MINISTERS’ KEY HEAT TARGETS AND MEASURES; AND LOCALDELIVERY PLANS FOR NHS BOARDS
GUIDANCE 200809
1.This Guidance sets out Ministers’ key operational targets and measures for the NHS (the HEAT core set) and describes work in progress in developing performance measures further in the future.
2.The Guidance reiterates the purpose of Local Delivery Plans (LDPs), their format and content, timescales for completing them, and further relevant information to help NHSBoards complete plans for 200809.
3.The Guidance for 200809 on HEAT Key Targets, Measures and LDPs has been developed within the context and framework of:
The ScottishGovernment National Performance Framework setting out strategic objectives, national outcomes and national indicators and targets as an integral part of the Strategic Spending review (see Annex 1a);
BetterHealth, Better Care- published on 12 December 2007;
Views and comments received on the LDP Review in summer 2007;
Initial recommendations of the Health ImprovementPerformance Management review;
Developmental work on proposals forNational Outcomes for Community Care; and other developmental work on targets and measures in the fields of community care, primary care, eHealth, newways of measuring waiting times and newwaiting times targets;
Work onbetter integration, at all levels, of workforce planning with service delivery and financial planning, including developing and aligning workforce planning within the LDP framework;
The evaluation of the HEAT Performance Management IT system.
4.A guiding principle has been to ensure that the HEAT core setmeasures the contribution made byNHSScotland toachieving the government’s objectives.
5.The Scottish Budget Spending Review 2007 includes a chapter setting out the National Performance Framework. Annex 1a describes the relationship between the National Performance Framework and HEAT and LDPs.
6.The principal changes from HEAT 2007-08 are summarised below and set out, in more detail, in the following Guidance:
A) Ministers’ CoreSet of HEAT Key Targets and Performance Measures
B) Local Delivery Plan Guidance
A) HEAT Core Set - Key Targets and Performance Measures
7.Throughout the year, people from across NHS Scotland have made contributions to further developing the HEAT core set for 2008-09. The Cabinet Secretary for Health and Wellbeing has now agreed the proposals put to her. The HEAT core set has been adjusted and improved in the light of Better Health Better Care and theSpending Review. The targets also better represent the spread of services provided by the NHS, by rebalancing between primary and community care, mental health, and acute care. The HEAT framework which NHS Scotland has found useful and is now familiar, has been retained.
8.There are now 7 targets on Health improvement whichconcentrate on the contribution madeNHS Scotland to overall objectives. For example, the smoking target concentrates on the successof Boards’ smoking cessation services, rather than on overall population smoking rates.
9.There are also 7 targets on Efficiency and Governance which will support the new Efficiency and Productivity programme. These include two new targets on Knowledge and Skills Framework and electronic referral management; and five new performance measures.
10.The 7 Access to Services targets include the new milestone maximum wait targets for inpatients and outpatients (15 week maximum wait by March 2009), and for the 8 key diagnostic tests (6 weeks by the same date). The overall 18 week referral to treatment target from December 2011 remains. Access Support Team will be working with NHS Boards to minimise risk to delivery and further reduce risk by early deliverywhere appropriate. The A&E 4-hour target has also been supplemented by a target to reduce A&E attendances which will help to measure Boards’ progress in shifting the balance of care from secondary to primary care.
11.Under Treatmentthere are 9 targets, including two new targets designed to focus effort on case management of patients with long term conditions who are identifiedas being at risk of readmission to hospital; and to improve the early diagnosis and management of patients with a dementia.
12.There are also a number of targets and measures that Boards are now meeting on an ongoing basis. They remain as standards within HEAT and performance against them will continue to be reported although Boards will not be expected to provide performance trajectories in their LDPs.
13. An overview of the changes and reason for change between HEAT 2007/08 and HEAT 2008/09 are set out in Annex 1b.
14.Of the 30 targets, performance data is not available for 2 of them - these are healthcare experience; and older people with complex care needs receiving care at home. Health Directorates will work with NHS Boards throughout 2008/09 to develop the information sources to support these targets.
