Kingston Hospital
(6), Royal Surrey (13), Epsomedical (2), King's College Hospital (0) and West
Hertfordshire Hospitals (0).

Figure 5: Surrey Downs CCG 62 day waits from urgent referral to first treatment

4.3 Ambulance response times - life threatening (defibrillator required) Category

A calls within eight minutes
There is a Remedial Action Plan (RAP) in place for SECAmb as the trust continues to
struggle to meet the Red 1 and Red 2 targets. However, SECAmb have been asked to

8
forward a revised performance trajectory based on the actions within the RAP as R1 &
R2 are both no longer achievable by year-end due to exceptionally high
activity/pressures over the last 6 weeks and the recent implementation of the
Ambulance Quality Indicator guidance. The original RAP will be superseded by a larger
recovery plan that will cover performance and quality issues, but will also include
governance and 111.

Figure 6: SECAmb Red 1 Recovery trajectory

Figure 7: SECAmb Red 2 Recovery Trajectory

9
SECAmb’s full year performance in 2015 was below the national standard of 75% for
Red1 with percentage at 72.6% and Red 2 with percentage at 70.8%. Whole year
performance for A19 was 94.3%, which is also below the national target of 95%.

Hospital handover delays continue to be a challenge across the region. Hospital

conveyance has continued to see an increased due to patient acuity being higher than
usual. A Regional KSS joint workshop is being arranged to take place in May to
highlight the challenges and to allow SECAmb to share their revised Immediate
Handover Policy.

4.3.1 Red 1 (March data)

This measure is part of the NHS Constitution and forms part of the calculation for the
Quality Premium payments to CCGs in 2015/16. If the target is not achieved then 20%
of the eligible funding will be removed.
Performance is assessed at whole trust level and has a target of 75%.
South East Coast Ambulance Service NHS Foundation Trust (SECAmb) failed 75%
target in 2015/16, with an overall performance of 72.6%, only first month April achieved
target with a performance of 75.9% in 2015/16, the rest of the eleven month all fell
below target, March produced poorest performance with 63.0%, whereas full year
2014/15 performance achieved the target at 75.3%.
For Surrey Downs CCG patients only, full year performance was 70.7%.

4.3.2 Red 2 (less time critical) (March data)

The following measure is part of the NHS Constitution and has a target of 75%.
Performance is assessed at whole trust level. It does not contribute towards the Quality
Premium.
Trust wide performance failed 75% target with 70.8% for the full year, monthly
performance fell below target in ten of twelve months, with March being the lowest at
51.3%. A 3.5% decrease compare to 2014/15 financial year (74.3%).
For Surrey Downs CCG patients only, full year performance was 65.6%.

10
5 CCG Operating Plan
5.1 Improving Access to Psychological Therapies (IAPT) (February data)
The commitment to continue to improve access to psychological therapy was set out in
‘Achieving Better Access for Mental Health Services by 2020’ and reinforced in the
2015 Comprehensive Spending Review. The primary purpose of these indicators is to
measure improvement in access rates to psychological therapy services via the national
Improving Access to Psychological Therapies (IAPT) programme for people with
depression and/or anxiety disorders.

There are four national performance indicators:

• The proportion of people in need of psychological therapies that have entered

treatment (target 15%);
• The proportion of people who have completed treatment who have moved to
recovery (target 50%);
• The proportion of people waiting no more than six weeks from referral to entering
a course of IAPT treatment (target 75%);
• The proportion of people waiting no more than eighteen weeks from referral to
entering a course of IAPT treatment (target 95%).
Surrey Downs CCG’s trajectory for people entering treatment equates to a monthly rate
of 1.25% over the financial year. This is equivalent to 334 people entering treatment
each month.
2744 patients entered treatment from April 2015 to February 2016. This equates to
10.3% of the CCG’s prevalence figure against the year to date target of 13.75%, a
shortfall of 930 people.
The CCG is also not achieving the National target in IAPT recovery rate, with December
at 50.5%, and year to date with 49.2%. However, the CCG is meeting the national
targets for IAPT referral to treatment times.
The CCG has an action plan to improve the uptake of psychological therapies and the
CCG has invited the Intensive Support Team to review actions taken. Current actions
are:
• The establishment of referral data to be supplied to locality meetings and
keeping IAPT on the agenda for GP practices
• Working with our Lead Commissioner on the re-validation (through AQP) of our
current providers
• Holding regular meetings with our providers to ensure issues or problems are
dealt with

11
 • PromotingIAPT through A&E, the Safe Haven (evening café), other centres and
forums to continue throughout the end of 15/16 and into 2016/17

