Malcolm Grant: I would like to move now to item six on the agenda, which is our normal
two-part paper, dealing first of all with NHS England Corporate Performance, and then
NHS Performance. I would like to invite Karen to introduce part one, please.
Karen Wheeler: Thank you, Malcolm. This is to provide the Board with an assurance around
how NHS England is doing on its business plan priorities for 2015/2016. We have been putting
in place a series of stock-takes throughout the year, culminating in a stock-take at the
end of the year, to confirm both that those programmes were on track to deliver the targets
for 2015/2016, as our business plan commitments; and secondly, importantly, since our business
plan for 2016/2017, which we have recently published, builds on those ten priorities
so that we will be taking those into this financial year and probably next, very substantially,
that those stock-takes have assured us that they are on track to continue to develop and
deliver against our priorities for the next year. Ultimately, they will play their part
in the Five Year Forward View targets that we are all very keen to deliver.
This just provides you with that assurance. We have provided you with all the detail on
all the programmes, but I have just pulled out two where we are not as green as we are
on the rest. I am not going to say very much more on that. I think the two others, child
protection information and care dot data; again, they are not individually priorities,
but they are part of a national portfolio of programmes that we report against. So I
am happy to take any questions on those, but it is largely to provide you with that assurance
that we are well set up for the delivery of this in the coming year.
David Roberts: You will be aware, Malcolm, that the Audit Committee has been through
the portfolio with Karen, and I would observe that the degree of central programme management,
oversight and control has stepped up materially in the last 12 months.
Malcolm Grant: Thank you.
Richard Barker: The Board members will have the performance report for March, which is
in our packs. March, of course, is also the final month of the business year for the NHS,
so it is a good time to reflect on the whole year, as well as just the last month and the
last few months. In terms of the whole year, firstly, I would just like to talk about A&E
performance and 18‑week performance. Simon referred to this in his introduction; in both
cases, over the whole year, well over 90% of patients have been delivered within the
targets concerned: that is a four-hour wait for A&E, and an 18‑week wait, obviously,
for the elective side of our work. If I could take A&E first, though: although
we have delivered 91.9% for the year-end, it has been quite challenging in the last
three months, and we have seen performance levels below 90%, which is not something that
we are pleased with, and we are urgently trying to address that and look at the root causes
of that deterioration and to put them right. It is worth saying, though, that whilst there
have been workload increases that have contributed to that, they are broadly within the parameters
that we would have planned for, and the deterioration of performance is not overall. So 20 systems,
for example, have been responsible for 50% of the deterioration on A&E performance. So
it is important that we target those areas that are particularly struggling and understand
that many parts of the system operate fairly well.
I think another point we need to make is that, even though the headline performance has deteriorated,
evidence around operational pressures and severe long waits show that they have been
very few this this winter; so in other words, we are performing better in terms of the extremes,
but the average performance has drifted out. One way of describing that is that for every
10% deterioration against the target, it is about 20 minutes’ additional wait for a
patient in A&E, and that is what we were dealing with: we are dealing with a flow problem that
needs to be brought more closely together with shorter waiting times, but also making
sure that we can treat people safely and avoid any extremely long waits. I think the latter
of those has been achieved successfully throughout the winter.
On the 18-week waiting times: again, March, we had about 3.5 million people waiting, and
only 8.5% of those had waited over 18 weeks. Again, the vast, vast majority of patients
had been seen well within the 18-week target. Again, it is similar to the A&E position:
20 trusts responsible for about 1.7% of the gap; so in other words, if those 20 trusts
had achieved their targets, the overall England performance would have been 91.7%, so 1.7%
higher. So for both A&E and RTT, we have a mixed picture: the overall performance is
poor, but we have some target areas where we really need to improve fast, as well as
seeing general improvements across the board.
In terms of some better news: on cancer, the 62-day cancer wait. In March, we achieved
83.8%, which is 3% higher than the figure we achieved in February, so we are making
progress on the cancer waits. In some other areas, we have made some excellent
progress across the year, particularly in the areas of mental health. So the improved
access to psychological therapies service, for example, we set ourselves a target of
a 15% population coverage rate on that. Our expectation is that that would be the level
of the population that needs those therapies, and we achieved a 16.6% coverage rate across
the year, so we are getting access to those patients who need to receive them. We set
ourselves a target of a 50% recovery rate, and we are on track for that: we achieved
47.9% towards the end of the year, and it continues to improve month on month.
Finally, we set ourselves the target that 75% of patients would be seen within six weeks;
not 18 weeks, but six weeks for this service, and we achieved 84.3%, so some good results
in psychological therapies services. Finally, on dementia services, we set ourselves
the target that we would diagnose two thirds of the population that is expected to have
dementia, and we achieved that, with a 67.5% performance by year-end.
