2. Performance Against the 2008/09 NHSScotland Targets
Each year the Scottish Government sets performance targets for NHS Boards to ensure that the resources made available to them are directed to priority areas for improvement, consistent with the Government's Purpose, and with the strategic direction set out in Better Health, Better Care. These targets are focussed on Health Improvement, Efficiency, Access and Treatment, and are known collectively as HEAT targets. In 2008/09 there were 30 HEAT targets. These relatively few, but important targets, helped NHSScotland deliver improvements in the quality of patient-centred care in line with Better Health, Better Care and helped demonstrate the contribution NHS Boards made towards delivering a number of the Scottish Government's National Outcomes:
- Our children have the best start in life and are ready to succeed;
- We have improved the life chances for children, young people and families at risk;
- We live longer, healthier lives;
- We have tackled the significant inequalities in Scottish society;
- We reduce the local and global environmental impact of our consumption and production; and
- Our public services are high quality, continually improving, efficient and responsive to local people's needs.
The Scottish Government, in partnership with NHS Boards and other stakeholders, carries out an annual review of the HEAT targets - taking account of views and developments from across Scotland. For example, work took place during 2008/09 to develop a target on drug misuse services to support recovery. While drug misuse services are a relatively small part of NHSScotland, it was recognised that action in this area has the potential to make a real difference to families and communities throughout Scotland.
Once the targets are agreed, NHS Boards prepare and publish their Local Delivery Plans which describe how they will achieve their stated objectives, including planned performance improvements for each target, risk management plans and the financial resources underpinning delivery. This year, Local Delivery Plans have also included an overview of local commitments NHS Boards have made to support delivery of Single Outcome Agreements 2.
Each year, the Cabinet Secretary for Health and Wellbeing holds each NHS Board to account in public. These annual reviews focus on the impact NHS Boards are making in delivering the Scottish Government's outcomes through HEAT targets and standards, and other local commitments. Plans are being developed for HEAT performance data to be reported through the Scotland Performs website 3 which gives the latest information on progress by the Scottish Government across a range of outcomes.
Delivery of targets and performance measures give Ministers, staff and the public the confidence that progress is being made in implementing the key strategies for NHSScotland in improving the quality of patient care.
Each year, HEAT consists of a number of targets which are due for delivery in that year, a number of well established targets which are due for delivery in the following years, and a number of new targets, agreed with NHSScotland as emerging priority areas for improvement and development. In many cases, the priority action in 2008/09 for this latter group of targets was to establish measures and agree baselines and appropriate improvement interventions - this forms the basis for developing agreed target levels of achievement and trajectories for future years.
For those targets that were due for delivery in 2008/09, an assessment has been made on whether the target has been achieved based on the relevant performance measure. The 2008/09 performance highlights include:
- delivery of the 62 day cancer target;
- further improvements in hospital waiting times, with NHSScotland effectively delivering 12 week maximum waits for outpatients and inpatients one year ahead of schedule;
- good progress on reducing HAI; and
- achieving financial balance and delivering the 2 per cent cash releasing efficiency savings to reinvest in frontline services.
Health Improvement
One of the main challenges to health and wellbeing is the existence of persistent health inequalities in Scotland. Better Health, Better Care explains that NHSScotland is putting health inequalities at the heart of its work, targeting resources on services that support disadvantaged people, particularly those with complex needs.
In its pursuit of improved health outcomes and reduced health inequalities, the Scottish Government recognises the challenges in developing an appropriate approach to setting targets for NHSScotland and monitoring performance. The Health Improvement Performance Management Review developed a suite of groundbreaking performance measures which identified new key short-term goals for NHS Boards to deliver. These support wider activity across the public sector to tackle the most significant challenges to improved health and reduced health inequalities in Scotland. In 2008/09, a number of these targets required NHSScotland to develop new capacity to deliver the interventions and to establish new data sources to manage performance.
In 2008/09 the health improvement targets were:
2008/09 HEAT Targets
H1: Coronary heart disease mortality in deprived areas
H2: Dental registrations among three to five year olds
H3: Children defined as overweight completing healthy weight intervention programmes
H4: Screenings using the appropriate alcohol brief intervention
H5: Staff educated and trained in suicide assessment/prevention
H6: Smoking cessation
H7: New-born children exclusively breastfed at 6-8 weeks
In summary, the Coronary Heart Disease ( CHD) target was achieved this year based on the latest available evidence for 2005-07. NHSScotland made impressive progress in developing agreed effective interventions and establishing data and evidence to support the achievement of the other six targets, one of which has been delivered early. By September 2008 over 80 per cent of all three to five year old children were registered with an NHS dentist - two years ahead of the target date.
H1: Coronary heart disease mortality in deprived areas
What is the target?
Reduce mortality from CHD among people aged under 75 in deprived areas.
Why is it important?
Deprived populations have considerably higher levels of mortality from CHD. This relationship is evident for all ages, but is strongest in the 0-64 age group, for whom death from CHD in the 10 per cent most deprived areas is 1.9 times higher than for Scotland overall. CHD also shares risk factors with the other 'big killers', so by targeting CHD, we can target these too. NHSScotland has since agreed the key contribution it can make to achieving progress towards this outcome of reduced inequality in premature CHD mortality, and for 2009/10 a new target for targeted health checks will be introduced.
H1: Coronary Heart Disease mortality in deprived areas (among people aged under 75)
Source: SG and GROS
Summary of Performance
Target delivered
The performance measure for this target is the level of CHD mortality in the 15 per cent most deprived areas. In helping to deliver this target 23,842 inequalities targeted cardiovascular health checks were carried out in 2008/09 through the Keep Well and Well North anticipatory care programmes.
