Improving and Sustaining Cancer Performance. Mary Fleming, Interim Director of Operations and Performance. Approve x Adopt Receive for information

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1 Trust Board Agenda Item 16. Date: Title of Report Purpose of the report and the key issues for consideration/decision Prepared by: Name & Title Presented by: Action Required (please X) Strategic/Corporate Objective(s) supported by this paper Improving and Sustaining The Trust board are asked to scrutinise and approve the report and action plan as assurance the Trust is working towards the key priorities set out by Monitor, NHS England and the National Trust Development Authority as part of the National Programme for improving outcomes. Mary Fleming, Interim Director of Operations and Mary Fleming Approve Adopt Receive for information objectives Is this on the Trust s risk register? No If, Score Which Standards apply to this report? CQC NHSLA BAF Objectives WWL Wheel Have all implications related to this report been considered? Finance Revenue & Capital National Policy/Legislation NHS Contract Human Resources Consultation/Communication Other: If action required please state: /No/NA Any Action Required Equality & Diversity Patient Eperience Governance & Risk Management Terms of Authorisation Human Rights Carbon Reduction / No/NA Any Action Required Previous Meetings Please insert the date the paper was presented net to the relevant group ECC Audit Quality & Safety Finance & Investment Management Board IM&T Strategy HR NED Other

2 Improving and Sustaining 1. EXECUTIVE SUMMARY Monitor, the National Trust Development Authority and NHS England have agreed to lead a national delivery group for improving 62 day performance which will work closely with the Waiting Time Taskforce and Intensive Support Team. This paper, and associated action plan, sets out the requirements of the Trust with regards to the key streams of work. 2. BACKGROUND Whilst the overall performance against cancer targets has been generally good, national performance against the 62 day standard has been below the 85% threshold for the last 5 consecutive quarters. Conversely, WWL has consistently eceeded this target with 91.3% of patients receiving treatment within 62 days of receipt of referral in 2014/15. In an effort to tackle these inequalities in outcomes and eperience of people with cancer, the Waiting Time Taskforce has identified 8 key priorities for all local health systems to implement as a matter of urgency. These priorities offer practical actions to help providers, and also support CCGs with effective commissioning of cancer services, to ensure that robust cancer resilience planning is undertaken in the current financial year (2015/2016). The attached Action Plan charts WWL s progress to date and is monitored through the monthly meeting and Strategy Group. One of the eight priorities is for the Board to receive 62 day cancer wait performance reports for each individual cancer tumour pathway, currently performance is reported at aggregate level. To comply with this standard, the September Trust report will contain the August position against the 62 day standard at tumour pathway level. A breach reallocation policy has been in place within the Greater Manchester cancer network since 2011, the aim of the policy is to ensure that patients on a 62 day pathway receive timely access to definitive cancer treatment. The policy sets out rules for the reallocation of breaches to the referring hospital which incentivises prompt referral and reduced delays from one provider to another. The Trust s performance report will show the pre and post reallocation position at the time of reporting. By the end of August, each Acute Trust will be required to complete a self assessment of compliance against each of the priorities. All Trusts will be segmented as poor, high concern, low concern or good based on current and recent performance data. Given WWL s compliance with National cancer waiting times, it is epected the Trust will

3 receive a rating of good and, as such, will be epected to share our learning with others, which we will be pleased to do. Trusts allocated poor or high concern will be epected, with the support of the Intensive Support Team, to produce an improvement plan by the end of August for review and sign off by its Regional Tripartite. Action Plan for Improving and Sustain 3. RECOMMENDATIONS The Trust Board are asked to approve the report and action plan as assurance we are working to full compliance against the National Key Priorities and Self Assessment.

4 Improving and Sustaining - 8 Key Priorities Action Plan and Self-Assessment Recommendation Lead Timescale Progress Status/Action 1 The Trust Board must have a named Eecutive Director responsible for delivering the national cancer waiting time standards Acting Director of Operations and N/A Mary Fleming is the Eecutive Lead responsible for the delivery of the national cancer waiting times standards Complete Boards should receive 62 day cancer wait performance reports for each individual cancer tumour pathway, not an all pathway average Every Trust should have a cancer operational policy in place and approved by the Trust Board. This should include the approach to auditing data quality and accuracy, the Trust approach to ensure MDT coordinators are effectively supported, and have sufficient dedicated capacity to fulfil the function effectively Every Trust must maintain and publish a timed pathway, agreed with the local commissioners and any other Providers involved in the pathway, taking advice from the Clinical Network for the following cancer sites: lung, colorectal, prostate and breast. These should specify the point within the 62 day pathway by which key activities such as OP assessment, key diagnostics, inter Provider transfer and TCI dates need to be completed. Assurance will be provided by regional tripartite groups Service Lead /Service Lead/Manchester August day performance split by tumour presented with the current Trust Board submission for overall 62 day performance showing pre and post reallocated position Trust access policy and tumour specific operational policies in place. Auditing data quality full eternal audits carried by Deloitte annually for the 62 day standard MC Prostate Pathway.pdf MC LGI Pathway.doc MC Lung Pathway.doc MC Breast Pathway.doc Tumour specific reports will be prepared for the September Trust Board report An over arching Services Operational policy to be developed and approved by the Strategy Board Complete

5 Recommendation Lead Timescale Progress Status/Action Each Trust should maintain a valid cancer specific PTL and carry out a weekly review for all cancer tumour pathways to track patients and review data for accuracy and performance. The Trust to identify individual patient deviation from the published pathway standards and agree corrective action. A root cause breach analysis should be carried out for each pathway not meeting current standards, reviewing the last ten patient breaches and near misses (defined as patients who came within 48hours of breaching). These should be reviewed in the weekly PTL meetings. Alongside the above, a capacity and demand analysis for key elements of the pathway not meeting the standard (1st OP appointment; treatment by modality) should be carried out. There should also be an assessment of sustainable list size at this point An Plan should then be prepared for each pathway not meeting the standard, based on breach analysis, and capacity and demand modelling, describing a timetabled recovery trajectory for the relevant pathway to achieve the national standard. This should be agreed by local commissioners and any other providers involved in the pathway, taking advice from the local Clinical Network. Regional tripartite groups will carry out escalation reviews in the event of non delivery of an agreed Plan. /Service Lead /Divisional s Divisional s/service Lead/ Divisional s/service Lead/ August 2015 October 2015 October 2015 Tumour specific PTL meetings held weekly with /Pathway Tracker/Divisional Representation Monthly Divisional meetings held Full breach analysis already carried out and reviewed monthly in the Team meeting. Also reviewed in the Divisional Meetings and reviewed by the tumour group MDTs Q1 + Q2 data to analysed to identify delays for those pathways not achieving the 85% standard If required to produce an improvement plan based on your Trust rating of poor / high concern or good / low concern, this will be produced based on the outcome of the above points Monthly performance meetings to identify areas of concern where patients have deviated from agreed pathways. Identify and agree internal timescales Near misses not currently reviewed. To be included in breach analysis for those pathways not achieving the 85% target Capacity and demand analysis to be undertaken in areas of concern plans where appropriate once Q1 + Q2 data analysed and areas/pathways of concerns have been identified