Operational Plan Public Version

Transcription

1 Operational Plan Public Version April P a g e

2 Contents 1 Introduction Activity planning Quality planning Approach to quality governance Summary of the quality improvement plans (specific areas) Summary of quality impact assessment process Summary of triangulation of quality with workforce and finance Workforce Planning Approach, support and governance Financial Planning Financial forecasts and modelling Efficiency savings for 2017/18 to 2018/ Capital Planning Link to emerging Sustainability and Transformation Plans (STPs) Foundation Trust application/membership and elections Foundation Trust context Membership strategy and engagement, next 12 months Plans for governor elections, training and development activities for engagement P a g e

3 1 Introduction This document sets out the Operational Plan for Central London Community Healthcare NHS Trust (CLCH) in the format prescribed by NHS planning guidance. CLCH is one of the largest dedicated community health service providers in the NHS, serving patients in nine London boroughs as well as the county of Hertfordshire. It employs over 3,000 staff working across more than 400 sites, delivering more than 70 different services. The Trust has a Care Quality Commission (CQC) rating of Good and in November 2016 was assigned the highest segment rating of 1 in NHS Improvement s new single oversight framework. Looking forward to the operational plan describes a number of priorities including: Refreshing our overarching Trust strategy aligned with priorities in the four Sustainability and Transformation Plan (STP) areas where we operate. Continuing to develop our strategic partnership with Capita, which provides a range of back office functions to the Trust. Consolidating our new community services in Harrow and Merton that went live in the first half of Managing the introduction of a contract value reduction for our Inner London CCGs in April Controlling agency staff use and spend in line with NHS targets. Embedding the Trust s new Quality Strategy for Delivering a QIPP programme of 9.7m in 2017/18 and a further 7.8m in 2018/19. The plan details the Trust budget for including a target surplus of 2.6% of turnover ( 5.0m in 2017/18 and 5.0m in 2018/19) in line with the Sustainability and Transformation Fund (STF) control total. The Trust plans to accept the control total but it needs to be recognised that this requires a substantial Quality, Innovation, Productivity and Prevention (QIPP) program that will be operationally very challenging to deliver. It should also be noted that there are communication challenges in explaining to our Local Authority commissioners the basis behind the large surplus requirement in the context of general financial austerity. The Trust is currently undertaking a refresh of its strategy, mindful of the changing NHS landscape post-five Year Forward View and the subsequent establishment of the MCP, PACS and ACO/P vehicles as potential forms for new care models. CLCH is at the heart of out-of-hospital care transformation across all the geographies that we serve. To this end, we are refreshing our strategy so that we are focused on working in true partnership with primary care federations, statutory health and social care providers, the voluntary sector and others. 3 P a g e

4 2 Activity planning As a community health provider, the majority of our clinical activity is currently funded under block contracts. Associated with each of these contracts is an Indicative Activity Plan (IAP). For activity planning we have been working with commissioners to assess activity levels against clinical service lines to understand demand and agree appropriate capacity. This process is a continuation of work that takes place monthly in contract performance meetings. In April 2016 CLCH transferred the management of our business information team to Capita as part of a wider strategic partnership to enhance the efficiency of back office functions. We have been working with Capita colleagues to improve the robustness of performance reporting of activity and Key Performance Indicators (KPIs) so as to provide a firm foundation for planning. Our activity planning has followed a number of steps: Preparation of a service line list showing: o Year-to-date (month 6) activity levels outturn for 2016/17 compared with plan o Comparison with prior years o Adjustments for seasonality and demographic growth o Adjustments for known service changes in year o Assessment of waiting times and referral rates in relation to KPI targets Review by operational service managers in the context of staffing and resource levels Review with commissioners. For our Inner London (Hammersmith & Fulham, Kensington & Chelsea, Westminster) services, commissioners have requested a substantial change in contracted services so as to meet commissioner funding constraints. This is described further below. For most other commissioners, the activity plans are more minor modifications of the 2016/17 plans. CLCH activity plans for are designed to ensure compliance with all key national targets such as 18 week waits. The Trust does not plan to outsource any activity capacity to independent sector providers. The commissioned activity plans do include seasonal variations and being mindful of the requirement to minimise agency spend across operational teams; we recognise that these plans may also be impacted by commissioner needs for additional winter surge capacity within community units. Activity plans reflect changes relating to known new business tender outcomes only. No assumptions are included about potential future bid outcomes. Our operational plan takes account of the four regional Sustainability and Transformation plans covering our service areas. However at this stage we are not aware of any specific STP proposal that impacts upon our activity planning assumptions. We will update our plans as the details of STP proposals develop during the planning period. 4 P a g e

