Paper I has been deferred until the August Board meeting.
NHS LEICESTER CITY
MEETING:
TRUST BOARD MEETING
PAPER J
DATE:
30 July 2009
REPORT TITLE:
Next Stage Review Update
SECTION:
Public
REPORT BY:
Vikki Taylor,
Management
Director
of
Strategy
and
Market
PRESENTER:
Vikki Taylor,
Management
Director
of
Strategy
and
Market
EXECUTIVE SUMMARY
This paper provides the Board with an update report for the Next Stage
Review. It is a report to update the board with respect to the stage of
development and implementation of the Next Stage Review programme, at
both the regional and local tiers of the work.
The report provides the following key points:




An update on the appointment of regional clinical leads;
An indication of the milestones for those regional developments which
will impact on services in 2009/10, including where consultation may be
required;
An update on the implications for communications and engagement
activities;
A progress report on the four local NSR work streams that have been
prioritised for 2009/10.
RECOMMENDATION
The Board is requested to:
NOTE this report.
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Paper J
NHS Leicester City Board Meeting
30 July 2009
NHS LEICESTER CITY
BOARD MEETING
30 JULY 2009
Update on Next Stage Review
Formation and Remit
1. The aim of this paper is to give an update on the Our NHS, Our Future Next Stage Review (NSR) work that has been progressing at both regional
and local level. In particular to focus on aspects of the work that will have
an impact on NHS LC in 2009/10.
2. The clinical leaders for all the NSR regional reference groups have now
been appointed and taken up their roles. Clinical engagement is a key
theme in both Lord Darzi’s final report, High Quality Care for All and the
East Midlands clinical vision, From Evidence to Excellence.
3. The nine clinical leaders are shown below:
 Maternity and Newborn – Dr Alsop, Consultant Obstetrician, Derby.
 Children’s Health – Dr Brooke, Consultant Paediatrician, Leicester.
 Planned Care – Dr Swart, Medical Director, Northampton.
 Mental Health – Dr Brewin, Associate Medical Director,
Nottinghamshire.
 Learning Disabilities – Dr Sabyasachi, Consultant in Psychiatry of
Learning Disabilities, Leicestershire.
 Staying Healthy – Prof. Horsley, Director of Public Health and Medical
Director, Northampton.
 Long Term Conditions – Jane Scullion, Respiratory Nurse Consultant,
Leicester.
 Acute Care – Dr Read, Consultant in Emergency Medicine & Head of
Service, Leicester.
 End of Life – Dr Graham-Brown, Director of Services for Older People
& Consultant Dermatologist, Leicester.
4. The clinical leaders form a regional cabinet for the East Midlands, bringing
together expert medical advice to drive forward plans to improve the
quality, safety and effectiveness of local health services.
Regional Programme
5. In June 2008 From Evidence to Excellence – Our Clinical Vision for
Patient Care was published. This outlines the NSR vision across the East
Midlands.
The second phase of the NSR concentrates on the
implementation of this vision and is being led by the Primary Care Trusts.
All nine PCTs in the East Midlands have agreed to work collaboratively on
certain aspects of the implementation programme, where there are
economies of scale or where changes will have impact across the whole
region.
Vikki Taylor
Director of Strategy and Market Management
1
Paper J
NHS Leicester City Board Meeting
30 July 2009
6. A number of service priorities were identified in From Evidence to
Excellence. These were subsequently agreed by the strategic
commissioning East Midlands Management Board as priorities for regionwide service change, to help save lives and improve quality and outcomes
for patients.
7. The diagram below illustrates the over-arching regional programme and
the initial priorities, whilst appendix A shows the intended milestones for
reconfiguration.
Over-arching Programme
Evidence to Excellence
Acute
Mental
Health
Children’s
East Midlands
Other
Counties
Major Trauma
Eating Disorders
Designation of
Neonatal
3 Digit Number
Perinatal
Psychiatric
Reconfig of Spec
Children’s Services
Lincolnshire
PPCI
CAMHS 4 Tier
Children’s & Young
People’s Cancer
Northamptonshire
Stroke
Learning
Disabilities
Vascular Services
Nottinghamshires
Derbyshires
LLR
8. Each of the regional work streams has a clinical reference group. These
groups all have a clinical representative from primary care, secondary
care, nursing and allied health professionals.
LLR Programme
9. In June 2008 Excellence for All was published. This document outlines
the over-arching 10 year vision for health and health services in LLR,
together with some key principles for service development.
10. To drive local commitments made in Excellence for All it has been agreed
that four work streams will be taken forward as a priority. There will be
project boards for each of these, led by a Chief Executive sponsor, with
clinical and managerial support and representation from other LLR
stakeholders, including patients.
Work stream
Acute Care
Chief Executive
Sponsor
Malcolm Lowe-Lauri
University Hospitals
Vikki Taylor
Director of Strategy and Market Management
Clinical Lead (s)
Jay Banerjee
2
Paper J
NHS Leicester City Board Meeting
30 July 2009
Maternity/Children’s
Planned Care
Long Term Conditions
Leicester (UHL)
Catherine Griffiths
(NHS LCR)
Tim Rideout
NHS Leicester City
(NHS LC)
Anthony Sheehan
Leicestershire
Partnership Trust (LPT)
Maternity: Jane
Porter and Ian
Scudamore.
Children’s: Adrian
Brooke
Shona Campbell
Robert Gregory
Acute Care
11. The initial stage (in progress) is to define the scope of the work required
for Acute Care. Currently we have a history of ideas and a patchwork of
initiatives but our predicament of multiple and confusing patterns of urgent
and emergency care continues. That in turn complicates the patient
experience and has seemingly done little to stem the flow of patients into
the numerous points of entry at UHL. The challenge of providing a
coherent system of urgent care is not unique to LLR but our performance
with respect to the over use of acute care and high conversion rates in
A&E means we perform badly when compared to other PCTs.
12. A key task of the board will be to redefine the problem and devise a
structured plan to solve it. This means creating an integrated concept for
the provision of urgent and emergency care. There is a need to
understand the level of change required in urgent care, how much of this
can be done incrementally and how much requires a transformational
approach.
13. Terms of reference for the Acute Care Board are in preparation. A clinical
lead and GP advisers, (one from each PCT) are being recruited. The
intentions of the Acute Care Board will be communicated to key
stakeholders such as the LLR Chief Executives, the Health Community
Steering Group, the Clinical Collaborative Interface Group and the full
Boards of our respective organisations. A full communications plan will be
devised for this work.
Maternity and Children’s Services
14. It has been agreed that the pre-existing maternity and childrens’ services
work streams will merge to become a priority work stream for the LLR
NSR. Following initial scoping meetings the following project areas were
identified as key areas of work, although it was acknowledged these are
not definitive.


Implementation of Maternity Matters.
Configuration of maternity and neonates.
Vikki Taylor
Director of Strategy and Market Management
3
Paper J
NHS Leicester City Board Meeting
30 July 2009






Admissions not related to delivery (coded as N12).
Diabetic pathway.
Non-elective care pathway.
Respiratory pathway.
Children’s commissioning.
Comprehensive CAMHS.
15. The Maternity and Childrens’ Services Board has been established and
terms of reference are being agreed. By July the plan is to establish a
Clinical Advisory Group and then in August a patient and public
stakeholders consultation group will be set up.
Planned Care
16. The role of the Planned (Elective) Care Board within the LLR health
economy is to establish a framework within which commissioner and
provider organisations can develop to achieve the transformation of
services required to sustainably deliver a ‘no-delays’ health economy and
the commitments made within Excellence for All.
17. The programme of work for the Planned Care Board will focus on priorities
that require a whole health economy solution and will be delivered through
cross organisational collaboration. The LLR Planned Care Strategy will
comprise a number of development areas with consequent
interdependencies. Initial priority areas are: Musculoskeletal; Therapies;
and Care Pathways (inc. Map of Medicine).
Long Term Conditions
18. Work has been taking place between key stakeholders to scope options
for the Long Term Condition (LTC) programme. There are a number of
significant initiatives across LLR but there may be more opportunities for
greater and more systemic impact on strategic and cross cutting themes.
By working together we can therefore realise additional significant
benefits. A key task of the board will be to redefine our objectives and
devise a structured plan to drive delivery. The initial proposal is to target
system wide approaches and concentrate on:




Population – risk stratification.
Systems – telemedicine & assistive technology.
People – care planning/personalisation.
Condition – complex/ multiple problems.
19. It is anticipated that the legacy LTC board will be reconstituted and form a
smaller board which sponsors a number of task and finish activities. The
number and membership of the task and finish groups is yet to be decided
and involvement of the wider stakeholder communities will be focused on
specific work streams. Terms of reference for the board are in preparation
and recruitment of a clinical lead is underway.
Vikki Taylor
Director of Strategy and Market Management
4
Paper J
NHS Leicester City Board Meeting
30 July 2009
Communication and Engagement
20. A Communication and Engagement Strategy has been developed which
sets out the approach to communication and engagement on phases two
and three of the NSR in LLR.