2015/16
Indicator Measure Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 YTD
target
Improving Access to Psychological Therapies (IAPT)

Proportion of the people that enter treatment against Percentage 15.0% 0.7% 0.8% 0.9% 1.0% 0.7% 0.6% 0.9% 1.2% 1.2% 1.1% 1.0% 10.3%
the level of need in the general population Patients entering treatment 4,006 181 202 244 269 199 171 252 328 318 304 276 2,744
Percentage 50.0% 50.3% 51.6% 53.3% 50.4% 47.3% 49.2% 47.1% 53.5% 44.2% 43.6% 50.5% 49.2%
Patients moving to recovery 78 79 97 114 69 95 74 77 69 85 95 932
Proportion of patients completing treatment who have Patients completing treatment 163 165 193 241 155 206 165 149 164 207 202 2,010
moved to recovery
Patients completing treatment who were
not at clinical caseness at initial 8 12 11 15 9 13 8 5 8 12 14 115
assessment

Proportion of patients completing treatment who Percentage 75.0% 91.4% 93.3% 92.2% 94.2% 91.0% 91.3% 93.9% 90.6% 94.5% 92.8% 94.6% 92.8%
commenced within 6 weeks of referral Patients waiting more than 6 weeks 14 11 15 14 14 18 10 14 9 15 11 145

Proportion of patients completing treatment who Percentage 95.0% 96.3% 98.8% 96.9% 97.9% 94.8% 97.6% 96.4% 94.6% 98.2% 98.1% 99.0% 97.3%
commenced within 18 weeks of referral Patients waiting more than 18 weeks 6 2 6 5 8 5 6 8 3 4 2 55

T able 3: Surrey Downs CCG IAPT performance

Surrey Downs CCG IAPT - Entering treatment

Centre for Psychology Ieso Digital Health KCA Dorking Healthcare Mind Matters Surrey
Number of people entering

350
300
treatment

250
200
150
100
50
0

Month

Figure 8: Surrey Downs CCG IAPT – people entering treatment

Surrey Downs CCG IAPT - Moving to recovery

Number of patients moving to

Centre for Psychology Ieso Digital Health KCA Dorking Healthcare Mind Matters Surrey
120

100
recovery

80

60

40

20

Month
Figure 9: Surrey Downs CCG IAPT – patients moving to recovery

12
5.2 Dementia Diagnosis (February data)
The current dementia diagnosis rate is 62.8% and the national target is 66.7%.

SDCCG continues to support practices with visits by the GP dementia lead and a data
analyst to ensure practices are identifying and coding effectively.

The CCG held an education event at the end of January, which reached ¾ of Surrey
Downs Practices with an attendance of over 40 people, including GPs, practice nurses
and Continuing Healthcare Team members. Topics covered were:

• Diagnosis and identification

• Prescribing and dementia pathways
• Alzheimer’s Society and Dementia Navigators
• SDCCG’s on-going support for practices

Due to the success of the event, the CCG will develop a second event aimed at
practices that hold Care Home contracts.

To ensure that there is a cohesive approach to dementia, the CCG will co-produce a
Joint Dementia Strategy with Surrey County Council. The CCG is also embedding
memory assessment within its community hub model as part of its integration strategy.

Figure 10:Estimated Dementia diagnosis rate

13
6 Recommendations and Next Steps
The Quality Committee is asked to:
1. Review and note the performance and actions taken.

14
Appendix A: Full Detail: Performance data
CCG Outcomes Indicator Set 2015/16 (19/04/2016)

2015/16 YTD
Indicator Measure Frequency Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16
target 15/16
1 Preventing people from dying prematurely
1.8 Emergency admissions for alcohol Age/sex standardised rate
Monthly 1.35 3.15 1.80 1.35 1.80 2.25 2.25 1.80 3.60 1.35 2.70 23.40
related liver disease (proxy measure) per 100,000 population
1.14 Maternal smoking at delivery Percentage of maternities Quarterly 4.6% 4.2% 4.8%
5.7%
1.15 Breast feeding prevalence at 6-8
Percentage of infants Quarterly 50.4% 50.4%
weeks
2 Improving quality of life for people with long term conditions
2.7 Unplanned hospitalisation for asthma, Age/sex standardised rate
Monthly 3.08 21.54 16.93 21.54 9.23 32.31 10.77 21.54 13.85 18.47 20.00 189.26
diabetes and epilepsy in under 19s per 100,000 population
3 Helping people to recover from episodes of ill health or following injury
3.4 Emergency admissions for children Age/sex standardised rate
Monthly 16.93 12.31 13.85 12.31 10.77 20.00 23.08 92.33 101.56 52.32 21.54 377.00
with lower respiratory tract infections per 100,000 population
4 Ensuring that people have a positive experience of care
Data not yet released by NHS England
5 Treating and caring for people in a safe environment and protecting them from avoidable harm
5.2i Incidence of Healthcare associated
Monthly 0 0 0 1 0 0 0 0 0 0 0 0 1
infection (HCAI): MRSA Number of infections
5.2iI Incidence of Healthcare associated reported
Monthly 76 6 5 11 9 4 17 5 3 11 7 8 86
infection (HCAI): C. difficile