5 The following paragraphs provide some specific points around activity planning pertaining to each of our four operational divisions. Inner Division The three Inner London CCGs (Central, West London and Hammersmith and Fulham) requested a substantial contract change for 2017/18 and 2018/19 amounting to an 18% contract value reduction over 2 years. CLCH has worked intensively with commissioners to agree on service changes and efficiencies to meet this target and agreement has now been reached. The CCGs and CLCH will work collaboratively on public and patient consultation around these changes. South Division South division is responsible for the delivery of our new Merton community services contract which went live in April The division has been working with commissioning colleagues to fine tune capacity as the new service is embedded. Additional capacity has been agreed for 2017/18 to meet expected increase in demand. There is no funding for winter pressures, however CLCH is present as a key partner in the A&E delivery group. North Division The North division is responsible for a range of services including the delivery of the new Harrow adult community service which went live in May As part of the new contract CLCH have transferred the clinical record system from SystemOne to EMIS with effect from 7 November It has been agreed with commissioners that following the EMIS transfer the activity plans will need to be reviewed to ensure they reflect coding on the new system. Agreement has been reached with Barnet for an updated activity plan regarding the agreed position. The North division is piloting SHREWD (Single Health Resilience Early Warning Database) as part of our resilience strategy. We intend to use this system to manage response to demand fluctuations. If effective we will extend it to the other three divisions. Children s Division Services in the Children s division are primarily commissioned by local authorities and not the NHS. The contract process for local authorities does not align with the NHS timetable and hence some of our local authority activity plans will not be agreed until later in the financial year. At this stage we are in discussions with a number of commissioners around revisions to activity and capacity to meet commissioning budget constraints. The Trust is working closely with local authorities to address their issues to minimise the impact on service quality e.g. through adjustments to skill mix in Health Visiting without compromise to child safety. 5 P a g e

6 3 Quality planning 3.1 Approach to quality governance The Trust executive lead for quality improvement is the Chief Nurse and Director of Quality Governance. The CLCH approach to quality governance is set out in the Trust s new quality strategy; Simply the Best, Every Time: A strategy for the delivery of outstanding care We have six campaigns: Three established: Campaign Description Lead Campaign One A Positive Patient Experience Campaign Two Preventing Harm Campaign Three Smart, Effective Care Changing behaviors and care to enhance the experience of our patients and service users Reducing unwarranted variations in care and increasing diligence in practice Ensuring patients and service users receive the best evidence based care, every time Director of Patient Experience Director of Patient Safety Medical Director Coordinating Council Patient Experience Patient Safety and Risk Clinical Effectiveness Enabling Strategies Patient and Public Involvement Strategy Risk Management Strategy Sign Up to Safety Continuous Improvement Strategy Research Strategy Clinical Framework..and three new: Campaign Description Lead Campaign Four Modeling the Way Providing world class models of care, education and professional practice Chief Nurse Coordinating Council Education and Development Enabling Strategies Education and Learning Strategy Campaign Five Here, Happy, Healthy and Heard Recruiting and retaining outstanding clinical workforce Director of Human Resources Workforce Partnership People Strategy Leadership Strategy Health and Well-being Strategy Campaign Six Value Added Care Using enhanced tools, technology and lean methodologies to manage resources well including time, equipment and referrals Medical Director/ Director of Transformation Getting Better Together Information Management and Technology Strategy, Quality, Innovation, Productivity and Prevention Strategy The annual quality accounts will define the Trust s annual quality objectives which will be based upon the key outcomes described in the new quality strategy. Achievement of the strategy is key to our journey to move from a good to outstanding rating with the CQC. CLCH s Steps to Excellence Things don t always go to plan and we know that the best meaning staff and teams can go through periods of challenge and performance can drop. Over the next 3 years we are concentrating on not only being able to identify at an early stage when things are going wrong, but also putting in a support 6 P a g e