There has been continued improvement year-on-year with the rate of CHD mortality in the most deprived areas reducing from 162.4 deaths per 100,000 population in 1998-2000 to 112.6 in 2005-2007 (the latest time period for which data is available). This target has been replaced in 2009/10 by a target to carry out 28,000 inequalities targeted cardiovascular health checks.
H2: Dental registrations among three to five year olds
What is the target?
80 per cent of all three to five year old children to be registered with an NHS dentist by 2010/11.
Why is it important?
This target reflects one aspect of the contribution NHSScotland is making towards improving Scottish children's oral health. It is complemented by a variety of preventive programmes involving both general dental practitioners and the community as a whole. It is an indication of how accessible dental care is to pre-school children and therefore their ability to access preventive care in general dental practice as the programmes develop.
H2: Dental registrations among three to five year olds
Source: ISD Management Information and Dental Accounting System ( MIDAS)
Summary of Performance
Target due for delivery in 2010/11 - delivered early
The performance measure for this target is the percentage of all three to five year olds who are registered with an NHS dentist.
There has been a steady rise over the course of the last year in this percentage, increasing from 77.3 per cent in the quarter ending March 2008 to 84.4 per cent in the quarter ending March 2009.
H3: Children defined as overweight completing healthy weight intervention programmes (developmental)
What is the target?
Achieve agreed completion rates for child healthy weight intervention programme by 2010/11.
This is a new target introduced in 2008/09, with the initial requirement on Boards to develop approaches and measures so that they are in a position to achieve the target.
Why is it important?
Attainment of the Scottish Government's purpose of a flourishing economy requires a healthy population. Obesity poses a real risk to the health of the population in Scotland and its ability to meet its overarching purpose of sustainable economic growth because of the burden of disease that accompanies obesity.
Summary of Performance
Target due for delivery in 2010/11
In 2008/09, the first year of the programme, 313 overweight children aged 5-15 years completed Scottish Government approved healthy weight intervention programmes in early adopting NHS Boards.
Following the introduction of this developmental target, NHS Boards have been working closely with stakeholders and have made significant progress in identifying a range of innovative approaches that can be adopted/adapted locally. They are simultaneously developing skills and capacity to delivery these interventions. The total number of interventions to be delivered over the three years of the programme until March 2011 will be agreed in the local delivery plan to be signed off by March 2010.
H4: Screenings using the appropriate alcohol brief intervention
What is the target?
Achieve agreed number of screenings using the setting-appropriate screening tool and appropriate alcohol brief intervention, in line with SIGN 74 guidelines by 2010/11.
This is a new target introduced in 2008/09, with the initial requirement on Boards to develop approaches and measures so that they are in a position to achieve the target.
Why is it important?
This target helps tackle harmful and hazardous drinking, which contributes significantly to Scotland's morbidity and mortality, and social harm.
Summary of Performance
Target due for delivery in 2010/11
Provisional data for 2008/09 shows that NHS Boards carried out 26,499 alcohol brief interventions.
NHS Boards have invested significant effort in building up their capacity over the first year of the programme and have local delivery plans in place to deliver a further 122,950 interventions over the next two years to achieve 149,449 alcohol brief interventions cumulatively over the period 2008/09 - 2010/11.
H5: Staff educated and trained in suicide assessment/prevention
What is the target?
Reduce the suicide rate between 2002 and 2013 by 20 per cent, supported by 50 per cent of key frontline staff in mental health and substance misuse services, primary care, and accident and emergency being educated and trained in using suicide assessment tools/suicide prevention training programmes by December 2010.
Why is it important?
Many people who are feeling suicidal give an indication of their intent, whether verbally or through changes in their behaviour. This is where training to increase the knowledge and skills of key frontline staff in the NHS plays a vital role. The more staff who feel confident and willing to explore possible signs of suicide risk and provide support and help, the higher the potential for saving lives.
Summary of Performance
Target due for delivery end 2010
Data for 2008 shows that 16 per cent of key frontline staff are educated and trained in using suicide assessment tools/suicide prevention training programmes.
NHS Boards have local delivery plans in place to maintain the current rate of delivery over the next two years to achieve the 50 per cent target by December 2010.
This target on suicide education and training reflects one aspect of the contribution NHSScotland is making towards preventing suicide. The 2002 National Strategy and Action Plan to Prevent Suicide (Choose Life) set a target to reduce suicides in Scotland by 20 per cent by 2013. This would mean a reduction from an age-sex-standardised rate of 17.4 per 100,000 population in 2000-2002 to 13.9 per 100,000 population in 2011-2013. The latest available data for 2006-2008 shows the suicide rate at 15.6 per 100,000 population, a reduction of 10 per cent in the first 6 years of the 11 year target period.
H6: Smoking cessation
What is the target?
NHS Boards to support 8 per cent of their smoking population in successfully quitting (at one month post quit) over the period 2008/09 - 2010/11.
Why is it important?
This target sets out the key contribution of NHSScotland to reduce the prevalence of smoking. Smoking has long been recognised as the biggest single cause of preventable ill-health and premature death. It is a key factor in health inequalities and is estimated to be linked to some 13,500 deaths and many more hospital admissions each year. The annual cost to NHSScotland of treating smoking related diseases is estimated to be more than £409 million.
Summary of Performance
Target due for delivery in 2010/11
Over 2008, NHSScotland smoking cessation services reported 18,890 successful quit attempts (at one month post quit), a 30 per cent increase on the number of successful quit attempts over 2007.