15
 NHS Constitution Metrics 2015/16 (19/04/2016)
2015/16
Indicator FY 2013/14 FY 2014/15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 YTD
target
Referral To Treatment (RTT) waiting times for non-urgent consultant-led treatment
Referral to treatment times (RTT):% of admitted patients who waited 18
94.1% 92.1% 90% 92.5% 92.7% 92.6% 92.7% 91.7% 89.3% 84.3% 84.6% 87.3% 84.4% 83.8% 87.1%
weeks or less
Referral to treatment times (RTT):% of non-admitted patients who waited 18
97.4% 95.7% 95% 96.6% 96.6% 95.9% 95.2% 94.3% 93.5% 93.4% 93.5% 93.7% 93.6% 94.0% 94.6%
weeks or less
Referral to treatment times (RTT):% of incomplete patients waiting 18
96.0% 95.2% 92% 95.5% 95.5% 95.5% 94.7% 94.4% 94.0% 94.1% 94.6% 94.1% 94.4% 94.7% 94.7%
weeks or less
RTT: Number of incomplete patients waiting >52 weeks 0 0 0 0 0 0 0 0 0 0 0 0
Diagnostic test waiting times
% Patients waiting within 6 weeks for a diagnostic test 99.3% 99.3% 99% 99.2% 99.5% 99.4% 99.4% 99.4% 99.3% 99.6% 99.6% 99.6% 99.3% 99.6%
Number of patients waiting over 6 weeks for a diagnostic test 28 32 21 25 22 23 24 15 14 16 27 14
A&E waits
A&E waits within 4 hours 95.8% 95.0% 95% 94.0% 95.1% 95.4% 95.8% 95.3% 93.8% 93.9% 94.4% 93.4% 91.8% 91.9% 94.1%
Cancer waits – 2 week wait
CB_B6: Cancer patients seen within 14 days after urgent GP referral 95.6% 94.9% 93% 93.4% 95.3% 95.2% 93.7% 94.0% 93.5% 95.6% 95.7% 96.2% 94.2% 94.3% 94.7%
92.2% 92.3% 89.6% 91.6% 91.9%
CB_B7: Breast symptom referrals seen within 2 weeks 93.5% 93% 96.3% 93.3% 94.1% 97.9% 96.0% 98.9% 93.5% 94.1%
92 breaches 7 breaches 11 breaches 9 breaches 9 breaches
Cancer waits – 31 days
CB_B8: Cancer diagnosis to treatment within 31 days 98.6% 98.0% 96% 97.6% 97.3% 98.3% 100.0% 99.0% 97.50% 98.9% 97.5% 99.1 96.3% 98.1 98.2%
93.1% 92.0% 93.8%
CB_B9: Cancer patients receiving subsequent surgery within 31 days 95.9% 94% 95.1% 95.4% 100.0% 94.7% 100.0% 100.0% 100.0% 100.0% 100.0% 98.1%
16 breaches 2 breaches 1 breach
CB_B10: Cancer patients receiving subsequent Chemo/Drug within 31 days 100.0% 99.6% 98% 100.0% 100.0% 100.0% 100.0% 100.0% 97.1% 100.0% 100.0% 100.0% 100.0% 100.0% 99.8%
CB_B11: Cancer patients receiving subsequent radiotherapy within 31 days 99.1% 97.1% 94% 100.0% 100.0% 97.9% 95.8% 91.8% 94.9% 97.8% 98.4% 96.7% 95.1% 100.0% 96.8%
Cancer waits – 62 days
78.4% 76.5% 78.7% 68.4% 71.8% 80.0% 82.9% 81.5%
CB_B12: Cancer urgent referral to treatment within 62 days 86.0% 85% 86.1% 86.4% 89.2% 90.4% 94.7%
138 breaches 16 breaches 13 breaches 24 breaches 24 breaches 12 breaches 12 breaches 134 breaches
89.7% 83.3% 66.7%
CB_B13: Cancer Patients treated after screening referral within 62 days 97.0% 90% 93.3% 91.7% 100.0% 100.0% 100.0% 100.0% 100.0% N/A 100.0% 93.4%
10 1 breach 1 breach
CB_B14: Cancer Patients treated after consultant upgrade within 62 days 90.0% 89.1% 86% 100.0% 100.0% 100.0% 100.0% 100.0% 80.0% 85.7% 100.0% 100.0% 100.0% 100.0% 97.5%
Category A ambulance calls (Trust level)
Life threatening (defibrillator required): Category A calls within 8 minutes -
76.8% 75.3% 75% 75.9% 74.4% 72.5% 73.3% 72.4% 72.7% 73.8% 72.5% 74.5% 73.2% 66.8% 63.0% 72.6%
Red 1
Life threatening (defibrillator NOT required): Category A calls within 8
73.9% 74.3% 75% 77.3% 76.0% 74.2% 73.3% 72.0% 73.2% 73.4% 71.1% 71.0% 68.0% 59.3% 51.3% 70.8%
minutes - Red 2
All life threatening: Category A calls within 19 minutes 97.0% 96.9% 95% 97.6% 97.2% 96.7% 96.2% 96.1% 96.7% 96.5% 96.2% 96.7% 94.8% 93.2% 89.4% 94.3%
Mixed Sex Accommodation breaches
Mixed Sex Accommodation breaches 12 5 0 0 0 0 0 0 1 1 0 0 1 0 3
Mental health
Care Programme Approach (CPA): The proportion of people under adult
mental illness specialties on CPA who were followed up within 7 days of 97.1% 97.3% 95% 96.8% 100.0% 100.0% 98.9%
discharge from psychiatric in-patient care during the period.