Phase one saw the development of the initial proposals of the NSR in
LLR and engagement upon those proposals.
These next two phases will see the firm development of those plans
and full implementation, requiring formal consultation, over the next 12
months and subsequent years.
21. In order to structure our approach to communications and engagement,
our various audiences for Leicester City, Leicestershire and Rutland are to
be placed into a series of groups, as shown in Appendix D.
22. The communication and engagement strategy establishes the central role
of the LLR Communications and Engagement Enabling Team in coordinating the NSR at the local level and the links regionally. It sets out
principles, objectives, key messages, approaches to stakeholder
engagement and proposed operational systems for communications such
as media handling.
Regional communications and engagement
23. Within the regional programme it has been agreed that all
communications, engagement and consultations should be led by the
PCTs. The PCT of the lead chief executive nominated for each of the
regional workstreams will take the lead for communication and
engagement and provide a consultation toolkit for the use of all other
PCTs in the East Midlands.
24. All of this work will be co-ordinated through the NSR LLR Communications
and Engagement Enabling Team, with strategic and day-to-day
operational management being provided by the NSR LLR
Communications and Engagement Manager who is based at NHS LC.
Recommendation
The Board is asked to receive and note the content of the paper.
Vikki Taylor
Director of Strategy and Market Management
5
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Paper J
Appendix A
NHS Leicester City Trust Board Meeting
30 July 2009
Process
Next Stage Review – Regional Milestones (2009/10)
2009
Project Jun
Deliverable
2010
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Public Engagement
Major Trauma
Fe
b
Mar
April
Option Appraisal
Acute Stroke (First 7
days)
Pre-consultation
Business Case
Issue Accreditation
Documents
Business Case
Public Consultations
Set up Steering Committee
Primary
Angioplasty
3 Digit Number
Formal Expression of Interest
Transfer of Ownership
Specialised Childrens
Services
Pathways Developed
Public Consultation
Services Specification Draft
Child & Adolescent Mental
Agree Job Description
Health
Establish Steering
Committee
Agree Project
Plan
for Project Manager
Low secure Learning
Disability Services
Eating Disorders
Perinatal Mental
Health
Neonatal Services
Establish Service Model
Designate Existing Low
Secure Services
Assess Need of Service
Agree Access Criteria
Approval Process
Approval Process
Establish Steering
Committee
Market Assessment
Options/Affordability Assessment
Establish Steering
Committee
Approval Process
Approval Process
Option Appraisal
Market Assessment
Options/Affordability
Preliminary
Recommendation
Blank Page
NHS LEICESTER CITY
MEETING:
TRUST BOARD MEETING
PAPER K
DATE:
30 July 2009
REPORT TITLE:
Performance Report as at May/June 2009
SECTION:
Public
REPORT BY:
Sarah Cooke,
Performance
Associate
Director,
Corporate
PRESENTER:
Sarah Cooke,
Performance
Associate
Director,
Corporate
EXECUTIVE SUMMARY
This report details:

The performance report for 2009/10 summarises the May/June 2009
for the Annual Health Check targets. It includes a Year to Date position
against trajectory and a Forecast Outturn position against target, where
data is available. Action Plans are included for targets that are
currently at risk, ensuring achievement by March 2010. The report also
details NHS Leicester City (NHS LC) position benchmarked against
other PCTs in the East Midlands

Existing Commitments - the Board should be aware that PCTs rated as
not fully met for existing commitments will automatically get rated as
“Weak” by the Care Quality Commission (CQC).

Of the 16 Existing Commitments, 14 are being “achieved”. Crisis
Resolution/home Treatment Services for mental health is forecast as
“underachieved” – NHS LC has been assured by LPT that this position
will be on target from June 09. Underperformance was a result of staff
sickness. Thrombolysis is rated as “fail” and EMAS performance is
being challenged by both UHL and NHS LC. Chlamydia screening is
now forecast as “achieved” based on the work programme in place.
Q1 trajectory has been “achieved”. NHS LC is still predicting ‘Fully
Met’ position for Existing Commitments as a reduction in the scores for
these indicators does not impact on the overall score for Existing
Commitments.
1

National Priority Indicators – There are now 27 National Priority
Indicators. Data is not yet available for many of the indicators but
comments have been included regarding the expected availability of
this data where possible. Full action plans have been received from
UHL for the Extended Cancer Targets, and data is now available on a
web based system for all providers. Robust action plans are in place
for Dental Services, Experience of Patients/Users, Immunisation,
Teenage Pregnancy, and Early Access to Maternity Services.

An overall forecast year end outturn position will be available on the
annual health check once data for the majority of indicators becomes
available.

Core Standards – NHS LC will continue to monitor Core Standards in
2009/10, and a library of evidence is being developed to ensure all
standards and Use of Resources continues to be monitored
consistently.
Further guidance is awaited from Care Quality
Commission (CQC).
BOARD ASSURANCE
The PCT Board needs to monitor the position of the organisation against
Existing Commitments, National Priority Indicators and Core Standards
targets.
RECOMMENDATION
The Board is requested to:
NOTE the year to date and forecasted position for indicators within the Annual
Health Check position for 2009/10.
2
NHS LEICESTER CITY TRUST BOARD
PERFORMANCE FRAMEWORK FOR 2009/10
ANNUAL HEALTH CHECK RATING FOR 2009/10 (May/June 09)
The following tables indicates the Care Quality Commissions' intentions for Annual Health Check Rating for 2009/10. A PCT will automatically be rated "weak" if Existing Commitment Indictors are "No
Met". An overall rating will be undertaken as data for the indicators becomes available.
Further guidance is awaited on Standards for Better Health and Use of Resources
QUALITY OF SERVICES - TARGETS ONLY
RAG
Description
G
Achievement
A
Underachieved
R
Failed
B
Data not Available
Existing Commitment Indicators for PCTs
2008-09 Outturn
08/09 Target
09/10
Current Position
(YTD)
Trajectory
(YTD)
09/10
Current Position
(FOT)
09/10 Target
(FOT)

NT1
Access to GUM clinics within 48 hours
99.89%
100%
100%
(May 09)
100%
100%
(May 09)
100%

EX6
All ambulance trusts to respond to 75% of Category A Calls within 8 minutes
76.06%
75%
76.36%
(May 09)
75%
76.36%
(May 09)
75%

EX7
All ambulance trusts to respond to 95% of Category A calls within 19 minutes
97.29%
95%
97.63%
(May 09)
95%
97.63%
(May 09)
95%

EX8
All ambulance trust to respond to 95% of Category B Calls within 19 minutes
95%
95%
96.16%
(May 09)
95%
96.16%
(May 09)
95%
Page 1 of 16
NHS LEICESTER CITY TRUST BOARD
PERFORMANCE FRAMEWORK FOR 2009/10
ANNUAL HEALTH CHECK RATING FOR 2009/10 (May/June 09)
Existing Commitment Indicators for PCTs
2008-09 Outturn
08/09 Target
09/10
Current Position
(YTD)
Trajectory
(YTD)
09/10
Current Position
(FOT)
09/10 Target
(FOT)

EX10
Commissioning of crisis resolution/home treatment services
866
815
189
(May 09)
203
774
(May 09)
815

NT9
Commissioning of early intervention in psychosis services
96
73
18
(May 09)
19
138
(May 09)
73

NT14
Data quality on ethnic group - completeness of coding on health data (Acute & Mental
Health)
99.43% (UHL)
100% (LPT)
100%
99.51% (UHL)
98.64% (LPT)
100%
99.51% (UHL)
98.64% (LPT)
100%
2.79%
3.5%
2.68%
(1 Apr - 4 Jun 09)
3.5%
2.68%
(1 Apr - 4 Jun 09)
3.5%
143.90%
100%
143.9%
100%
143.9%
100%
0
0
(0.00%)
0
(May 09)
0
(0.00%)
0
(May 09)
0
(0.00%)
(May 09)
(May 09)

EX13
Delayed Transfers of Care - Now a Vital Sign - VSC10 with revised definition to include
delayed discharges from acute and non-acute settings, including mental health

EX14
100% of people with diabetes to be offered screening for the early detection of (and
treatment if needed) of diabetic retinopathy

EX15
A maximum wait of 26 weeks for in-patient procedure

EX16
A maximum wait of 13 weeks for out-patient appointment
0
(0.006%)
0
(0.00%)
1
(May 09)
0
1
(May 09)
0

EX17
3 month maximum wait for revascularisation
0
(0.00%)
0
(0.00%)
0
0
0
0

EX19
Thrombolysis Call to Needle of at least 68% within 60 minutes where thrombolysis is
preferred local treatment for heart attacks
67%
68%
54.55%
68%
54.55%
68%

EX20
Total time in A&E: four hours or less
(Official QMAE data at
outturn)
98%
98.41%
(June 09)
98%
98.41%
(June 09)
98%

VSB12
Emotional health and well being and child and adolescent health services (CAMHS)
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4

VSB13
Chlamydia Screening
15.5%
17%
4.3%
(as at 22/06/09)
4.0%
27.9%
25%
98.44%
Page 2 of 16
(May 09)
(May 09)
(May 09)
(May 09)
NHS LEICESTER CITY TRUST BOARD
PERFORMANCE FRAMEWORK FOR 2009/10
ANNUAL HEALTH CHECK RATING FOR 2009/10 (May/June 09)
RAG
Description
G
Achievement
A
Underachieved
R
Failed
B
Data not Available
2008-09 Outturn
08/09 Target
09/10
Current Position
(YTD)
Trajectory
(YTD)
09/10
Current Position
(FOT)
09/10 Target
(FOT)
Admitted
95.15%
90%
94.26%
94.26%
(May 09)
94.26%
94.26%
(May 09)
Non Admitted
97.83%
95%
98.02%
98.02%
(May 09)
98.02%
98.02%
(May 09)
100%
95%
100%
100%
(May 09)
100%
100%
(May 09)
1
0
1
1
(May 09)
1
1
(May 09)
Data has been
published results
being assessed
83.7%
Annual Data
86.8%
Annual Data
86.8%
177058
202578
Data Available in
August
206,630
Data Available in
August
206,630
94.70%
100%
(revised target
97.50%)
94.70%
100%
(revised target
97.50%)
National Priority Indicators for PCTs
NHS reported waits for elective care (18 Weeks Referral to Treatment)

VSA04
Direct Access Audiology
6 weeks diagnostics

VSA06
Patient reported measure of GP access (GP Access Survey)