15.The remaining 28 targets will be performance managed using 33 key performance measures (some of the targets are expressed in a way that requires 2 or more measures to adequately reflect performance). Boards are being asked to provide LDP Delivery Trajectories for these 33 key performance measures. The trajectories for child healthy weight intervention and appropriate alcohol brief intervention are developmental in 2008-09 because data is only now becoming available. Further detail on the key performance measures is set out in Annex 2 Heat Targets : Methods and Sources.
16.LDPs should provide33 trajectories showing planned levels of performance against each of the key performance measures over the 3 years 200809to 201011.
17.In aggregate, the 30 HEAT targets linked to 33 key performance measures set out how NHS Scotland contributes to meeting the Scottish Government’s targets and outcomes for the people of Scotland.
18.The HEAT targetswill be kept under review with the help of the Boards, and we intend to update targets and measures by Autumn 2008, subject to approval by the CabinetSecretary for Health and Wellbeing. The HEAT Performance Management ITsystem ( will continue to be available to NHS Boards. As well as providing latest information on performance by Board against each of the key performance measures, it includesinformation about performance on supplementary measures.
HEAT Targets : Health ImprovementH1 : Reduce mortality from Coronary Heart Disease among the under75s in deprived areas.
H2 : 80% of all three to five year old children to be registered with an NHS dentist by 2010/11.
H3 : Achieve agreed completion rates for child healthy weight intervention programme by 2010/11.
H4: 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.
H5 : Reduce suicide rate between 2002 and 2013 by 20%, supported by 50% 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 2010.
H6 : Through smoking cessation services, support 8% of your Board’s smoking population in successfully quitting (at one month post quit) over the period 2008/9 – 2010/11.
H7 : Increase the proportion of new-born children exclusively breastfed at 6-8 weeks from 26.6% in 2006/07 to 33.3% in 2010/11.
HEAT Targets : Efficiency and Governance
E1 : Universal utilisation of CHI
E2 : NHS Boards to achieve a sickness absence rate of 4% from 31March 2009.
E3 : NHS boards to ensure that all employees covered by Agenda for Change have an agreed KSF personal development plan by March 2009.
E4 : NHS Boards to deliver agreed improved efficiencies for 1st outpatient attendance DNA, non-routine inpatient average length of stay, review to new outpatient attendance ratio and day case rate by March 2011.
E5 : NHS boards to operate within their agreed revenue resource limit; operate within their capital resource limit; meet their cash requirement.
E6 : NHS boards to meet their cash efficiency target.
E7 : To increase the percentage of new GP outpatient referrals into consultant led secondary care services that are triaged online for clinical priority and appropriate recipient service to 90% from December 2010.
HEAT Targets : Access to Services
A1 : Ensure that anyone contacting their GP surgery has guaranteed access to a GP, nurse or other health care professional within 48 hours.
A2 : The maximum wait from urgent referral to treatment for all cancers is two months.
A3 : To respond to 75% of Category A calls within 8 minutes from April 2009 onwards across mainland Scotland.
A4: As a milestone in achieving 18 weeks referral to treatment, no patient will wait longer than 15 weeks from GP referral to a first outpatient appointment from 31 March 2009.
A5 : 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.
A6 : As a milestone in achieving 18 weeks referral to treatment, no patient will wait longer than 6 weeks for one of the 8 key diagnostic tests from 31 March 2009.
A7 : NHS Boards will achieve agreed reductions in the rates of attendance at A&E, from 2006/7 to 2010/11; and from end 2007 no patient will wait more than 4 hours from arrival to admission, discharge or transfer for accident and emergency treatment.
HEAT Targets : Treatment
T1 : By 2008-09, we will reduce the proportion of older people (aged 65+) who are admitted as an emergency inpatient 2 or more times in a single year by 20% compared with 2004/05 and reduce, by 10%, emergency inpatient bed days for people aged 65 and over by 2008.