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CCG Operating Plan 2015/16 (19/04/2016)
2015/16
Indicator Measure Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 YTD
target
Improving Access to Psychological Therapies (IAPT)
Proportion of the people that enter treatment against Percentage 15.0% 0.7% 0.8% 0.9% 1.0% 0.7% 0.6% 0.9% 1.2% 1.2% 1.1% 1.0% 10.3%
the level of need in the general population Patients entering treatment 4,006 181 202 244 269 199 171 252 328 318 304 276 2,744
Percentage 50.0% 50.3% 51.6% 53.3% 50.4% 47.3% 49.2% 47.1% 53.5% 44.2% 43.6% 50.5% 49.2%
Patients moving to recovery 78 79 97 114 69 95 74 77 69 85 95 932
Proportion of patients completing treatment who have Patients completing treatment 163 165 193 241 155 206 165 149 164 207 202 2,010
moved to recovery
Patients completing treatment who were
not at clinical caseness at initial 8 12 11 15 9 13 8 5 8 12 14 115
assessment

Proportion of patients completing treatment who Percentage 75.0% 91.4% 93.3% 92.2% 94.2% 91.0% 91.3% 93.9% 90.6% 94.5% 92.8% 94.6% 92.8%
commenced within 6 weeks of referral Patients waiting more than 6 weeks 14 11 15 14 14 18 10 14 9 15 11 145

Proportion of patients completing treatment who Percentage 95.0% 96.3% 98.8% 96.9% 97.9% 94.8% 97.6% 96.4% 94.6% 98.2% 98.1% 99.0% 97.3%
commenced within 18 weeks of referral Patients waiting more than 18 weeks 6 2 6 5 8 5 6 8 3 4 2 55
Dementia diagnosis
Percentage 66.7% 62.7% 62.7% 62.7% 62.7% 63.0% 62.4% 62.9% 62.8%
Estimated diagnosis rate (ages 65+)
Dementia register size 2,685 2,525 2,525 2,525 2,525 2,535 2,513 2,533 2,526
Monthly Activity Return (MAR)
Elective Ordinary FFCEs (G&A) Variation against plan -10.2% 8.2% -3.5% -1.0% -0.3% -5.1% -5.8% 9.2% -5.4% -7.9% 2.4% -1.6%
Elective Day Case FFCEs (G&A) Variation against plan 4.2% 7.1% 8.5% 1.1% -3.0% 2.3% 3.9% 7.5% -4.5% 5.0% 2.7% 3.5%
Total Elective FFCEs (G&A) Variation against plan 1.7% 7.3% 6.4% 0.8% -2.5% 1.0% 2.2% 7.8% -4.6% 2.8% 2.7% 2.6%
Non-Elective FFCEs (G&A) Variation against plan 5.7% 2.5% 6.7% 2.0% -6.8% -0.2% 0.0% 11.5% 9.7% 6.2% 9.5% 4.4%
All First Outpatient Attendances (G&A) Variation against plan -2.0% 2.1% 3.5% -0.8% 8.6% 4.4% 3.6% 26.4% 27.2% 40.1% 33.8% 13.6%
First Outpatient Attendances following GP Referral
Variation against plan -3.2% 2.2% 2.5% 0.5% 5.1% 5.3% 2.1% 29.7% 35.3% 49.6% 42.1% 14.9%
(G&A)
GP Written Referrals Made (G&A) Variation against plan 35.4% 35.3% 25.5% 33.1% 32.0% 24.9% 42.4% 48.5% 63.6% 75.3% 77.0% 42.3%
Other Referrals for a First Outpatient Appointment
Variation against plan -26.3% -24.9% -31.4% -28.9% -29.5% -17.9% -15.9% -13.2% -18.1% -1.0% -6.5% -16.2%
(G&A)
Total Referrals (G&A) Variation against plan 15.1% 15.5% 6.8% 12.0% 11.0% 11.4% 23.3% 28.2% 35.4% 48.7% 48.1% 23.5%
A&E activity trajectory
A&E attendances - all types Variation against plan -3.1% 17.2% -0.5% -2.8% -12.2% -3.0% -1.6% 1.9% -3.3% -1.8% 4.1% 8.9%
Plan 7,057 7,292 7,057 7,292 7,292 7,057 7,292 7,057 7,292 7,292 6,822 71,983
Actuals 6,835 8,546 7,024 7,088 6,404 6,846 7,175 7,188 7,050 7,162 7,102 78,420