VSB18
Dental Services

VSA11

VSA12

EX3

VSA13

EX4

VSA08

EX5
31-Day Standard for Subsequent Cancer Treatment (Chemo & Surgery)
31-Day Standard for Subsequent Cancer Treatment (Radiotherapy)
Maximum Waiting Times of one month from diagnosis to treatment for all cancers
Extended 62 Day Cancer Treatment Targets
Maximum Waiting Time of two months from urgent referral to treatment of all cancers
Breast Symptom Two Week Wait
2 Week Maximum Wait from urgent GP referral to first out-patient appoint for all urgent
suspected cancer referrals
91.43%
100%
(revised target 97.50%)
96.0%
79%
(revised target
97.50%)
100%
96%
(revised target
97.50%)
100%
96%
(revised target
97.50%)
99.31%
98%
97.74%
98.00%
97.74%
98%
Part one: 100%
Part Two: 100%
100%
Part one: 100%
(revised target
84.5%)
Part Two: 100%
95.16%
95%
84.5%
(revised target)
(Apr -Dec 08)
(Apr -Dec 08)
84.48%
36%
50%
B
99.58%
98%
93.26%
(Apr-Dec 08)
Page 3 of 16
95.83%
100%
95%
84.5%
(revised target)
100%
(revised target 93.3%)
98%
93.3%
(revised target)
Part one: 100%
(revised target
84.5%)
Part Two: 100%
84.48%
B
93.26%
95.83%
100%
95%
84.5%
(revised target)
100%
(revised target 93.3%)
98%
93.3%
(revised target)
NHS LEICESTER CITY TRUST BOARD
PERFORMANCE FRAMEWORK FOR 2009/10
ANNUAL HEALTH CHECK RATING FOR 2009/10 (May/June 09)
National Priority Indicators for PCTs
09/10
Current Position
(YTD)
Trajectory
(YTD)
09/10
Current Position
(FOT)
09/10 Target
(FOT)
2008-09 Outturn
08/09 Target
Male
840.58
814
Female
596.70
598
% of eligible 50 year old women with a breast screening test result
63%
61%
65%
72%
65%
72%
% of eligible 50-73 year old women screened for breast cancer in the last three years
65%
70%
63%
72%
63%
72%
% of children in Reception with height & weight recorded who are obese
10.8%
11.1%
% of children in Reception with height & weight recorded
88.9%
86%
% of children in Year 6 with height & weight recorded who are obese
20.3%
21.5%
21%
% of children in Year 6 with height & weight recorded
88.4%
86%
86%
86%
IP: 76
OP:77
A&E: 76
MH:
PC:
IP: 76
OP:77
A&E: 78
MH:74
PC:79
Annual Data
IP: 79
OP:79
A&E: 79
MH:79
PC:80
Annual Data
IP: 79
OP:79
A&E: 79
MH:79
PC:80
All Age All Cause Mortality - based on calendar year 2007. Waiting for 2008 data.
Targets for 2008 are: Male - 801; Female - 552.

VSB01
Annual Data
801
552
Annual Data
801
552
Extension of NHS Breast Screening

VSA09
Childhood Obesity

VSB09
Self Reported Experience of Patients/Users
11%
Data Available in
August
87%
11%
Data Available in
August
87%
21%

VSB15

VSB05
Smoking Cessation
2548
2418
537
(June 09)
550
(Jun 09)
2431
2418

VSA03
Incidence of CDIFF
144
214
32
(May 09)
18
(May 09)
108
192

VSB17
NHS Staff Survey based Measures of Job Satisfaction
Survey on an annual basis
3.49
3.60
Annual Data
3.62
Annual Data
3.62

VSB14
Drug Misusers recorded as being in effective treatment
5.7%
5%
6.5%
6.1%
6.5%
6.1%

VSB11
Survey on annual basis. National data in support of 2008-09 rating still awaited for
Mental Health and Primary Care.
(Calendar year)
(Feb 08-Jan 09)
(Feb 08-Jan 09)
Breastfeeding at 6-8 weeks
Prevalence
46.7%
40.8%
Status Recorded
89.7%
85.0%
Page 4 of 16
Data Available in
August
37.2%
90.0%
Data Available in
August
37.2%
90.0%
NHS LEICESTER CITY TRUST BOARD
PERFORMANCE FRAMEWORK FOR 2009/10
ANNUAL HEALTH CHECK RATING FOR 2009/10 (May/June 09)
National Priority Indicators for PCTs
2008-09 Outturn
08/09 Target
09/10
Current Position
(YTD)
Trajectory
(YTD)
09/10
Current Position
(FOT)
09/10 Target
(FOT)
Individuals who complete immunisation
Note: 2008-09 targets are on primary doses



VSB10
VSB03
VSB02
Note: 2009-10 targets are on booster doses
Note: 2009-10 targets are on booster doses
Aged 1 (DTaP/IPV/Hib)
Aged 2 (PVC)
Aged 2 (Hib/MenC)
Aged 2 (MMR)
Aged 5 (DTaP/IPV)
Aged 5 (MMR)
94.2%
93.7%
95.7%
93.0%
96.0%
94.1%
93.30%
95.90%
95.60%
90.20%
96.90%
94.2%
Girls 12-13 (HPV)
50.0%
77.20%
77.20%
Aged 13-18 (Td/IPV) - School leaver booster
75.0%
84.90%
84.90%
80%
Actual 2007
115.4
Target 2007
118.9
Annual Data
110.3
110.3
115.8
(2007)
129.2
(2007)
Annual Data
72%
65%
48.00%
65%
54.84%
70%
75%
50%
(local target)
25%
(national target)
Awaiting Data
45%
Awaiting Data
45%
Cancer Mortality Rate - Based on calendar year 2007. Waiting for 2008 data. Target for
2008-09 is 110
CVD Mortality Rate - Based on calendar year 2007. Waiting for 2008 data. Target for
2008-09 is 87
Data Available in
August 09
93.30%
95.90%
95.60%
90.20%
96.90%
94.2%
(2009)
87.2
(2009)
Data Available in
August 09
93%
90%
90%
90%
89%
85%
70%
Annual Data
Annual Data
(2009)
87.2
(2009)
Quality Stroke Care
Proportion of people who spend at least 90% of their time on a stroke unit

VSA14
Proportion of people who have a TIA who are scanned and treated within 24 hours

VSB08
Teenage Pregnancy
50.1
(2007)
46.1
(2007)
Annual Data
36.01
Annual Data
36.01

VSB06
Early Access for Women to Maternity Services
80.67%
80%
87.08%
82.00%
79.95%
85.00%
Page 5 of 16
NHS LEICESTER CITY TRUST BOARD
PERFORMANCE FRAMEWORK FOR 2009/10
ANNUAL HEALTH CHECK RATING FOR 2009/10 (May/June 09) - BENCHMARKED PERFORMANCE, EAST MIDLANDS
The following tables indicates the Care Quality Commissions' intentions for Annual Health Check Rating for 2009/10. A PCT will automatically be rated "weak" if Existing Commitment Indictors are "Not Met". An overall rating will be undertaken as data for the indicators
becomes available.
Further guidance is awaited on Standards for Better Health and Use of Resources
Benchmarked data is based on NHS East Midlands data sources - where data is not available the PCT is assessing the ability to develop local monitoring
QUALITY OF SERVICES - TARGETS ONLY
RAG
G
A
R
Description
Achievement
Underachieved
Failed
B
Data not Available
Existing Commitment Indicators for PCTs
NHS LEICESTER CITY
EAST MIDLAND & EAST MIDLAND PCTS
09/10 Target
09/10
Current Position
(YTD/FOT)
PCT Position in
East Midlands
TIME PERIOD
EMSHA
BASSETLAW
DERBY CITY
DERBY
COUNTY
LEICESTER
CITY
LEICS &
RUTLAND
LINCS
NTHANTS
NOTTS CITY
NOTTS
Mar-09
99.90%
100.00%
100.00%
100.00%
99.90%
100.00%
100.00%
100.00%
100.00%
100.00%

NT1
Access to GUM clinics within 48 hours
100%
100%
(May 09)
1/9

EX6
All ambulance trusts to respond to 75% of Category
A Calls within 8 minutes
75%
76.36%
(May 09)
N/A

EX7
All ambulance trusts to respond to 95% of Category
A calls within 19 minutes
95%
97.63%
(May 09)
N/A

EX8
All ambulance trust to respond to 95% of Category
B Calls within 19 minutes
95%
96.16%%
(May 09)
N/A

EX10
Commissioning of crisis resolution/home treatment
services
815
774
FOT
4/9
Year end 08/09
8748/7716
295/197
547/516
1272/1217
963/815
1135/956
1342/1155
1270/1050
745/731
1179/1079

NT9
Commissioning of early intervention in psychosis
services
73
138
(May 09)
3/9
Year end 08/09
695/583
15/17
40/39
94/91
90/73
66/60
109/82
90/84
99/55
92/82
N/A
N/A
NATIONAL BENCHMAKED DATA NOT AVAILABLE, LOCAL MONITORNG BEING DEVELOPED
May-09
EAST MIDLAND AMBULANCE SERVICE PERFORMANCE SEE NHS LEICESTER CITY

NT14
Data quality on ethnic group - completeness of
coding on health data (Acute & Mental Health)
100%
99.51% (UHL)
98.64% (LPT)
(May 09)

EX13
Delayed Transfers of Care - Now a Vital Sign VSC10 with revised definition to include delayed
discharges from acute and non-acute settings,
including mental health
3.50%
2.68%
(1 Apr - 4 Jun 09)
N/A
N/A
NATIONAL BENCHMAKED DATA NOT AVAILABLE, LOCAL MONITORNG BEING DEVELOPED

EX14
100% of people with diabetes to be offered
screening for the early detection of (and treatment
if needed) of diabetic retinopathy
100%
143.9%
(May 09)
N/A
N/A
NATIONAL BENCHMAKED DATA NOT AVAILABLE, LOCAL MONITORNG BEING DEVELOPED

EX15
A maximum wait of 26 weeks for in-patient
procedure
0
0
(May 09)
N/A
Apr-09
0
0
0
0
0
0
0
0
0
0

EX16
A maximum wait of 13 weeks for out-patient
appointment
0
1
(May 09)
N/A
Apr-09
3
0
0
0
0
0
2
1
0
0

EX20
Total time in A&E: four hours or less
98%
98.41%
(June 09)
6/8
(joint with LCR)
wkending
21/06/09
98.76%
CRHFT
98.81%
ULHT
98.1%
NGH
99.23%
NUH
99.42%
SFHFT
97.66%

VSB12
Emotional health and well being and child and
adolescent health services (CAMHS)
Level 4
Level 4
N/A
N/A