T2 : QIS clinical governance and risk management standards improving.
T3 : Reduce the annual rate of increase of defined daily dose per capita of anti-depressants to zero by2009/10, and put in place the required support framework to achieve a 10% reduction in future years.
T4 : Reduce the number of readmissions (within one year for those that have had a psychiatric hospital admission of over 7 days by 10% by the end of December 2009).
T5 : To reduce all staphylococcus aureus bacteraemia (including MRSA) by 30% by 2010.
T6 : To achieve agreed reductions in the rates of hospital admissions and bed days of patients with primary diagnosis of COPD, Asthma, Diabetes or CHD, from 2006/7 to 2010/11.
T7 : Improvement in the quality of healthcare experience.
T8 : Increase the level of older people with complex care needs receiving care at home.
T9 : Each NHS Board will achieve agreed improvements in the early diagnosis and management of patients with a dementia by March 2011.
B) Local Delivery Plan Guidance
19.LDPs set out the delivery agreement for 2008-09 to 2010-11 between DGHealth and each NHS Board, using the 33 key performance measures.
- Health Improvement for the people of Scotland– improving life expectancy and healthy life expectancy;
- Efficiency and Governance Improvements– continually improve the efficiency and effectiveness of the NHS;
- Access to Services– recognising patients' need for quicker and easier use of NHSservices; and
- Treatment Appropriate to Individuals– ensure patients receive high quality services that meet their needs.
LDPs - Format and Content
20.The format and content of the LDPs for 2008-09 will support their purpose of recording agreement on Boards’ planned progress towards meeting key targets. They will cover a period of 3years, with the opportunity to review and adjust future years' plans each year. The LDP templates for 200809, to be completed by all Boards, are attached as Annexes3a, 3b and 4. As for 2007-08, the LDPs include DeliveryTrajectories and RiskNarrative for each target and these are supported by financial and workforce plans.
LDP Risk Narrative
21.Boards should, as in previous years, use the LDP Risk Narrative(Annex3a) to provide contextual informationon risk to delivery of each target and how risks are being managed regarding:
Delivery: briefly highlight local issues and risks which may impact on the achievement of targets and/or the planned performance trajectories towards targets and how these risks will be managed.
Workforce: brief narrative, and relevant projections where applicable and possible, on the workforce implications of each of the key targets. This should includean assessment staff availability, need for any training and development required, and affordability. There is no need to repeat generic workforce risks that apply to all targets.
Finance:Where applicable boards should identify and explain any specific issues e.g. cost pressures or financial dependencies specifically related to achieving the target. There is no need to repeat generic financial risks that apply to all targets.
Improvement: Where applicable, boards should briefly outline any risks to sustainable improvement required to deliver targets and how these are being managed.
22.Boards should seek to cover the main risks in a maximum of 2paragraphs under each of the 4headings. Cross-refer to local plans where necessary. Please use the LDP proforma – otherwise we will have to return plans for revision.
LDP Delivery Trajectories
23.Setting out planned performance against key measures in the LDPDelivery Trajectories (Annex3b) will enable Boards and DGHealth to track actual operational performance against Boards’ plans. It therefore provides an objective, factual basis to discuss with Boards any operational performance issues that may arise during the plan period and to offer support to achieve improvement if that is needed. Please ensure that the correct proforma is completed in line with the guidance and if in doubt, ask for guidance. For example, please submit the proforma in EXCEL and not as a WORD document; submit the proforma as a standalone document and not embedded within the LDPRisk Narrative; and ensure that planned levels use the correct units / measure (rates etc) and at the requested time frequency. If the blank proforma are completed correctly first time, the whole process will be much simpler and quicker for Boards and the Health Directorates. If they are not completed as requested, we will have to return them to be corrected.