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Appendix B: Glossary

The following terms shall have the following meanings unless the context requires
otherwise:
A&E Accident and Emergency
ACG Adjust Clinical Grouper
AQP Any Qualified Provider
ASCOF Adult Social Care Outcomes Framework
BCF Better Care Fund
BI Business Intelligence
CAU Community Assessment Unit
CCG Clinical Commissioning Group
CDSS Computer Decision Support Software
CES Commissioning Enablement Service
CHC Continuing Health Care
CMS Contract Management Solutions
COPD Chronic Obstructive Pulmonary Disease
CPA Care Programme Approach
CPT Combined Predictive Tool
CQRM Clinical Quality Review Meeting
CQUIN Commissioning for Quality and Innovation
CSH Central Surrey Health
CSO Commissioning Support Officer
CSU Commissioning Support Unit
DH Department of Health
DHR Domestic Homicide Review
DTA Decision To Admit
DTOC Delayed Transfers of Care
ED Emergency Department
EDICS Epsom Downs Integrated Care Services
ESTH Epsom and St Helier University Hospitals NHS Trust
FFT Friends and Family Test
GP General Practitioner
HCAI Healthcare Associated Infection
HES Hospital Episode Statistics
HHR Hampshire Health Record
HRG Healthcare Resource Groups
HSCIC Health and Social Care Information Centre
HSE Health and Safety Executive
HSMI Hospital Standardised Mortality Ratios
HWB Health and Wellbeing Board
IAPT Improving Access to Psychological Therapies
IC Information Centre
INR International Normalised Ratio
IP In-Patient
JSNA Joint Strategic Needs Assessment

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KHFT Kingston Hospital NHS Foundation Trust
LA Local Authority
LES Local Enhanced Services
LT Local Team
MRSA Methicillin-Resistant Staphylococcus Aureus
MSA Mixed Sex Accommodation
MSK Musculoskeletal
N3 The National Network
NHS National Health Service
NHSE NHS England
OOH Out of Hours
OP Out-Patient
PA Personal Assistant
PALS Patient Advice and Liaison Service
PARR Patients at Risk of Re-Hospitalisation
PBC Practice Based Commissioning
PbR Payment by Results
PC Personal Computer
PH Public Health
PIR Post Infection Review
PYLL Potential Years of Life Lost
QA&E Quality Assurance and Evaluation
QIPP Quality, Innovation, Productivity and Prevention
QOF Quality and Outcomes Framework
QTD Quarter To Date
RTT Referral to Treatment Time
SABP Surrey and Borders Partnership NHS Foundation Trust
SASH Surrey and Sussex Healthcare NHS Trust
SCR Serious Case Review
SDCCG Surrey Downs Clinical Commissioning Group
SECAmb South East Coast Ambulance Service NHS Foundation Trust
SHMI Summary Hospital-level Mortality Indicator
SSAB Surrey Safeguarding Adults Board
SSCB Surrey Safeguarding Children Board
STEIS Strategic Executive Information System
SUS Secondary Uses Service
TCI To Come In (date)
TDA Trust Development Authority
T&O Trauma and Orthopaedics
TTR Time in Therapeutic Range
VCSL Virgin Care Services Limited
YTD Year To Date (the NHS financial year commencing 1st April and ending
31st March)

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