VSB13
Chlamydia Screening
25%
27.9%
(FOT)
3/9
Year end 08/09
9.80%
13.00%
17.20%
14.00%
DHFT
99.71%
UHL
98.68%
BENCHMARKED DATA NOT AVAILABLE
14.50%
Page 6 of 16
21.00%
13.20%
17.00%
15.50%
15.50%
NHS LEICESTER CITY TRUST BOARD
PERFORMANCE FRAMEWORK FOR 2009/10
ANNUAL HEALTH CHECK RATING FOR 2009/10 (May/June 09) - BENCHMARKED PERFORMANCE, EAST MIDLANDS
The following tables indicates the Care Quality Commissions' intentions for Annual Health Check Rating for 2009/10. A PCT will automatically be rated "weak" if Existing Commitment Indictors are "Not Met". An overall rating will be undertaken as data for the indicators
becomes available.
Further guidance is awaited on Standards for Better Health and Use of Resources
Benchmarked data is based on NHS East Midlands data sources - where data is not available the PCT is assessing the ability to develop local monitoring
RAG
G
A
R
Description
Achievement
Underachieved
Failed
B
Data not Available
NHS LEICESTER CITY
09/10 Target
09/10
Current Position
(YTD/FOT)
Admitted
90%
94.26%
Non Admitted
95%
98.02%
Direct Access Audiology
95%
100%
0
1
National Priority Indicators for PCTs
EAST MIDLAND & EAST MIDLAND PCTS
PCT Position in
East Midlands
TIME PERIOD
EMSHA
BASSETLAW
DERBY CITY
DERBY
COUNTY
LEICESTER
CITY
LEICS &
RUTLAND
LINCS
NTHANTS
NOTTS CITY
NOTTS
95.10%
96.60%
95.70%
95.90%
93.70%
94.30%
91.70%
96.00%
97.40%
96.70%
97.70%
99.20%
99.10%
98.60%
96.80%
98.20%
94.20%
98.50%
99.20%
98.80%
NHS reported waits for elective care (18 Weeks
Referral to Treatment)

VSA04
8/9
(joint with LCR April 09 Position)
Apr-09
NATIONAL BENCHMAKED DATA NOT AVAILABLE, LOCAL MONITORNG BEING DEVELOPED
N/A
6 weeks diagnostics
NATIONAL BENCHMAKED DATA NOT AVAILABLE, LOCAL MONITORNG BEING DEVELOPED
206,630
B
8/9
(Qtr 4 08/09 88.6%)
Maximum Waiting Time of two months from urgent
referral to treatment of all cancers
95%
B
8/9
(08/09 Position)
April 09 (post
rule changes)
88%
(Nat.aver.
87.2%)
83.30%
82.90%
96.30%
83.30%
89.10%
87.10%
84.50%
81.80%
89.10%
VSB05
Smoking Cessation (per 100,000 population)
2418
2431
3/9
Q3, 08/09
Year end 08/09
102.60%
118.70%
100.80%
100.50%
105.40%
100.10%
93.80%
105.00%
105.90%
112.20%

VSA03
Incidence of CDIFF
192
108
1/9
May-09
332/523
6/8
21/17
54/98
18/32
46/81
70/89
55/96
14/26
48/76

VSB17
NHS Staff Survey based Measures of Job
Satisfaction
Survey on an annual basis
3.62
B
N/A
2008 Staff
Survey
3.47
3.63
3.53
3.61
3.49
3.45
3.61
3.47
3.67
3.59

VSB03
Cancer Mortality Rate - Based on calendar year
2007. Waiting for 2008 data. Target for 2008-09 is
110
110.3
(2009 calendar
year target)
B
5/9
(LC - 115.39)
2005-07
England
Average
119.12
127.88
112.43
112.45
115.39
101.28
113.68
119.96
137.99
116.31