7 structure to turn around poor practice and celebrate outstanding care. We have found that teams who have gone through difficult times and to whom we have put in extra support to turn around, have not just stopped poorly performing but have in fact become exemplar sites. With this in mind, we have designed a ladder of excellence which gives all teams the opportunity to become a quality development unit. Quality development units will be reassessed annually. 3.2 Summary of the quality improvement plans (specific areas) i) National Audits Plan 2017/18 Plans The Trust plans to continue its participation in the National Clinical Audit and Patient Outcomes Programme (NCAPOP) audits during 2017/2018. It is a requirement identified in the NHS standard contract and it is one of the key performance indicators that the Trust will participate 100% in all applicable national audits. The current national audits in which the Trust has registered include: COPD: Chronic obstructive pulmonary disease: Measures and reports the delivery of care as defined by standards embedded in guidance. Stroke: Sentinel stroke national audit programme: Assesses the quality of the Trust and delivery of multi-disciplinary inpatient stroke health services. National diabetes audit (adult): Provides an infrastructure for the collation, analysis, benchmarking and feedback of local data across the NHS. The Trust may participate in additional national audits whenever these present, including national audits that are not part of the Trust s Quality Account. ii) Safe staffing The Trust will continue to: develop models of staffing at a service level including skill mix and safe staffing levels rebase establishments and undertake monthly monitoring of this using agreed key performance indicators implement e-rostering across the Trust work in partnership with other healthcare providers to pilot the nurse associate role and the Capital Nurse Foundation programme 7 P a g e

8 develop and implement apprentice roles throughout the Trust invest in workforce transformation to release time to care. iii) End of life care The Trust will continue to: provide high quality, compassionate end of life care ensure the involvement and engagement of all key stakeholders in decisions about end of life care ensure the delivery of competent care for patients at the end of life. Specific aims include: Improving end of life care and patient/carer experience, improving access to end of life care services, improving choice and co-ordination of services and increasing the proportion of patients who are cared for and die in their preferred place of care. iv) Infection control The Annual Hygiene Code compliance assessment will be conducted in March 2017 and areas for improvement will be incorporated into the 2017/18 infection prevention work and audit programme. The monitoring of KPIs will be achieved through the audit and surveillance programme. v) Falls The falls steering group has three specific areas of focus for 2017/18.These are: assessment of cognitively impaired patients, continence management, and ensuring that appropriate patients are admitted to the rehabilitation units. These areas have been identified through the incidents occurring in 2016/2017. We are planning to produce additional standards and guidelines for the cognitive and continence management of patients during rehabilitation. vi) Sepsis The Trust provides mandatory training for all clinical staff on Sepsis. A revised policy on patient deterioration will be in place from 2017 which includes sepsis. Performance is reviewed at the Trust Clinical Effectiveness Group chaired by the Medical Director. vii) Pressure ulcers The Trust will continue to use a Trust-wide action plan to share learning from pressure ulcer investigations. New staff training has been introduced and the programme will be monitored to assess attendance, impact and feedback. viii) National CQUINs (Commissioning for Quality and Innovation) CLCH will liaise with NHS commissioners to implement the national CQUINs related to community health Trusts as listed below. NHS guidance means there are no local CQUINs for NHS staff health and wellbeing 2. Proactive and safe discharge 3. Wound care 4. Preventing ill health by risk behaviours 5. Physical health for people with severe mental illness 6. Personalised care support planning 8 P a g e