NHS Boards have local delivery plans in place to accelerate the current rate of increase in the next two years to deliver 83,978 successful quit attempts cumulatively across Scotland over the period 2008/09 - 2010/11.
Smoking Cessation and Alcohol Reduction
Louise's Story
Louise is helping to prove that it's never too late for people to improve their health. In the last 18 months she has stopped smoking, lost weight and is now working hard to cut back on alcohol - all thanks to support provided by the NHS.
Louise is one of the successes of the Keep Well programme which offers health checks and advice on a range of lifestyle issues. For the 61-year-old from Edinburgh, it started when her GP at her local medical centre referred her to a smoking cessation clinic.
"I was smoking about 40 cigarettes a day and thought I could never give up," recalled Louise. However, with the support of group therapy sessions and with the help of nicotine patches and an inhaler, she changed her mind. Louise stopped smoking in March last year and has never looked back.
She then decided to lose weight though a programme led by a practice nurse. This included questions about Louise's drinking habits which found she was exceeding the recommended weekly amounts. She was referred for alcohol counselling which is helping her to cut down.
Before taking part in the programme Louise was finding it difficult to do her housework and could only walk short distances. "I feel so much better now. I need to do more with the drinking. It's difficult but I'm making progress."
H7: New-born children exclusively breastfed at 6-8 weeks
What is the target?
Increase the proportion of new-born children exclusively breastfed at 6-8 weeks from 26.6 per cent in 2006/07 to 33.3 per cent in 2010/11.
Why is it important?
The Scottish Government's Better Health, Better Care Action Plan noted that food and nutrition is one of the key areas in which parents influence child health during pregnancy, the early years and beyond. As a result, NHS Boards have been set this target to improve breastfeeding rates which will help increase the long-term health benefits experienced by children who are breastfed.
Summary of Performance
Target due for delivery in 2010/11
The performance measure for this target is the proportion of new-born children exclusively breastfed at 6-8 weeks.
In the year ending December 2008, 26.4 per cent of all babies receiving a 6-8 week review were exclusively breastfed, a marginal increase on the 26.2 per cent reported in the year ending March 2007.
NHSScotland has committed to delivering a 25 per cent increase on baseline performance across all Boards by 2010/11 (in effect increasing the proportion of new-born children exclusively breastfed at 6-8 weeks to 33 per cent) and are developing innovative approaches to do so. Breastfeeding rates vary by geographical area and are strongly linked to deprivation and maternal age. For example, as of year ending March 2009 the rate in NHS Lanarkshire is 18.4 per cent whereas the rate in NHS Highland is 32.7 per cent. There are many factors that influence feeding choices and changing the culture around breastfeeding is a significant challenge.
Efficiency and Governance
As NHSScotland received over £10 billion of public money in 2008/09 (£2,059 per head of population), it is important that it secures best value from these resources and is as efficient as possible in the delivery of frontline and support services.
In early 2008, a new Efficiency and Productivity Programme was introduced. This programme supports NHSScotland to deliver more consistent, higher quality and efficient services and levels of productivity. The programme supports NHS Boards to share emerging best practice, to reduce waste, and to identify and challenge variation in care and service.
In 2008/09 the efficiency and governance targets were:
2008/09 HEAT Targets
E1: Community Health Index ( CHI) usage
E2: Sickness absence
E3: Staff with a Knowledge and Skills Framework personal development plan
E4: Productivity
E5: Financial performance
E6: Cash efficiencies
E7: Electronic management of referrals
In summary, in 2008/09 NHSScotland achieved its financial targets relating to spend against Revenue Resource Limit ( RRL) and the Efficient Government savings target of 2 per cent. It also effectively delivered on CHI usage (lab requests with a valid CHI). The sickness absence rate decreased on the previous year from 5.14 per cent in April 2008 to 4.43 per cent in March 2009. The percentage of staff with a Knowledge and Skills Framework ( KSF) personal development plan increased from 14 per cent in April 2008 to 92 per cent in March 2009 and the target was achieved by July 2009.
E1: Community Health Index usage
What is the target?
Universal utilisation of Community Health Index ( CHI).
Why is it important?
The CHI number is a unique identifier for every individual, and provides the basis for NHSScotland to link information across the range of services provided. Use of the CHI number in every document or record for every patient increases quality, speed and efficiency of all health services, and introduces the ability to share information more effectively.
E1: Percentage of lab requests with valid Community Health Index ( CHI)
Source: eHealth CHI Programme Data
Summary of Performance
Target delivered
The performance measure for this target is 97 per cent of all laboratory requests to include a CHI number. NHSScotland's performance against this target improved from 88 per cent in April 2007 to 96 per cent in April 2008. In 2008/09 this performance improved further, with 97 per cent of all laboratory requests containing a CHI number in March 2009.
A new CHI performance measure has been developed for 2009/10.
E2: Sickness absence
What is the target?
NHS Boards to achieve a sickness absence rate of4 per cent from 31 March 2009.
Why is it important?
Sickness absence in NHSScotland can result in cancelled appointments and procedures, increased pressure on staff and less effective care for patients, increased costs of employing bank and agency staff and reduced efficiency.
E2: Sickness absence
Source: ISD
Summary of Performance
Target not met but significant progress achieved
The performance measure for this target is the percentage of total available hours that are lost to sickness absence.
The rate of monthly sickness absence has significantly decreased over the last two years, from 5.36 per cent in March 2007, to 5.06 per cent in March 2008, to 4.43 per cent in March 2009, but fell just short of the 4 per cent target. The significant progress achieved does however equate to around 650,000 more hours worked in NHSScotland in 2008/09 than in 2007/08.
E3: Staff with a KSF personal development plan
What is the target?