VSB18

EX4

Dental Services
Year end 08/09
94.10%
101.00%
83.50%
94.80%
88.60%
97.70%
99.40%
94.00%
89.50%
93.50%
Page 7 of 16
PERFORMANCE MANAGEMENT FRAMEWORK MEETING
PERFORMANCE FRAMEWORK FOR 2009/10
EXISTING COMMITMENTS (FORMERLY KNOWN BY "EXISTING NATIONAL TARGETS") PERFORMANCE AS AT MAY 2009
INDICATOR RESPONSIBILITY & DESCRIPTION
EX19: THROMBOLYSIS
ACCOUNTABLE DIRECTOR:
VIKKI TAYLOR
OPERATIONAL MANAGER:
TBC
INDICATOR MEASURE:
Thrombolysis - Deliver a 20% point increase per year in the proportion of people suffering from a heart attack who receive thrombolysis within 60 minutes of calling for professional
help.
CURRENT PERFORMANCE 2008/09
2007/08
Outturn
Apr-08
May-08
Jun-08
Jul-08
Aug-08
Sep-08
Oct-08
Nov-08
Dec-08
Jan-09
Feb-09
Mar-09
ACTUAL (Cumulative
position to date)
47%
53%
62%
62%
65%
69%
67%
66%
66%
65%
65%
67%
PLAN
68%
68%
68%
68%
68%
68%
68%
68%
68%
68%
68%
68%
Apr-09
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
68%
68%
68%
68%
68%
68%
68%
68%
68%
68%
2008/09
Outturn
ACTUAL (Cumulative
position to date)
67%
56%
54.55%
PLAN
68%
68%
68%
0809 Threshold
(Confirmed)
Achieve >68%
Under Achieve
>=48%
0809 Threshold
(Confirmed)
Achieve >68%
Under Achieve
>=48%
CONFIRMATION OF SECURED RESOURCES TO DELIVER 2009/10 TARGET:
RESOURCES REQUIRED
PLANNED DATE
No additional financial resources required
N/A
CURRENT POSTION (IN PLACE/REQUIRED)
LEAD
Meeting on 28/05/09 between LCR PCT, UHL and EMAS to review implementation of actions in the assurance plan, determine root
causes of failure to achieve target and agree steps to achieve the target sustainably.
CURRENT PERFORMANCE
Actual
Plan
% patients thrombolysed
80%
70%
60%
50%
40%
30%
20%
10%
0%
Apr-09
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Page 8 of 16
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Alison Hassell
PERFORMANCE MANAGEMENT FRAMEWORK MEETING
PERFORMANCE FRAMEWORK FOR 2009/10
EXISTING COMMITMENTS (FORMERLY KNOWN BY "EXISTING NATIONAL TARGETS") PERFORMANCE AS AT MAY 2009
INDICATOR RESPONSIBILITY & DESCRIPTION
EX19: THROMBOLYSIS
ACCOUNTABLE DIRECTOR:
VIKKI TAYLOR
OPERATIONAL MANAGER:
TBC
INDICATOR MEASURE:
Thrombolysis - Deliver a 20% point increase per year in the proportion of people suffering from a heart attack who receive thrombolysis within 60 minutes of calling for professional
help.
COMMENTARY ON ACTION PLANS
Performance Issues
As at April 09, UHL are reporting an actual of 56% against a 68% target. UHL are progressing the removal of 5 patients through the extenuating circumstances process with the Care Quality Commission. If agreed the target will be achieved.
Action Plan
Progress to Date/Update
Summary
1)
Performance position for November states that UHL are hititng the target. Follwong the CPM (15/01/09) it has been agreed that there
exists a requirement for joint review of the actions. John Roberts to liaise with PCT.
A review of the options for ongoing methodology between UHL and PCT to ensure that the
reporting between the two organisations is consistent.
UHL concentrating on introduction of new 24 hour stroke/thrombolysis service.
2)
Performance and dual targets discussed at UHL Contract Technical meeting and the following was agreed: UHL and PCT in agreement
that the Acute shall work to the HCC target of 68% and not the contractual target of 60%. The 09/10 contract shall be amended to
reflect this.
3)
A root cause analysis has been undertaken of the breaches - The UHL Trust total breaches from April 08 to January 09 sit at 41. Of
these, 24 (58.54%) relate to a delay in EMAS processes, 4 (9.76%) relate to a delay in GGH processes, 3 (7.32%) relate to a delay in
LRI processes, 5 (12.20%) are delays caused by ambulance ECG being non-diagnostic and the final 5 (12.20%) are delays not
categorised. UHL have had discussions with EMAS who are working with national protocols. Further work is required to ascertain
whether EMAS work can be improved to national protocols. UHL to review the seven cases (as mentioned above).
Action
Review of performance situation has been undertaken with UHL/EMAS
By When
Responsibility
01/02/2009
Complete
Celia Hilgenberg /
Shamshad Walker
01/03/2009
Complete
Michael Whitworth/
Tasleema Taib
01/04/2009
Complete
Alison Hassell/
Tasleema Taib
May-09
Alison Hassell/
Tasleema Taib
As a result of the review on performance with UHL/EMAS, a meeting is to be set up in May 09 with EMAS to discuss improvement of
service following national protocols.
4)
UHL are in negotiation with the Care Quality Commission through the extenuating circumstances process to remove a number of
patients from the monitoring due to clinical issues. The target will be achieved if a positive outcome results.
Page 9 of 16
PERFORMANCE MANAGEMENT FRAMEWORK MEETING
PERFORMANCE FRAMEWORK FOR 2009/10
VITAL SIGNS (NATIONAL REQUIREMENTS) - PERFORMANCE AS AT MAY 2009
INDICATOR RESPONSIBILITY & DESCRIPTION
VSA11: 31-DAY STANDARD FOR SUBSEQUENT CANCER TREATMENTS (CHEMOTHERAPY & SURGERY)
ACCOUNTABLE DIRECTOR:
VIKKI TAYLOR
OPERATIONAL MANAGER:
INDICATOR MEASURE:
By March 2009, no patient to wait over 31 days for subsequent/adjuvant treatment for chemotherapy & surgery
TBC
PERFORMANCE TO DATE
March 08
Outturn
Feb-09
Mar-09
Q4 Total
Apr-09
May-09
ACTUAL
N/A
87.88%
94.59%
91.43%
96.8%
94.7%
PLAN
N/A
100%
100%
100%
100%
97.50%
97.50%
97.50%
97.50%
31 day Wait
NEW PLAN (BASED
ON NEW DATA
COLLECTION
BASELINES)
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
97.50%
97.50%
97.50%
97.50%
97.50%
97.50%
97.50%
97.50%
97.50%
97.50%
97.50%
PREDICTED RECOVERY BY:
CONFIRMATION OF SECURED RESOURCES TO DELIVER 2009/10 TARGET:
RESOURCES REQUIRED
PLANNED DATE
CURRENT POSITION (IN PLACE/REQUIRED)
To be identified in UHL action plan (see performance issues narrative)
M Nattrass UHL
Actual
Plan
31 day standard for subsequent cancer treatment (Chemotherapy and Surgery)
% patients seen with 31
days
102.00%
100.00%
98.00%
96.00%
94.00%
92.00%
90.00%
88.00%
86.00%
84.00%
82.00%
80.00%
Feb-09
Mar-09 Q4 Total
Apr-09
May-09
Jun-09
Jul-09
LEAD
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Page 10 of 16
ACTION PLAN
COMMENTARY
2009/10 PROPOSED PLANS FOR PERFORMANCE
Plans for 2009/10
Planned
Date
Progress to Date/Remedial Actions
(as at 23 December 2008)
Mike Nattrass UHL/
Andrew Clarke
ACTION (1)
Ensure best practice regarding information
systems are implemented
ACTION (2)
Ensure data monitoring systems are in place
ACTION (3)
Assess performance to ensure target is
achieved
ACTION (4)
Six performance notices have been issued for
failure to meet national targets.
Jul-09
Remedial actions plans due 10th July 09
Alison Hassell / Peter
Huskinson
ACTION (5)
UHL to devise action plan to address notices
Jul-09
Action plan delivered
Helen Seth/Suzanne
Hinchliffe
Sept 08
Complete
Jan-09
Complete for surgical patients, ongoing work re some
chemotherapy patients
Responsibility
Surgical data monitoring now in place. Reporting to PCT
will take place as patients complete their treatment in
January. Chemo patient data now expected in February.
The Commissioning & Performance Team will assess data
Dec 08
once received to ensure targets are being achieved. Any
Complete
issues will be raised directly with UHL
Mike Nattrass UHL/
Mike Hotson
Mike Nattrass UHL/
Mike Hotson
Page 11 of 16
Following a meeting with the Director of Operations to review their action plan, UHL are reporting that systems are in place for the identification
and monitoring of patients undergoing surgical procedures. From data submitted to the PCT recently from their preliminary analysis, 75% of
patients are hitting the target without taking into account any relevant clock stops and without the benefit of prospective tracking. Mechanisms
are now in place to deal with these. Work to prospectively identify some chemotherapy patients is still ongoing and technical issues are being
resolved. These are expected to be dealt with by the end of January. Preliminary analysis by UHL showd the chemo patients to be at 96%.
Agreement that from now all data should be fed to Simon Freeman via John Roberts.
First batch of 'regular' data reports expected first week in February.
Data submitted is incomplete. Escalation now to level 3 - Simon Freeman to assume responsiblity, meeting arranged with Director of Ops at
UHL to progress. Further action plan will follow.
Status report and action plan produced as result of meeting with UHL Dir of Ops.
Circulated to PCT Directors and CEOs. Appended to A&P reports.
Complete data to be delivered by 16/03.
Following further meeting with Director of Ops and Dir of Performance (NHS LCR) and Dir of
Strategy (NHS LC) status report and action plan updated. Detailed action plan expected from
UHL by end April demonstrating how surgical breaches to be addressed (chemo patients on target).
To be followed up with further meeting early May.
No Action plan supplied by end of April. Briefing paper discussed at Chief Execs Meeting on 11/5. Outcome UHL to produce action plan and achieve improvements within 2 months. Assistance sought from Cancer
Network. Lack of progress at this stage will result in contractual sanctions being applied. Director level
meeting to take place on 21/5 to review progress.
Contractual performance notices in progress of being served. Comprehensive action plan not yet received. Discussed at June
Chief Execs meeting again with committment from MLL to progress. Assistance from Cancer Network secured.
Further review meeting to take place end JuneData submitted is incomplete. Escalation now to level 3 - Simon Freeman to assume
responsiblity, meeting arranged with Director of Ops at UHL to progress. Further action plan will follow.
Status report and action plan produced as result of meeting with UHL Dir of Ops.
Circulated to PCT Directors and CEOs. Appended to A&P reports.
Complete data to be delivered by 16/03.
Following further meeting with Director of Ops and Dir of Performance (NHS LCR) and Dir of
Strategy (NHS LC) status report and action plan updated. Detailed action plan expected from
UHL by end April demonstrating how surgical breaches to be addressed (chemo patients on target).
To be followed up with further meeting early May.
No Action plan supplied by end of April. Briefing paper discussed at Chief Execs Meeting on 11/5. Outcome UHL to produce action plan and achieve improvements within 2 months. Assistance sought from Cancer
Network. Lack of progress at this stage will result in contractual sanctions being applied. Director level
meeting to take place on 21/5 to review progress.
Contractual performance notices in progress of being served. Comprehensive action plan not yet received. Discussed at June
Chief Execs meeting again with committment from MLL to progress. Assistance from Cancer Network secured.
Further review meeting to take place end June
Performance notices served. Action plan received 13/07 Performance improvement expected.by September 09.
Overall annual performance projected to be achieved by exceeding the target for the last 2 quarters.
PERFORMANCE MANAGEMENT FRAMEWORK MEETING
PERFORMANCE FRAMEWORK FOR 2009/10
VITAL SIGNS (NATIONAL REQUIREMENTS) - PERFORMANCE AS AT MAY 2009
INDICATOR RESPONSIBILITY & DESCRIPTION
VSA09: EXTENSION OF NHS BREAST SCREENING PROGRAMME TO WOMEN AGED 50 AND 50-73
ACCOUNTABLE DIRECTOR:
VIKKI TAYLOR
OPERATIONAL MANAGER:
TBC
INDICATOR MEASURE:
By Mar 10, 72% Of eligible 50 year old women will have the test result and 72% of 50-73 yr old women will have be screened for breast cancer in the last