24.The HealthDelivery Directorate will continue to support Boards in benchmarking their performance,and will work on spreading good practice associated with good and improving performance.
25.This quantified and measured approach to performance planning and monitoring does not imply any reduction in the importance of the qualitative aspects of performance. Providing assurance to the Board, itsClinical Governance Committee and the public about the quality of healthcare services continues to be a vital task for each Board. Local monitoring of quality will continue to be augmented at the national level by NHSQIS’s reviews of NHSBoards' performance against national clinical standards. QIS reports will continue to be monitored by DGHealth.
26.DGHealth will agree LDPs with each Board for 2008-09. However it is important that Boards continue with their own local, community and regional planning arrangements involving their partners, staff and communities. This will help toensure that local and regional partners continue to play a full role in planning and delivering health care and relatedservices.
LDPs - Process and Timescales
27.The proposed timetable for LDPs for the 200809 year is set out below:
14December 2007 / - / Final LDP guidance withHEAT"core set” issued to Boards.December 2007 to February 2008 / - / Boards prepare draft LDPs; informal discussion with DG Health Directorates.
18February 2008 / - / Boards submit LDPs to DG Health: Delivery Directorate.
February/March 2008 / - / LDPs discussed and signed off between DGHealth and each Board as the performance delivery agreement for the planning period.
20 March 2008 / - / Submission of final LDP
By end March 2008 / - / All LDPs agreed and signed off by Boards.
Summer 2008 / - / NHS Boards participate in Annual Review.
Late Summer 2008 / - / Review period for HEAT/LDPs.
Autumn 2008 / - / DGHealth issues revised guidance on coreset and LDPs for 200910.
Trajectory Change Control Process
28.Once an LDP has been agreed and signed off by DGHealth and the Board, any midyear alterations to trajectories need to be agreed between the HealthDelivery Directorate and the Board. The trajectorychange controlprocess to alter trajectories will be operated by the performance management teams in Health Delivery Directorate. If a Board wants to propose changes to trajectories after they are agreed and signed off, they should contact John Connaghan, Director of Delivery, in the first instance.
HEAT Change Control Process
29.The HEAT change control process (for HEAT Targets and Measures) will as before consist of an annual review and be coordinated by the Health Delivery Directorate. A review will take placeover summer2008 and any proposals for change will go to Ministers for approval. Any changes agreed by Ministers would be incorporated into the LDPGuidance for 2009-10.
NHS Area Board Planning
30.As noted above, NHS area Boards should continue with planning arrangements at local and regional level, engaging with local and regional partners across the full range of health policy, planning, service redesign and delivery issues. Boards should ensure that these activities and their LDPs are consistent with the direction set in BetterHealth, BetterCare. Boards are free to use the formats and timings that suit them and their partners, within existing agreements and guidance on local, community and regional planning. Boards should ensure that they continue to fulfil their statutory obligations on cooperation and public involvement. Boards should also ensure that local and regional planning supports their performance agreement with DGHealth set out in the LDP, and that focus and alignment is maintained across the full range of local service planning and delivery to ensure achievement of planned progress towards meeting the key targets in the LDP.
31.The LDP process is consistent with the current work being undertaken by NHSBoards in developing, supporting and setting objectives for CHPs. Clearly the efforts and performance of CHPs will be vital in meeting some of the key targets and Boards need to ensure that CHPs play their full part in helping to meet the key targets as planned.
32.The LDP process continues to sit within the broader planning framework for NHSBoards. The LDP therefore does not make this planning framework redundant: other elements of the current planning arrangements will continue - for example, Pay Modernisation Plans (HDL2005/28) and Regional Planning (HDL2004/46). The achievement of targets set out in LDPs is also underpinned by service delivery and improvement work across the Service including that co-ordinated bythe Improvement and Support and Access Teams in the Health Delivery Directorate and policy leads within HealthDirectorates. This detailed underpinning work will continue to play a vital role in supporting Boards to meet the targets set out in the LDP.