NHS Boards to ensure that all employees covered by Agenda for Change have an agreed KSF personal development plan by March 2009.
Why is it important?
This target supports implementation of the NHS Knowledge and Skills Framework ( KSF). The NHSKSF is the one strand of the modernised NHS pay system Agenda for Change. Implementation of KSF will ensure staff have regular development reviews against KSF outlines and agreed personal development plans. This supports effective workforce development leading to improved services for patients.
E3: Staff with a KSF personal development plan
Source: e KSF
Summary of Performance
Target near miss but achieved by July 2009
This target supports implementation of the NHSKSF which provides a fair and objective framework on which to base review and development for all Agenda for Change staff. The percentage of all Agenda for Change staff who had an agreed KSF personal development plan increased from 14 per cent in April 2008 to 92 per cent in March 2009. The target of 100 per cent was achieved by July 2009.
E4: Productivity
What is the target?
The overall target is for NHS Boards to deliver agreed improved efficiencies for first outpatient attendance did not attend ( DNA), non-routine inpatient average length of stay, review to new outpatient attendance ratio and day case rate by March 2011.
Why is it important?
This target supports the new Efficiency and Productivity Programme aimed at improving the efficiency of NHSScotland.
Summary of Performance
Target due for delivery in 2010/11
E4.1: Day case rates
In 2008, the percentage of British Association of Day Surgery ( BADS) surgical procedures that were performed in a day case or outpatient setting was 68.8 per cent, against a target of 83 per cent by March 2011. This was a marginal increase on the 68.3 per cent in 2007.
NHS Boards have developed action plans in 2008/09 to achieve the day case rates target. This will be challenging and requires change on a number of levels across the system including clinical culture change, revisions to theatre scheduling and timeliness of pre-operative assessment as well as revisions to the recording of procedures delivered in the outpatient setting.
E4.2: Non-routine inpatient average length of stay - delivered early
The average length of stay per hospital episode (for acute inpatients discharged following an urgent, emergency or other non-routine, unplanned admission) target of 3.9 days by March 2011 was achieved early, with an average length of stay of 3.9 days recorded for the year ending March 2008.
E4.3: Review to New Outpatient Attendance ratio - delivered early
Provisional data shows the ratio of review to new outpatient attendance was 2.2 in the year ending March 2008 against a target of 2.2 for year ending March 2011, showing the target was delivered early.
E4.4: New Outpatient Appointment Did Not Attend ( DNA) Rates
Provisional data shows the new outpatient appointment DNA rate in year ending March 2008 was 10.4 per cent, a slight increase on the rate of 10.1 per cent for year ending March 2007. NHS Boards have developed local delivery plans to achieve the 9.2 per cent target by March 2010 while recognising that this will be a challenging target.
Improving Efficiencies Across a Range of Services
NHS Borders' Story
NHS managers and frontline staff at NHS Borders are working together to examine the efficiency of local services to ensure the best value for money is achieved.
It is based on using information which compares the performance of services both within NHS Borders and against similar services in other parts of Scotland. Analysing such information can help to show if there are unexplained differences in activities such as the use of beds, GP referrals patterns, lengths of stay and treatment costs.
Ross Cameron, Medical Director, said: "We are examining a wide range of services and clinical behaviours and comparing them to a range of peer group boards and hospitals across the UK. Where we find examples where we fall below the upper quartile in performance for a particular clinical activity, we pose the question to the clinicians, "Is there a local explanation for this or can we improve efficiency?"
John Glennie, Chief Executive of NHS Borders said: "By using data in an open way to ask questions about variations in clinical practice, we have started to think differently about how we use the resources at our disposal, whilst also improving the quality of care."
The process involves constructively challenging the current way services are provided and redesigning them where necessary. NHS Borders believes that this is essential if it is to provide services for the future that are sustainable, offer value for money, are based on the latest evidence and lead to improvements in patient care.
E5: Financial performance
What is the target?
NHS Boards are required to operate within their Revenue Resource Limit ( RRL), their Capital Resource Limit ( CRL) and meet their Cash Requirement.
Why is it important?
NHS Boards have an obligation to operate within their allocated funds and ensure value for money.
Summary of Performance
Target delivered
All NHS Boards met their 2008/09 financial targets, delivering a combined planned underspend of £58.0 million which was used to fund a number of key additional projects providing improved services. The level of non-recurrent reliance has also reduced significantly from £92 million in 2006/07 to £23 million in 2008/09. The overall position for NHSScotland was financial balance.
E6: Cash efficiencies
What is the target?
NHS Boards to meet their 2 per cent Efficient Government savings target.
Why is it important?
This target supports public sector efficiency through the generation of 2 per cent cash releasing efficiency savings per annum that are reinvested in key frontline services.
E6: Cash efficiency savings, target and actual, 2008/09
Source: Monthly Management Financial Returns
Summary of Performance
Target delivered
NHS Boards are required to deliver efficiency savings of 2.0 per cent relative to their baseline funding. For the financial year 2008/09, NHS Boards exceeded the combined target of £154.5 million by £49.0 million, delivering combined savings of £203.5 million. Of this total, £160.8 million of savings were achieved on a recurring (ongoing) basis.
E7: Electronic management of referrals
What is the target?
To increase the percentage of new GP outpatient referrals into consultant led secondary care services that are managed electronically to 90 per cent from December 2010.
Why is it important?
Managing referrals electronically reduces risk and speeds up the process. This target supports patient equity and focus, and efficiency by improving the timeliness and effectiveness of the referral management process.