three years.
PERFORMANCE TO DATE
% of eligible 50
year old women
with a breast
screening test
result
% of eligible 50 73 year old
women
screened for
breast cancer in
the last three
years
March 08
Outturn
Apr-08
ACTUAL
N/A
69%
PLAN
N/A
50%
ACTUAL
N/A
61%
PLAN
N/A
70%
May-08
Data
unreliable
50%
Data
unreliable
70%
Jun-08
Jul-08
Aug-08
Sep-08
Oct-08
Nov-08
Dec-08
Jan-09
Feb-09
Mar-09
Apr-09
May-09
56%
70%
80%
73%
68%
61%
54%
64%
61%
61%
66%
65%
50%
50%
50%
50%
52%
53%
54%
56%
57%
61%
70%
70%
52%
73%
73%
70%
68%
61%
49%
67%
60%
65%
65%
63%
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
72%
72%
ACTION PLAN
Jun-09
Jul-09
Aug-09
Sep-09
Plans for 2009/10
Planned
Date
Progress to Date/Remedial Actions
(as at )
70%
70%
71%
71%
ACTION (1)
Page 12 of 16
Dec-09
Jan-10
Feb-10
Mar-10
Threshold 0809
(Confirmed)
71%
72%
72%
72%
72%
72%
Under achieve:
<70%, >=60%
Achieve: >65%
72%
72%
72%
72%
As attarget
This
Marchis09,
deferred.
both targets
Service
have
hasbeen
not yet
achieved.
commenced. Await
Responsibility
Nov-09
Achieve: >70%
COMMENTARY
2009/10 PROPOSED PLANS FOR PERFORMANCE
Oct-09
72%
72%
72%
72%
72%
72%
Under achieve <65%,
>=50%
PERFORMANCE MANAGEMENT FRAMEWORK MEETING
PERFORMANCE FRAMEWORK FOR 2009/10
VITAL SIGNS (NATIONAL REQUIREMENTS) - PERFORMANCE AS AT MAY 2009
INDICATOR RESPONSIBILITY & DESCRIPTION
VSA14: QUALITY STROKE CARE (REDUCTION IN STROKE MORTALITY AND DISABILITY)
ACCOUNTABLE DIRECTOR:
VIKKI TAYLOR
OPERATIONAL MANAGER:
MICHAEL KAISER
INDICATOR MEASURE:
The expected position is 80% of patients spend at least 90% of their time on a stroke unit and 60% of higher risk TIA cases are treated within 24 hours by 2010/11
In order to deliver their contribution to the national position the DH expect to see
1) in
PERFORMANCE TO DATE
ACTIVITY TYPE
TRAJECTORIES
Jan-09
Feb-09
Mar-09
FOT
ACTUAL
Apr-08
Mar-08
Jun-08
Jul-08
Aug-08
Sep-08
Oct-08
Nov-08
Dec-08
74.4%
83.7%
104.2%
74%
PLAN
58.0%
62.0%
65.0%
65%
ACTUAL
100.0%
100.0%
42.9%
60%
PLAN
58.0%
62.0%
65.0%
65%
ACTUAL
76.70%
84.60%
88.40%
71.90%
PLAN
58.0%
62.0%
65.0%
65%
UHL
This data is for NHS LC patients only.
The data shown for UHL is now supplied by the I&CP information team.
Definitions confirmed by DoH as:
Proportion of people who spend at
least 90% of their time on a stroke
unit
(161*,163*,164*)
LCR Community Hospitals
The data shown for NHS LCR Community Hospitals is supplied by the I&CP
information team.
As per National Sentinel Audit (NSS), there is a cohort
UHL/LCR Combined
ACTIVITY TYPE
(ICD10 I61,I63 & I64 only)
TRAJECTORIES
ACTUAL
PLAN
UHL
2009/10
Proportion of
people who
spend at least
90% of their time
on a stroke unit
(161*,163*,164*)
Apr-09
May-09
56.67%
48.00%
65%
65%
0.00%
86.67%
65%
65%
56.67%
48.00%
65%
65%
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Total
65%
67%
67%
67%
69%
69%
69%
70%
70%
70%
70%
PREDICTED
RECOVERY BY:
ACTUAL
LCR Community Hospitals
PLAN
This data is for NHS LC patients only.
65%
67%
67%
67%
69%
69%
69%
70%
70%
70%
70%
ACTUAL
UHL/LCR Combined
PLAN
The data shown for UHL is now supplied by the I&CP information
team.
The data shown for NHS LCR Community Hospitals is supplied by
the I&CP information team.
PREDICTED
RECOVERY BY:
There has not been a cohort of patients removed from t
65%
67%
67%
67%
69%
69%
69%
70%
70%
70%
70%
Jun-08
Jul-08
Aug-08
Sep-08
Oct-08
Nov-08
Dec-08
(Q3)
Jan-09
Feb-09
Mar-09
FOT
PREDICTED
RECOVERY BY:
ACTIVITY TYPE
Proportion of people who have a TIA
who are scanned and treated within
24 hours
TRAJECTORIES
Apr-08
Mar-08
ACTUAL
100&
75%
66.67%
75%
PLAN
25%
25%
25%
25%
There will be no 'local trajectory' for TIA for 2009/10. However, we
will be measuring a different performance target via the acute
contract.
Despite being green at the end of 2008/09, the DH guidance on the
measurement has been amended and the service
NATIONAL TARGET
TRAJECTORIES
ACTUAL
2009/10
UHL
PLAN
Apr-09
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Q4 Total
28%
33%
33%
33%
39%
39%
39%
45%
45%
45%
45%
Not yet available
28%
28%
PREDICTED
ACHIEVEMENT BY:
CONFIRMATION OF SECURED RESOURCES TO DELIVER 2009/10 TARGET
RESOURCES REQUIRED
PLANNED DATE
CURRENT POSITION (IN PLACE/REQUIRED)
No additional resources are required, but please note the actions list.
Page 13 of 16
LEAD
PERFORMANCE MANAGEMENT FRAMEWORK MEETING
PERFORMANCE FRAMEWORK FOR 2009/10
VITAL SIGNS (NATIONAL REQUIREMENTS) - PERFORMANCE AS AT MAY 2009
INDICATOR RESPONSIBILITY & DESCRIPTION
VSA14: QUALITY STROKE CARE (REDUCTION IN STROKE MORTALITY AND DISABILITY)
ACCOUNTABLE DIRECTOR:
VIKKI TAYLOR
OPERATIONAL MANAGER:
INDICATOR MEASURE:
The expected position is 80% of patients spend at least 90% of their time on a stroke unit and 60% of higher risk TIA cases are treated within 24 hours by 2010/11
In order to deliver their contribution to the national position the DH expect to see
1) in
PERFORMANCE MONITORING
BENCHMARKING PERFORMANCE
Proportion of people who spend at least 90% of their time on a stroke unit at UHL
Patients treated for >50% of stay in Stroke Unit (Sentinel Audit)*
90
100.00%
80
76
80
90.00%
68
70
80.00%
70.00%
60
60.00%
50
50.00%
40
40.00%
30
30.00%
20
20.00%
10
10.00%
0
55
43
58
54
46
36
29
30
32
0
UHL
LCR Community Hospitals
Total
Mar-10
Feb-10
Jan-10
Dec-09
Nov-09
Oct-09
Sep-09
Aug-09
Jul-09
Jun-09
May-09
0.00%
Apr-09
Proportion of people
MICHAEL KAISER
UHL/LCR Combined
Page 14 of 16
EAST ENGLAND
United
Derby Chesterfield United Nottingham University
United SherwoodNorthampton United
Kettering
Royal Lincolnshire University Hospitals ofLincolnshireMIDLANDS
General Lincolnshire Hospitals
General Lincolnshire Forest
Hospitals Foundation Hospital Hospitals Hospital Leicester Hospitals SHA overall
Hospitals Hospitals Hospital
Hospital
(Louth
Foundation (Lincoln
(Pilgrim
(Grantham
County
County)
Hospital)
and District
Hospital)
Hospital)
PERFORMANCE MANAGEMENT FRAMEWORK MEETING
PERFORMANCE FRAMEWORK FOR 2009/10
VITAL SIGNS (NATIONAL REQUIREMENTS) - PERFORMANCE AS AT MAY 2009
INDICATOR RESPONSIBILITY & DESCRIPTION
VSA14: QUALITY STROKE CARE (REDUCTION IN STROKE MORTALITY AND DISABILITY)
ACCOUNTABLE DIRECTOR:
VIKKI TAYLOR
OPERATIONAL MANAGER:
INDICATOR MEASURE:
The expected position is 80% of patients spend at least 90% of their time on a stroke unit and 60% of higher risk TIA cases are treated within 24 hours by 2010/11
In order to deliver their contribution to the national position the DH expect to see
1) in
ACTION PLAN
MICHAEL KAISER
COMMENTARY
Plans for
2009/10
Planned Date
2009/10 PROPOSED PLANS FOR PERFORMANCE
Progress to Date/Remedial Actions
(as at end of June 2009)
Responsibility
Monthly Performance: As at Dec 08 , 37.5% of people spent at least 90% of their time on a stroke unit against
the monthly trajectory of 52%. The trajectory has not been achieved.
Cumulative Performance: As at Feb 2009, 42.45% of people spent at least 90% of their time on a stroke unit
against the monthly trajectory of 52%. The trajectory has not been achieved.
Development of plan
to ensure that 70% of
people spend 90% of
their time on a stroke
unit within UHL.
Ongoing
ACTION (2)
Improvement of
patient pathway at
UHL.
31.03.10
Some patients arrive at A&E at LRI instead of the Stroke Unit at LGH. Transferring is dependant upon transportation availability and
bed availability on the Stroke Unit. The Stroke unit needs to be moved to the LRI. UHL have assured NHS LCR that the St
Michael Kaiser
ACTION (3)
An investigation has
commenced into the
feasibility of a Stroke
clinical system being
implemented
31.12.09
The East Midlands PCT Stroke Leads will use national funds to procure an East Midlands wide stroke system (but different Patient
Master Index's (PMI's)). The system (Dendrite) will be in place before October 2009. It will result in more accurate data fo
Michael Kaiser
ACTION (4)
TIA Performance
31.11.09
DH have now revised the Stroke Vital Sign Indicator (VSA14). It has significant effects on the measurement of the Stroke & TIA vital
signs indicators. As a result of the amendments we now only need to submit Q4 data for Stroke and do not need to submit
Michael Kaiser
ACTION (1)
UHL have assured NHS LCR that the Stroke Unit will move to the LRI within 2009 (as per Action 2). This will improve UHL's
performance against this target - MK IS TO CHASE THIS WITH HELEN SETH
Data is refreshed on a monthly basis, and therefore % achieved will alter.
Michael Kaiser
UHL have also commenced a clinical review of all those patien
Page 15 of 16
PERFORMANCE MANAGEMENT FRAMEWORK MEETING
PERFORMANCE FRAMEWORK FOR 2009/10
VITAL SIGNS (NATIONAL REQUIREMENTS) - PERFORMANCE AS AT MAY 2009
INDICATOR RESPONSIBILITY & DESCRIPTION
VSB06 - EARLY ACCESS FOR WOMEN TO MATERNITY SERVICES
ACCOUNTABLE DIRECTOR:
TOBY SANDERS
OPERATIONAL MANAGER:
MEL THWAITES
By March 2010, 85% of women should have seen a midwife or an obstetrician for health and social care assessment of needs and risk by 12 weeks of their
pregnancy
INDICATOR MEASURE:
CURRENT PERFORMANCE 2008/09
ACTUAL
Percentage of women who have seen a
(Cumulative)
midwife or a maternity healthcare
professional, for health and social care
assessment of needs, risks and choices
by 12 completed weeks of pregnancy
PLAN
2008-09
Outturn
Apr-09
79.43%
79.02%
81.08%
82.39%
80%
82%
82%
82%
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Cumulative to date
79.95%
83%
83%
83%
84%
84%
84%
85%
85%
85%
85%
ACTION PLAN
Plans for 2009/10
Vital Sign refresh completed in line with DH trajectory of 90% by 2011. Trajectory set for 09/10 is
85% by Q4. Submitted to the SHA.
2009/10 PROPOSED PLANS FOR PERFORMANCE
Progress to Date/Remedial Actions
Planned
(as at 11 Jun 2009)
Date
Responsibility
ACTION (1)
Implementation of Maternity Matters
Model
Dec-09
Action Plan developed with key stakeholders for implementation of
Model. Operational group set up to monitor implementation of
Model.
Yasmin Sidyot
ACTION (2)
Mainstreaming of Maternity Support
workers in Community Midwifery to
increase capacity and support early
access to midwife
Sep-09
Investment has been secured through LOP. Business Case has
been developed with a view to submitting before the end of June 09.
Yasmin Sidyot
ACTION (3)
Promote early and direct access to
maternity services in the community and
within Primary care services
Sep-09
Once Business Case under Action (2) has been approved, work will
commence. Communications to go out to all households in Leicester
City, raising awareness of early access.
Yasmin Sidyot
ACTION (4)
Development of Specialist Midwifery
team for vulnerable groups to improve
access to services for vulnerable women
Aug-09
Case of need has been submitted, awaiting approval from the panel
approving Business Cases.
Yasmin Sidyot
Page 16 of 16
Communication via NHS Leicester Newsletter out to all households in Leicester to promote direct
and early access to midwife. Work being targeted with specific areas where there is a high number
late bookings. Looking at increasing clinic venues in these areas.
Maternity Health Equity Audit completed with EMPHO to look at the inequalites in health in relation
to maternity. Presentation attached for information.
NHS LEICESTER CITY
MEETING:
TRUST BOARD MEETING
DATE:
30 July 2009
REPORT TITLE:
University Hospitals Leicester (UHL) Service Level
Agreement (SLA) Performance Report as at July 2009
SECTION:
Public
REPORT BY:
Clare Winter, Head of Procurement Strategy & Market
Management
PRESENTER:
Vikki Taylor,
Management
Director
PAPER L
of
Strategy
&
Market
EXECUTIVE SUMMARY
Appendix 1 of this report details:

2009/10 performance on Service Level Agreement (SLA) with
University Hospitals Leicester (UHL) with position as at June 2009.

18 weeks orthopaedic issues are around admitted and out-patients,
patients on waiting lists and new patients. This is putting additional
pressure on the private sector. Monitoring of this situation is being
undertaken as part of the 18 week team which meets every two weeks.

In relation to accident and emergency UHL have agreed to bring in a
third party, to look at a whole system root cause analysis. This was
agreed at the UHL contract performance management meeting.
Appointment of the third party is being managed by the Associate
Director of Acute Care (County). As yet no decision has been made as
to who to appoint. A further update of the status of the appointment
should be available August 2009.

In relation to cancer, there have been are three performance notices
issued. UHL produced an action plan on 10 July 2009. This has been
received and is currently being reviewed by the contracts team. The
Director of Strategy and Market Management and the Director of
Information are due to meet with the UHL Director of Operations to
pursue.
Appendix 2 is a report produced by the Deputy Director of Quality providing an
overview of the findings from the National Patient Survey for the UHL and puts
forward recommendations for improving and monitoring performance.
BOARD ASSURANCE
The PCT Board needs to monitor the position of the SLA with UHL.
RECOMMENDATION
The Board is requested to:
NOTE the current position for 2009/10 as outlined in Appendix 1.
NOTE that the actions to address the performance of UHL as detailed in
Appendix 2 and to provide assurance to the Trust Board will be through the
Commissioning and Governance Committee.
NHS LEICESTER CITY TRUST BOARD
SECTION 3 - TARGET PERFORMANCE AS AT MAY 2009
UNIVERSITY HOSPITALS OF LEICESTER
The following table details the targets within the UHL contract with NHS Leicestershire County & Rutland and NHS Leicester City, and the
associated performance to date.
Description
RAG
G
Achievement
A
Underachieved
R
Failed
B
Data not Available
Performance Indicators for 2009/10
09/10
May 09
09/10 Target
Cancelled Operations
0.86%
0.80%
Cancelled Operations - re-offer of Admission within 28 days
100%
100%
79%
(week ending
05/07/09)
100%
97.7%
(June)
98%
Current Rating

A
4b1

G

R
4b2
Choose & Book Slot Availability

A
4b3
A&E - Maximum 4 hour Wait
Page1
NHS LEICESTER CITY TRUST BOARD
SECTION 3 - TARGET PERFORMANCE AS AT MAY 2009
UNIVERSITY HOSPITALS OF LEICESTER
Performance Indicators for 2009/10
09/10
May 09
09/10 Target
100%
100%

G
4b4
Revascularisation - Maximum wait of 3 months

A
4b5
Cancer - Maximum wait of one month (31 days) from diagnosis to treatment
96.62%
97.5%
Target to be
confirmed

G
4b6
Cancer - Maximum wait of two months (62 days) from urgent referral to treatment for all
cancers
85.29%
84.5%
Target to be
confirmed

A
4b7
Cancer - Maximum wait of two weeks for urgent GP referral referral to first OP appointment
92.34%
93.3%
Target to be
confirmed

G
4b8
Rapid Access Chest Pain Clinic - Maximum wait of two weeks
100%
100%

B
4b9
SUS Data Quality
B
10%

G
4b11
Delayed Transfer of Care
City 1.22%
County 1.06%
(June)
2.40%

G
Diabetic Retinopathy Screening - Offered
Jun 09 position
City 155.0%
County 135.5%
Combined: 143.4%
100%
Diabetic Retinopathy Screening - Early Detection
Jun 09 position
City 79.1%
County 79.9%
Combined: 79.6%
85%
100%
(May 09)
100%
4b12

R

G
4b13
Waiting Times - Maximum Wait of 26 weeks for elective admission
Page2
NHS LEICESTER CITY TRUST BOARD
SECTION 3 - TARGET PERFORMANCE AS AT MAY 2009
UNIVERSITY HOSPITALS OF LEICESTER
09/10
May 09
09/10 Target
Waiting Times - Maximum Wait of 13 weeks for out-patient appointment
100%
100%
Waiting Times - Maximum Wait of 6 weeks for diagnostic tests
100%
100%
97.5% County
97.6% City
See Schedule 14
of Contract
Performance Indicators for 2009/10

G
4b14

G
4b15

Waiting Times - 2 week wait for Imaging

R
4b16
Thrombolysis - call to needle 60 mins
55.56%
68%

G
4b17
GU Medicine - Access to GUM Clinic within 48 hours of contacting the service
99.95%
100%

G
4b18
Data Quality on Ethnicity
99.51%
100%

B
Infant Health & Inequalities - Smoking during pregnancy
B
17%

B
Infant Health & Inequalities - Breast feeding initiation
B
65%

G
4b22
18 Week Referral to Treatment - Non-Admitted Patients
97.60%
95%

G
4b23
18 Week Referral to Treatment - Admitted Patients
94.06%
90%

B
4b24
Data completeness for Admitted & Non-Admitted Patients
Data within
Tolerances
90%

B
4b25
Cancer - Breast Symptom 2 Week Wait
B
100%
4b20
Page3
NHS LEICESTER CITY TRUST BOARD
SECTION 3 - TARGET PERFORMANCE AS AT MAY 2009
UNIVERSITY HOSPITALS OF LEICESTER
Performance Indicators for 2009/10
09/10
April 09
09/10 Target

B
4b26
Cancer - Extension of NHS Breast Screening Programme to women aged 47-49
and 71-73
B
72%

B
4b28
Cancer - 31 Day Standard for Subsequent Cancer Treatments (Chemo & Surgery)
B
100%

B
4b29
Cancer - 31 Day Standard for Subsequent Cancer Treatments (Radiotherapy)
B
96%

R
4b30
Cancer - Extended 62 Day Treatment Target
85.29%
(April)
100%

B
4b31
Cancer - Cervical Screening
B
30%

G
LC: 88.98%
LCR: 74.35%
(April)
70%
Stroke Care - No. of people with TIA who are seen and treated within 24 hours
B
45%
Stroke Care - People who spend at least 90% of their time on a stroke Unit
4b33

B

B
4b34
Access to Maternity Services
B
82%

B
4b35
Rate of Hospital Admissions for ambulatory care sensitive conditions
B
2.5% reduction
on 07/08 baseline

B
4b36
Rate of Hospital Admissions for unintentional & deliberate injuries to children & young
people
B
1% reduction on
07/08 baseline

B
4b37
Satisfaction with A&E/Ambulance Hand Over
B
90%

G
4b40
Emergency Admission Rates
LC PCT 26.48%
LCR PCT 31.91%
(April)
24.20%

G
4b41
Emergency ratio of > 4 hour NEL admissions
LC PCT 62.1%
LCR PCT 67%
(April)
TBC
Page4
NHS LEICESTER CITY TRUST BOARD
SECTION 3 - TARGET PERFORMANCE AS AT MAY 2009
UNIVERSITY HOSPITALS OF LEICESTER
Performance Indicators for 2009/10
09/10
April 09
09/10 Target

B
4b42
Emergency re-admissions
B
90%

B
4b44
Follow Up ratio's
B
Maintain 05/06
basline

B
4b45
Consultant to Consultamt Referrals
B
5% reduction on
04/05 baseline
Page5
Blank Page
Appendix 2
Paper L
NHS Leicester City Board Meeting
30 July 2009
NHS LEICESTER CITY
TRUST BOARD MEETING
30 JULY 2009
National Inpatient Survey- University Hospitals of Leicester 2008
Report by Sharon Robson (Deputy Director of Quality)
Introduction
1. The purpose of this paper is to inform the Board of the findings from
the National Inpatient Survey for University Hospitals of Leicester
(UHL) 2008 and put forward recommendations for improving and
monitoring performance.
Sixth National Inpatient Survey
2. On 13 May 2009, the Care Quality Commission (CQC) published the
results of the sixth national inpatients survey, undertaken in NHS trusts
in England. The survey of adult inpatients, involved 165 acute and
specialist NHS trusts. Overall 72,000 patients responded to the survey
with a response rate of 54%.
3. The survey comprised of 62 questions, presented in the following 8
categories:








Admission to hospital (9 questions)
Hospital and ward (11 questions)
Doctors (4 questions)
Nurses (5 questions)
Your care and treatment (9 questions)
Operations and procedures (6 questions)
Leaving hospital (12 questions)
Overall (6 questions)
Scoring methodology
4. The CQC survey benchmarked scores by converting responses to
particular questions into scores. For each question in the survey, the
individual responses were scored on a scale of 0 to 100, with a score
of 100 equating to ‘the best possible,’ patient care, and 0 equating to
the ‘worst,’ possible care. Three categories are provided to
demonstrate performance, which include:



Lowest 20% of Trusts or on the threshold (RAG rated red)
Remaining 60% of Trusts (RAG rated amber)
Highest 20% of Trusts or on the threshold (RAG rated green)
1
Appendix 2
Paper L
NHS Leicester City Board Meeting
30 July 2009
Summary of UHL Results and Performance
5. Overall UHL’s performance has deteriorated from 2007, and is
presented as follows.