Overall, it is a mixed picture. Some good performance in the mental health arena; some
challenging performance in the acute side of things. Overall, for the year, there has
been strong performance in terms of nine out of ten patients seen, and I think you also
have to give credit to all our staff both inside and outside of hospitals for achieving
that, set against the broad increase in in workload: around 2% on the emergency side
and 3% on the waiting list side. That is the summary of the report, Chairman.
Malcolm Grant: Thank you, Richard. The access requirements of the NHS constitution are amongst
the most demanding in the world for an entire population. Other systems have insured groups
for whom there are other access requirements. What will concern everybody, I think, is the
drift away from observance of those; it is almost as if is non-observance is the new
normal. Just taking A&E, for example, there are still
some trusts who are meeting the 95% requirement of the constitution. Are there things that
are being transferred in terms of knowledge and learning, from how they organise their
patient flow and their staff, which through the UAEC Review or elsewhere are being transmitted
into being used in a mentoring and supportive way for other trusts that are still struggling?
Richard Barker: The answer is yes, but the whole purpose of the Urgent and Emergency
Care Review is that we knew that, without changes to the way we manage emergency care,
the demographic pressures we were facing would bring problems that we are experiencing. So
the best systems have adopted some of the practices identified in the review; some have
a way to go to achieve that. One reason why we have been under pressure in the last two
or three months is some unpredictable things have happened: we have a late onset of flu,
so that has created more bed pressures. In terms of bed capacity itself, whereas in previous
years we just would have bought more beds to absorb more pressures, it is less possible
to do that now, for a couple of reasons. One is workforce pressures, and secondly it is
not right to open extra beds if you do not have the right safety in there, the right
number of nurses per patient. Those things have been difficult.
Finally, there have been pressures in relation to discharge, particularly in the social care
end, where there has been a 34% increase in discharges while waiting for social care.
All of those things are risks, and the best organisations have managed those well; they
have adopted new processes and reformed. Many organisations have yet to do it. The challenge
for us to bring forward aspects of the Urgent and Emergency Care Review, share the good
practice of those who are achieving successfully, and embed that across the board, and that
is the key to us turning performance around and making the improvements we need to.
Malcolm Grant: Increasingly, in close partnership with NHSI?
Richard Barker: Absolutely. Michelle Mitchell: Thank you, Richard, for
your clear explanation of some of the causes and possible solutions. Could you tell us
whether you think some of the deteriorating performance is a trend, or whether it will
get better by the end of the year? Richard Barker: Well, we have clearly observed
a trend in both A&E performance and RTT 18‑week performance, and this has been happening for
around two years. Without wanting to repeat the answer to the previous question, we knew
there was going to be more pressure, and hence the need to make the changes we need to make,
and we really do need to accelerate those changes, now.
As I described in the overall report, we need two sets of tactics really. One is to bring
rapid support to those systems that are struggling most, and it is a relatively small number
across England: there are 170 Type-1 A&Es in England, and the 20 we described causing
40–50% deterioration are quite a small percentage of the 170. Working with NHS Improvement,
we are doing our best to offer support and resource. We have the Emergency Care Improvement
Programme, and we are expanding its coverage from 25 to 40 systems, and that would cover
the 20 we are talking about. So we really need to bring resource from the best practices
across England, helping those systems to see and adopt that practice. Then of course, we
have to ensure that that is actually taken up and followed through.
Michelle Mitchell: You have confidence that the numbers will improve?
Richard Barker: As long as we do what we have planned to, that should happen as a natural
consequence: we bring the improvement techniques, people adopt them, and we have certainly seen
from the evidence of the best that that can bring results.
David Roberts: I think, Simon, this is from the majority of the citizens’ perspective,
A&E performance, RTT performance. We have done well on other things, let us be clear;
it is not a complete bad news story. However, on the big things there is real concern. Therefore,
I wonder whether you could share with the Board some of the thinking that you have with
Jim on how we change this trend line and get to an improving position? Recognising that
this is not going to change overnight. Simon Stevens: I think what Jim would say
is that the principal purpose of NHS Improvement is what it says on the tin, i.e., improvement.
So looking out to next March, 2017, their expectation is that the NHS provider sector
will be in a better position on those performance measures than it was in March 2016, and that
is part of what we expect to see given that we have funded activity growth through the
commissioning system and the contracting round for this coming year, and made available the
£1.8 billion on the sustainability fund, and there is this specific set of trajectories
that are being agreed with individual organisations based on what is a realistic improvement level
for them individually.
Malcolm Grant: Richard, Karen, thank you verymuch for that.