E7: Percentage of referrals received through SCI Gateway
Source: SCI Gateway and Local Systems
Summary of Performance
Target due for delivery in December 2010
The performance measure for this target is the percentage of new GP outpatient referrals into consultant led secondary care services that are managed electronically. Data systems are being established for this performance measure and in the interim the percentage of total referrals that are received through the Scottish Care Information ( SCI) Gateway electronic referral system has been used as a proxy for this target.
In order to deliver the overall target of 90 per cent for the electronic management of outpatient referrals into consultant led secondary care, it is estimated that 95 per cent of referrals require to be received through SCI Gateway by December 2010.
The percentage of referrals received through SCI Gateway increased by 8 percentage points in 2008/09, from 72.7 per cent in April 2008 to 80.8 per cent in March 2009. NHS Boards have local delivery plans in place to continue the current rate of increase until December 2010 to achieve this aspect of the target.
Access to Services and Waiting Times
Better Health, Better Care sets out the importance of improving the quality of healthcare by making access to primary care easier and delivering quicker treatment times. Providing services that fit in with the day-to-day lives of patients will help improve access and patient experience as shorter waits can:
- lead to earlier diagnosis and better outcomes;
- reduce worry and uncertainty for patients;
- help tackle inequalities by reducing variations between hospitals and NHS Boards; and
- save time, energy and resources that are expended in dealing with backlogs for diagnosis and treatment.
In 2008/09 the access targets were:
2008/09 HEAT Targets
A1: 48-hour access to primary care team
A2: All-cancer waiting times
A3: Ambulance response times
A4: Outpatients waiting over 15 weeks from GP referral
A5: Inpatients/day cases waiting over 15 weeks
A6: Patients waiting over 6 weeks for key diagnostic tests
A7: Accident and Emergency
The overall picture is of excellent progress, with NHSScotland achieving all the access targets that were due for delivery in 2008/09. This included NHSScotland effectively delivering 12 week maximum waits for outpatients and inpatients one year ahead of schedule, as well as the 62 day cancer target.
A1: 48-hour access to the primary care team
What is the target?
Ensure that anyone contacting their GP surgery has guaranteed access to a GP, nurse or other healthcare professional within 48 hours.
Why is it important?
Often a patient's first contact with the NHS is through their GP. It is vital, therefore, that every member of the public has fast and convenient access to their local primary care services to ensure better outcomes and experiences for patients. From 2009/10, this target has been extended to cover advance booking. The related performance measure will be monitored through the results of a new survey which directly measures the experience of patients in getting access to primary care services.
Summary of Performance
Target delivered
The measure is the percentage of practices, in an NHS Board area, claiming to meet the 48-hour access requirements to be eligible for the Directly Enhanced Services ( DES) payment.
The latest DES payment information, for quarter ending December 2007, shows that 100 per cent of practices reportedly met the requirements for access to a GP, nurse or other healthcare professional within 48 hours.
This target has been replaced in 2009/10 by a new target to provide 48-hour access or advance booking to an appropriate member of the GP practice team by 2010/11. This will be measured by the new GP Access Survey. Information from this survey for 2008/09 shows that the proportion of positive responses for 48-hour access to an appropriate healthcare professional was 90 per cent and for booking an appointment with a GP more than 48 hours in advance was 75 per cent.
A2: All-cancer waiting times
What is the target?
95 per cent of patients diagnosed with cancer to begin treatment within two months of urgent referral.
Why is it important?
Waiting times are closely linked with increased anxiety and concern for patients and their families, making timeliness and access integral to delivery of a quality service, particularly when an urgent referral is made.
A2: All-cancer waiting times
Source: Regional Cancer Networks
Summary of Performance
Target delivered
96 per cent of urgently referred patients diagnosed in the quarter ending March 2009 began treatment within 62 days. This has increased from 87.3 per cent for the quarter ending June 2007. The target of 95 per cent was met for the first time in the quarter ending December 2008 (treating 95.4 per cent of such patients) and this performance has been sustained in the most recent quarter.
Reducing Cancer Waiting Times
Mark's Story
It was most men's worst nightmare. Mark was told by his doctor that the hard lump he had found in one of his testicles was cancer.
What followed was a desperately worrying time for the 37-year-old care worker and his family.
The good thing from Mark's point of view was that there was no delay. Less than a month after he first reported the problem to his GP, all the necessary tests were completed and Mark had surgery to remove the testicle.
"I was told that this system is built for speed and it certainly was in my case," he said. "Everything happened quickly. I couldn't fault it at all."
Mark had another scare when tests carried out after the operation indicated that the cancer may have spread. "That was the worst time," he recalled. "I thought then that I did have cancer and wouldn't live to see my two boys grow up."
Once again, he was given a quick referral to the Beatson Cancer Centre in Glasgow where further tests confirmed there was no spread and everything was fine. Mark continues to have regular check-ups and has been told there is very little chance of the cancer returning.
A3: Ambulance response times
What is the target?
To respond to 75 per cent of Category A calls within eight minutes by March 2009 (mainland NHS Boards only).
Why is it important?
Patients in situations categorised as potentially immediately life threatening (Category A) need the Ambulance Service to respond as quickly and safely as possible in order to maximise the outcome for the patient both in health and in experience terms.
A3: Ambulance response times
Source: Scottish Ambulance Service
Summary of Performance
Target delivered
The performance measure for this target is the percentage of Category A calls responded to within eight minutes.
In March 2009, 77 per cent of Category A calls were responded to within eight minutes, against the target of 75 per cent. This is a 9 percentage point increase on the 68 per cent recorded for March 2008.
A4: Outpatients waiting over 15 weeks from GP referral
What is the target?