28 red scores in 2008, compared to 7 red in 2007
3 green scores in 2008, compared to 0 green in 2007
31 amber scores in 2008, compared to 54 amber in 2007
6. A detailed breakdown of this performance is provided in Appendix A.
7. One new question has been introduced to the survey, and relates to
patients wanting to complain about the care they received. This has
been rated amber.
8. In each of the eight categories of the survey, UHL’s performance was
as follows:
Admission to hospital
9. Performance was in the lowest 20% of Trusts or on the threshold in two
questions relating to: privacy when patients are being examined in the
Accident and Emergency Dept, and choice of first appointment.
10. Performance was in the highest 20% of Trusts or on the threshold in
the question relating to the time that patients have to wait for hospital
admission.
11. Compared to 2007, UHL’s performance is down in 5 questions, and
has improved in 4 questions.
Hospital and ward
12. Performance was in the lowest 20% of Trusts or on the threshold in two
areas: storage of personal belongings, and choice of food.
13. Performance was in the highest 20% of Trusts or on the threshold two
areas: disturbance by noise at night from other patients, and
disturbance by noise at night by hospital staff.
14. Compared to 2007, UHL’s performance is down in 3 questions,
remains the same in 1 question, and has improved in 7 questions.
Doctors
15. Performance was in the lowest 20% of Trusts or on the threshold for
three questions relating to: confidence and trust in doctors, doctors
2
Appendix 2
Paper L
NHS Leicester City Board Meeting
30 July 2009
talking as though patients weren’t there, and doctors washing and
cleaning their hands between touching patients.
16. Compared to 2007, UHL’s performance is the same in 3 questions, and
has improved in 1 question.
Nurses
17. Performance was in the lowest 20% of Trusts or on the threshold in
three questions relating to: having important questions answered in a
way that could be understood, confidence and trust in nurses, and
nurses washing and cleaning their hands between touching patients.
18. Compared to 2007, UHL’s performance is down in 1 question, remains
the same in 2 questions, and has improved in 2 questions.
Your care and treatment
19. Performance was in the lowest 20% of Trusts or on the threshold in
four questions relating to: involvement in decision-making, having
someone to talk to about worries and fears, privacy on examination,
and pain control.
20. Compared to 2007, UHL’s performance is down in 6 questions,
remains the same in 1 question, and has improved in 2 questions.
Operations and procedures
21. Performance was in the lowest 20% of Trusts or on the threshold in
one question relating to explanation during operations or procedures.
22. Compared to 2007, UHL’s performance is down in 2 questions, and
has improved in 4 questions.
Leaving hospital
23. Performance was in the lowest 20% of Trusts or on the threshold in
eight questions relating to: take home medications (including
explanations about their purpose, the side-effects, having a clear
understanding of medicines, and provision of supporting information),
being informed of danger signals on return home, and family and
carers being given information.
24. Compared to 2007, UHL’s performance is down in 9 questions,
remains the same in 1 question, and has improved in 2 questions.
3
Appendix 2
Paper L
NHS Leicester City Board Meeting
30 July 2009
Overall
25. Performance was in the lowest 20% of Trusts or on the threshold in 4
questions relating to: being treated with respect and dignity, rating how
well doctors and nurses work together, overall rating of care, and
having posters and leaflets visible explaining how to make a complaint
of care received.
26. Compared to 2007, UHL’s performance was down in 3 questions, and
has improved in 2 questions.
Next Steps
27. The Quality Directorate will be working with the Coordinating PCT to
ensure UHL improve performance in those areas identified in the
survey.
28. A meeting with UHL arranged to discuss an action plan for
improvement.
29. Monitoring of the action plan will be undertaken through UHL’s Clinical
Quality Review Group.
RECOMMENDATION
The Board is requested to:
NOTE the contents of the report.
NOTE that the actions to address the performance of UHL and to provide
assurance to the Trust Board will be through the Commissioning and
Governance Group.
4
Appendix A
Paper L
NHS Leicester City Board Meeting
30 July 2009
Appendix A-National Inpatient Survey - Comparison of UHL Scores for 2007 and 2008 surveys
Key
Bottom 20% Trusts or on threshold (red)
Middle 60% Trusts (amber)
New = New question
NA = question not asked
Upper 20% Trusts or on threshold (green)
* Please note a score of 100 equates to 'the best possible' patient care
and a score of 0 equates to 'worst' possible care.
Question
No of respondents
Admission to hospital
How much information about your condition did you
get in the Emergancy Department?
Were you given enough privacy when being examined
or treated in the Emergency Department?
How long did you wait before being admitted to a bed
on a ward?
Were you offered a choice of hospital for your first
hospital appointment?
Overall, how long did you wait to be admitted to
hospital?
How do you feel about the length of time you were on
the waiting list before your admission to hospital?
Were you given a choice of admission date?
Was your admission date changed by the hospital?
Upon arrival, did you feel that you had to wait a long
time to get to a bed on a ward?
The hospital and ward
When you were first admitted to a bed on a ward, did
you share a sleeping area, for example a room or bay,
with patients of the opposite sex?
While staying in hospital, did you ever use the same
bathroom or shower area as patients of the opposite
sex?
Were you ever bothered by noise at night from other
patients?
Were you ever bothered by noise at night from
hospital staff?
In your opinion, how clean was the hospital room or
ward that you were in?
How clean were the toilets and bathrooms that you
used in hospital?
Did you feel threatened during your stay in hospital by
other patients or visitors?
Did you have somewhere to keep your personal
belongings whilst on the ward?
How would you rate the hospital food?
Change in
UHL
UHL
performance
Score
Score
between 2007
2007
2008
and 2008
462 (54%) 449 (54%)
79
81
2
84
82
-2
64
60
-4
19
27
8
51
57
6
76
33
86
30
4
-3
91
90
-1
82
79
-3
69
77
8
73
71
-2
61
65
4
79
82
3
82
85
3
79
83
4
96
96
0
60
49
56
52
4
3
Appendix A
Paper L
NHS Leicester City Board Meeting
30 July 2009
-1
Were you offered a choice of food?
80
79
Did you get enough help from staff to eat your meals?
Doctors Section
73
71
-2
78
80
2
87
87
0
81
81
0
78
78
0
77
78
1
84
83
-1
85
85
0
71
74
3
82
82
0
80
81
1
67
67
0
80
77
-3
61
62
1
56
55
-1
81
80
-1
93
91
-2
82
79
-3
63
62
-1
88
89
1
86
83
-3
85
86
1
68
71
3
89
90
2
When you had important questions to ask a doctor,
did you get answers that you could understand?
Did you have confidence and trust in the doctors
treating you?
Did doctors talk in front of you as if you weren’t there?
As far as you know, did doctors wash or clean their
hands between touching patients?
Nurses Section
When you had important questions to ask a nurse, did
you get answers that you could understand?
Did you have confidence and trust in the nurses
treating you?
Did nurses talk in front of you as if you weren’t there?
In your opinion, were there enough nurses on duty to
care for you in hospital?
As far as you know, did nurses wash or clean their
hands between touching patients?
Your Care and Treatment
Did a member of staff will say one thing and another
say something different.
Were you involved as much as you wanted to be in
decisions about your care and treatment?
How much information about your condition or
treatment was given to you?
Did your family or someone else close to you have
enough opportunity to talk to a doctor?
Did you find someone on the hospital staff to talk to
about your worries and fears?
Were you given enough privacy when discussing your
condition or treatment?
Were you given enough privacy when being
examined or treated?
Do you think the hospital staff did everything they
could to help control your pain?
After you used the call button how long did it usually
take before you got help?
Operations and Procedures
Beforehand, did a member of staff explain the risks
and benefits of the operation or procedure in a way
you could understand?
Did a member of staff explain what would be done
during the operation or procedure?
Did a member of staff answer your questions about
the operation or procedure?
Were you told how you could expect to feel after you
had the operation or procedure?
Did the anaesthetist explain how he or she would put
you to sleep or control your pain?
After the operation or procedure, did a member of
staff explain how the operation or procedure had
gone?
Leaving Hospital
Did you feel you were involved in decisions about your
discharge from hospital?
What was the main reason for the delay?
How long was the delay?
Were you given any written or printed information
about what you should or should not do after leaving
hospital?
Did a hospital staff explain the purpose of the
medicines you were to take at home?
Did a member of staff tell you about medication side
effects to watch for ?
Were you told how to take your medication in a way
you could understand?
Were you given clear written or printed information
about your medicines?
Did a member of staff tell you about any danger
signals you should watch for after you went home?
Did hospital staff give your family or someone close to
you all the information they needed?
Did hospital staff tell you who to contact if you were
worried about your condition or treatment ?
Did you receive copies of letters sent between
hospital doctors and your family doctor (GP)?
Overall Section
Overall, did you feel you were treated with respect and
dignity while you were in the hospital?
How would you rate how well the doctors and nurses
worked together?
Overall, how would you rate the care you received?
During your hospital stay, were you ever asked to
give your views on the quality of your care?
Did you ever see any posters or leaflets explaining
how to complain about the care you received?
Did you want to complain about the care your
received in hospital?
Appendix A
Paper L
NHS Leicester City Board Meeting
30 July 2009
77
78
-1
68
60
75
65
58
71
-3
-2
-4
67
61
-6
81
80
-1
45
42
-3
81
81
0
73
67
-10
50
47
-3
52
50
-2
69
75
6
41
42
1
88
85
-3
73
72
-1
75
74
-1
6
9
3
29
31
2
NA
91
New
Blank Page
NHS LEICESTER CITY
MEETING:
TRUST BOARD MEETING
PAPER M
DATE:
.
REPORT TITLE:
30 July 2009
SECTION:
Public
REPORT BY:
Meena Ackbarally, Assistant Director, Mental Health
Learning Disability Prison
PRESENTER:
Vikki Taylor,
Management
Leicestershire Partnership Trust (LPT) Service Level
Agreement (SLA) Performance Report as at April/May
2009
Director
of
Strategy
&
Market
EXECUTIVE SUMMARY
Appendix 1 details:

2009/10 performance on Service Level Agreement (SLA) with
Leicestershire Partnership Trust (LPT) with position as at May 2009.

There are continued data quality issues with LPT. An action plan has
been received from LPT on the 13 July 2009 which is being reviewed
by the PCT.

Month 2 performance on key performance indicators show 6 targets
are achieved, one under achieved, namely Crisis Resolution Service
and the one on delayed transfers of care not achieved.
Crisis Resolution has been monitored on a weekly basis. At the
Finance and technical meeting LPT have assured the PCT that target
will be met in month 3 as there is only one patient waiting at present.
Action Plan for delayed discharge being reviewed by PCT.

Quality Report submission for June 2009 needs improvement. Reports
were not submitted for 2 areas and incomplete submission in another
two areas. As this is unacceptable it has been escalated to the
contracts meeting on the 27 July 2009.
BOARD ASSURANCE
The PCT Board needs to monitor the position of the organization on the SLA
with LPT.
RECOMMENDATION
The Board is requested to:
NOTE the current position for 2009/10.
Appendix 1
Paper M
NHS Leicester City Board Meeting
30 July 2009
NHS LEICESTER CITY TRUST BOARD
SERVICE LEVEL AGREEMENT PERFORMANCE SUMMARY
SUMMARY - LEICESTERSHIRE PARTNERSHIP TRUST
The current contract with LPT has a value of £42,024m. It is an activity based contract with the exception of day care which is a block contract and has a value of
£2.13m. This service is being unbundled, a project plan is in place. £220k is held in reserve and will only be paid to LPT when they deliver as per the project plan.
Accurate Data submission has been problematic in 08/09. A Data Quality Improvement Plan is in place with financial triggers for LPT if they do not deliver as per
plan. Month 2 activity data demonstrates that LPT is performing to planned activity with the exception of Day Care, Outpatients/Community Mental Health Teams
and Crisis Resolution.
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