As a milestone in achieving 18 weeks referral to treatment, no patient will wait longer than 15 weeks from GP/ GDP referral to a first outpatient appointment from 31 March 2009.
Why is it important?
Shorter waits can lead to earlier diagnosis and better outcomes for many patients as well as reducing unnecessary worry and uncertainty for patients and their relatives. It also reduces inequalities by addressing variations in waiting times between NHS Boards or individual hospitals.
A4: Outpatients waiting over 15 weeks from GP/ GDP referral
Source: New Ways
Summary of Performance
Target effectively delivered
This measure is the number of outpatients waiting over 15 weeks at month end census ( GP/ GDP referrals only).
The number of outpatients waiting over 15 weeks at month end census decreased from 2594 patients in April 2008 to 1 patient in March 2009.
NHSScotland effectively delivered this target for 12 weeks, as the number of outpatients waiting over 12 weeks at month end census ( GP/ GDP referrals only) decreased from 13,640 patients in April 2008 to 43 patients in March 2009.
A5: Inpatients/day cases waiting over 15 weeks
What is the target?
As a milestone in achieving 18 weeks referral to treatment, no patient will wait longer than 15 weeks for inpatient or day case treatment from 31 March 2009.
Why is it important?
Access to treatment and waiting times are key issues for patients. Waiting for admission to hospital for an operation can be a time of anxiety, worry and stress for patients. Swift and safe access to treatment leads to better outcomes. It also reduces inequalities by addressing waiting time variations across NHS Boards or individual hospitals.
A5: Inpatients/day cases waiting over 15 weeks
Source: New Ways
Summary of Performance
Target effectively delivered
This measure is the number of inpatients/day cases waiting over 15 weeks at month end census.
The number of inpatients waiting over 15 weeks at month end census decreased from 1,528 patients in April 2008 to 87 patients in March 2009.
NHSScotland effectively delivered this target for 12 weeks, as the number of inpatients waiting over 12 weeks at month end census decreased from 5,458 patients in April 2008 to 216 patients in March 2009.
A6: Patients waiting over six weeks for key diagnostic tests
What is the target?
As a milestone in achieving 18 weeks referral to treatment, no patient will wait longer than six weeks for one of the eight key diagnostic tests from 31 March 2009.
Why is it important?
Earlier access to diagnostic tests leads to quicker diagnosis and better outcomes for many patients. It also reduces unnecessary worry and uncertainty for patients and their relatives, as well as reducing inequalities by addressing variations in waiting times between NHS Boards or individual hospitals.
A6: Patients waiting over six weeks for key diagnostic tests
Source: ISD Diagnostic Official Statistics
Summary of Performance
Target effectively delivered
This measure is the number of patients waiting over six weeks for one of the following eight key diagnostic tests: MRI Scan; CT Scan; barium studies; ultrasound non-obstetric; gastroscopy; sigmoidoscopy; colonoscopy; and cystoscopy.
The number of patients waiting over six weeks for one of these diagnostic tests decreased from 4,772 patients in April 2008 to only 53 patients in March 2009.
A7: Accident and Emergency
What is the target?
The overall target is for NHS Boards to achieve agreed reductions in the rates of attendance at Accident and Emergency (A&E), from 2006/07 to 2010/11; and from end 2007 no patient will wait more than four hours from arrival to admission, discharge or transfer for accident and emergency treatment.
Why is it important?
A patient arriving at A&E requires to be seen quickly to ensure the best quality outcome for the patient, which also leads to a better patient experience.
This target supports shifting the balance of care from secondary to primary care services, and also the delivery of sustainable unscheduled care services.
A7.1: Rates of attendance at A&E
Source: ISD Scotland EDIS and GROS
A7.2: Wait times at A&E (patients waiting no more than 4 hours)
Source: ISDEDIS
Summary of Performance
A7.1: Rates of attendance at A&E (developmental)
Target due for delivery in 2010/11
The performance measure used for this target is the number of unplanned A&E attendances per 100,000 population per month.
There was a steady decrease in the rate of unplanned attendances at A&E between March 2008 and February 2009, however there was an increase in the rate in March 2009 (care needs to be taken when interpreting these statistics due to seasonal fluctuations).
Following the introduction of this developmental target, the range and quality of data on A&E attendances has significantly improved. NHS Boards have carried out pilots on social marketing about access to services, identified priority patient groups and provided management reports to GP practices. Given the complexity of the whole system engagement, and the required behavioural change among staff and public, it is clear now that delivery of this target requires a longer timeframe than the original delivery of agreed reductions in A&E attendances by 2010/11. This will be reflected in a modified target to be agreed in the suite of HEAT targets for 2010/11.
A7.2: Wait times at A&E
Target effectively delivered
The performance measure used for this target is the percentage of patients seen waiting no more than four hours from arrival to admission, discharge or transfer for accident and emergency treatment.
The percentage of patients waiting no longer than four hours increased from 96.7 per cent in September 2007 to 97.7 per cent in March 2009, peaking at 98.6 per cent in July 2008.
Treatment and Quality of Services
Better Health, Better Care acknowledges that the NHS in Scotland is improving, with shorter waiting times and reducing mortality from the major killer diseases, but the speed of this improvement should be accelerated, with an emphasis on safety, reliability and integration.
The patient safety and patient experience programmes across NHSScotland support the delivery of real, measurable improvements in the quality of outcomes for patients. In addition, these programmes also support greater levels of productivity and efficiency which, in turn, impact positively on economic growth, productivity and participation, underpinning the achievement of the Scottish Government's Purpose.
In 2008/09 the treatment targets were:
T1: Reduce emergency readmissions and emergency bed days (amended) 4
T2: NHSQIS clinical governance and risk management
T3: Use of anti-depressants
T4: Psychiatric readmissions
T5: Healthcare Associated Infection
T6: Hospital admissions for long-term conditions
T7: Improvement in the quality of healthcare experience (under development) 5
T8: -Increase the level of older people with complex care needs receiving care at home (under development) 5
T9: Dementia
All of the Treatment targets are not due for delivery in 2008/09, however good progress is being made by NHSScotland and the target to reduce the number of psychiatric readmissions was achieved early, with a decrease of 20 per cent recorded between the year ending December 2004 and the year ending September 2007.
T2: Clinical governance and risk management
What is the target?
NHS Quality Improvement Scotland ( NHSQIS) clinical governance and risk management standards improving.
Why is it important?
NHSQIS sets important standards for quality and safety across NHSScotland. All NHS Boards are supported to achieve and surpass these in order to maximise the quality of service and the resultant outcomes for all patients. NHSQIS published Clinical Governance and Risk Management Standards and undertook reviews of all NHS Boards. The outcome of these reviews enabled a baseline to be set for each Board. All Boards are required by this target to demonstrate continuous improvement in terms of clinical governance and risk management. Accordingly, each NHS Board set a trajectory for improvement. NHSQIS will carry out a further round of reviews in 2009/10 to determine the level of progress achieved across NHSScotland.
Health Board | 2006/07 QIS Score |
|---|
Ayrshire & Arran | 6 |
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Borders | 6 |
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Dumfries & Galloway | 6 |
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Fife | 6 |
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Forth Valley | 6 |
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Grampian | 6 |
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Greater Glasgow & Clyde | 6 |
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Highland | 8 |
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Lanarkshire | 6 |
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Lothian | 5 |
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Orkney | 3 |
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Shetland | 7 |
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Tayside | 7 |
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Western Isles | 3 |
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NHS 24 | 5 |
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NHS Education for Scotland ( NES) | 8 |
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NHS Health Scotland | 5 |
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NHS National Services Scotland ( NSS) | 6 |
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NHS Quality Improvement Scotland ( QIS) | 6 |
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National Waiting Times Centre Board | 6 |
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Scottish Ambulance Service ( SAS) | 10 |
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State Hospital | 8 |
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Summary of Performance
Baseline information only
The target looks at the progress by each Board, in terms of number of points achieved (max. 12), for each of the three standards within QIS Clinical Governance and Risk Management Assessment. Baseline data for 2006/07 are available and a further round of reviews will be undertaken throughout 2009/10. The Scottish Patient Safety Programme ( SPSP) supports improvements in the quality and safety of care. There is now good evidence of sustainable improvements in reducing Healthcare Associated Infections, adverse surgical incidents and adverse drug events, as well as improving critical care outcomes and the organisational and leadership culture on safety.
T3: Use of anti-depressants
What is the target?
Reduce the annual rate of increase of defined daily dose per capita of anti-depressants to zero by 2009/10, and put in place the required support framework to achieve a 10 per cent reduction in future years.
Why is it important?
The World Health Organisation estimates that one in five of the population will experience depression at some point in their lives with 5-10 per cent of the population needing intervention at any given time. Whilst many people will experience symptoms at one or two points in their life, others will have enduring symptoms requiring ongoing management. The target is aimed at driving improvements in the appropriateness of anti-depressant prescribing, whilst also encouraging NHS Boards to increase the availability of, and improve access to, alternative and complementary forms of non-pharmacological interventions.
T3: Anti-depressants
Source: Prescribing Information System Data warehouse ( ISD)
Summary of Performance
Target due for delivery in 2009/10
The performance measure used for this target is the rate of increase of anti-depressant defined daily doses ( DDDs) per capita (aged 15 and over).
NHS Boards have local delivery plans in place to achieve the target of a zero rate of increase by 2009/10.
The number of DDDs per capita was 35.66 in year ending March 2009, compared with 35.24 for year ending December 2008. This is a rate of increase of 1.2 per cent, which is an improvement on the 1.6 per cent increase recorded for the year ending March 2007 on year ending December 2006.
T4: Psychiatric readmissions
What is the target?
Reduce the number of readmissions (within one year) for those that have had a psychiatric hospital admission of at least seven days by 10 per cent by the end of December 2009.
Why is it important?
Health and social care services are working together to provide good quality support and care in the community. Reduced levels of readmissions to psychiatric hospitals is a key indicator that these services are being provided appropriately, both before leaving hospital, after the first admission, and subsequently in the community.
T4: Psychiatric readmissions
Source: ISD Scotland SMR04
Note: Data for the year ending 30 September 2007 may be incomplete and subject to change in future ISD releases.
Summary of Performance
Target due for delivery in 2010/11 - delivered early
The performance measure used for this target is readmission data for the number of patients, admitted for at least seven days, with an index discharge in the reporting period who are then readmitted for at least seven days within a year of that discharge.
The number of readmissions has reduced steadily over the period covered by the chart, from 4,551 readmissions in the year ending December 2004 to 3,626 in the year ending September 2007 (a decrease of 20 per cent).
T5: Healthcare associated infection
What is the target?
To reduce all staphylococcus aureus bacteraemia (including MRSA) by 30 per cent by end March 2010.
Why is it important?
Healthcare associated infections ( HAI) are distressing, both for patients and their families. This target acts as a quality indicator to assess whether the NHS is continuing to provide a safe healthcare environment and a high quality of patient care; and for determining if the range of interventions that form part of a comprehensive three year delivery plan to drive down the risk of infection, overseen by the national HAI Taskforce, is having a positive impact.
T5: Healthcare associated infection
Source: Health Protection Scotland
Summary of Performance
Target due for delivery in 2010
The measure records the number of identifications of staphylococcus aureus bacteraemias (including MRSA and MSSA) as detailed in Health Protection Scotland's Scottish Surveillance of Healthcare Associated Infection Programme ( SSHAIP) protocols.
The baseline year for this target is 2005/06, and for year ending March 2009 NHSScotland secured a 20 per cent reduction against baseline (2,227 infections in 2008/09 against 2,778 infections in 2005/06). For 2009/10, a new national target to reduce rates of C. difficile by 30 per cent by 2011 was introduced. Early progress was made in 2008/09 when rates of C. difficile fell by 17 per cent compared with 2007/08. The level of national hand hygiene compliance also improved from 88 per cent to 93 per cent over the year.
NHS Boards have local delivery plans in place to continue the current level of reduction in all staphylococcus aureus bacteraemia (including MRSA) over the next year to deliver the 30 per cent reduction by March 2010.
Reducing Healthcare Associated Infection
Margo's Story
Margo knows how much is being done in hospitals in Forth Valley to combat the so-called superbug MRSA because she has been on inspection visits to check the state of cleanliness.
Margo is a member of the Patient Panel in NHS Forth Valley and is delighted that patient representatives like herself have been closely involved in work to reduce the risk of infection.
"Patient Panel members are invited to go round with a domestic supervisor with a check list of things to see," said Margo. "I have checked inside cupboards, inspected ward areas and looked at floors and ceilings to see how clean they are. We also make sure notices are up to date and that there is compliance with all the necessary procedures such as staff using hand gels regularly and visitors using them when entering wards."
This is just one of the many ways the NHS is involving members of the public in its work. It is all part of the process to build a mutual NHS where patients and the public are active partners in NHSScotland and not just passive recipients of care.
"Our involvement shows that hospitals are taking these matters seriously," added Margo.
One initiative she was pleased to be involved in was a competition for local schools to raise awareness of the importance of things like regular hand washing to combat infection. It resulted in the production of a calendar of children's drawings which was distributed widely throughout the area to spread the message about good hygiene.
T6: Hospital admissions for long-term conditions
What is the target?
To achieve agreed reductions in the rates of hospital admissions and bed days of patients with primary diagnosis of chronic obstructive pulmonary disease, asthma, diabetes or coronary heart disease from 2006/07 to 2010/11.
This is a new target introduced in 2008/09, with the initial requirement on NHS Boards to develop approaches and measures so that they are in a position to achieve the target.
Why is it important?
This target provides a focus on identifying people at risk of admission using proactive, planned and integrated case management and an anticipatory approach to care. It encourages better flow of people out of hospital and a shift towards self management, innovation and building capacity for care at home.
T6: Hospital admissions for long-term conditions
Source: SMR01
Summary of Performance
Target due for delivery in 2010
The performance measure used for this target is the number of hospital episodes for specified long-term conditions, per 100,000 population.
There was a marginal decrease in the number of hospital admissions between 2006/07 and 2007/08, from 1,964 admissions per 100,000 population in 2006/07 to 1,951 in 2007/08.
NHS Boards have local delivery plans in place to achieve reductions, to be agreed by March 2010, in the number of hospital episodes for specified long-term conditions over the period 2006/07 to 2010/11. The recently published Long Term Conditions Action Plan sets out a range of actions which will support NHS Boards in achieving this target.
Reducing Hospital Admissions for People with Long-term Conditions
Thomas' Story
Thomas has developed a set of strategies to keep the chest problems that have plagued a large part of his adult life under control.
He suffers from chronic obstructive pulmonary disease ( COPD) which can make it difficult to breathe properly.
NHSScotland has been working hard to support people like Thomas who suffer from long term conditions for which there is no cure. Other such conditions include heart problems, diabetes and asthma.
Thomas has been supplied with a nebuliser to use at home as well as various inhalers to help him when his breathing gets difficult. He benefits from a system developed by the NHS and the Meteorological Office to warn COPD sufferers of weather patterns that can make their condition worse. Thomas is alerted by phone of impending cold or muggy weather that can affect his breathing.
Exercise is also important and Thomas has built that into his normal routine. "I play golf most days. I try to keep myself moving, keep myself fit."
The 79-year-old retired sales representative says his condition has worsened as he has got older. However, he is determined to make the most of things. "I take all the advice I am given and I do the best I can," he said.
T9: Dementia
What is the target?
Each NHS Board will achieve agreed improvements in the early diagnosis and management of patients with dementia by March 2011.
Why is it important?
Research by Alzheimer's Scotland indicates that up to 63,500 people in Scotland currently suffer from dementia. The target supports a commitment to achieve improvements in the early diagnosis and management of people with dementia. This is supported by physical and mental health reviews every 15 months along with an assessment of carers needs which includes an appraisal of the impact of caring on the care giver.
T9: Dementia
Source: QOF register
Summary of Performance
Target due for delivery in March 2011
The performance measure used for this target is the number of people with a diagnosis of dementia on the Quality and Outcomes Framework ( QOF) dementia register. The baseline for this measure is the number of people with a diagnosis of a dementia on the QOF dementia register in 2006/07 (29,761 people). The number of people on this register increased from 29,761 in 2006/07 to 31,407 in 2008/09, an increase of 5.5 per cent.
NHS Boards have local delivery plans in place to significantly increase performance over the next two years to achieve a 33 per cent increase on the baseline by March 2011. This is equivalent to 39,582 people with a diagnosis of a dementia on the QOF dementia register.