9 ix) Sustainability and Transformation Plans (STPs) CLCH has been represented in STP work streams that relate to the four STP areas that we cover (North West London, North Central London, South West London, and Hertfordshire & West Essex. This involvement is enabling the CLCH strategy to be consistent with the emerging STP priorities, including moving care from acute to primary and community care environments, reducing unwarranted variation in care standards, promoting clinical excellence, supporting a reduction in acute length of stay, promoting self-management and patient activation and working more effectively across the wider system pathways. x) The four priority standards for seven day care These standards apply to the acute hospital system and are not currently applicable to CLCH. xi) Mortality CLCH has a well-established process for reviewing all inpatient deaths, including hospice deaths, led by the Medical Director. Further work is being undertaken by the Medical Director (informed by objective research and evidence) to establish how mortality reviews could be standardised across the diverse caseload of a community trust. Emergent recommendations will be presented to the Board for consideration. 3.3 Summary of quality impact assessment process All QIPP schemes (clinical and non-clinical) are assessed for risks to clinical delivery and quality using a standard template and reviewed in a divisional star chamber by the Medical Director and Chief Nurse. The ultimate responsibility for clinical sign off of QIPPs lies with the Medical Director and Chief Nurse and no QIPP schemes can go ahead in the Trust without their approval. The schemes are assessed against Patient Experience, Patient Safety and Clinical Effectiveness. The schemes are required to demonstrate that the service is currently running within the expected parameters for each area and these are monitored on a bi-monthly basis at a QIPP and quality meeting with the Divisional Directors of Operations and their senior management team, the Associate Directors of Quality and the Chief Nurse and Medical Director. Each scheme is also risk assessed and when the final risk and score is agreed by the Medical Director and Chief Nurse, placed on the Trust risk register if appropriate and monitored monthly at the above meeting. The cumulative effect of the schemes will also be monitored at this meeting and risks are added to the Trust risk register. Only the Chief Nurse/ Medical Director can agree and confirm the clinical risk scores based on the risk assessment and no schemes can be confirmed for commencement without approval from the Medical Director/ Chief Nurse. CLCH has had in place for some years a methodology for continuous improvement. The continuous improvement strategy, led by the Medical Director, describes the way in which staff are trained and supported to undertake change projects. The continuous improvement strategy also supports the Trust s quality strategy, QIPP programme and transformation work. A number of KPIs for Quality and Workforce are monitored against each QIPP scheme. 9 P a g e

10 3.4 Summary of triangulation of quality with workforce and finance The Trust s quality strategy includes a red flag process for the early identification of quality deterioration at individual service level. A monthly list is produced which highlights services which either do not meet two of the key criteria or who have not met one for more than one month. The six criteria are: Absence of consistent leadership for 2 months or more Vacancies over 12% Sickness over 5% A 10% or greater increase in incidents causing harm Increase in complaints A reported serious incident or internal serious incident Following identification of potential or actual problem, an assessment is made by the Associate Director of Quality for the division to identify if rapid intervention, controls and mitigation are needed. The responsible Associate Director for Quality in conjunction with the Chief Nurse or Deputy Chief Nurse will also determine if the situation warrants the support of a Quality Action Team. Red flag reports are reviewed monthly at Divisional level and at the Trust Quality Committee. As part of the business planning cycle, each clinical division undertakes a demand and capacity review and analysis for their services. This work helps to inform the quality schedule for the year and the areas of support needed by each clinical division. Prior to completing the workforce and financial plan components of the Operational Planning process, the Trust ensures that plans are triangulated to reflect the assumptions in the Long Term Financial Model. The Workforce plans are signed off by the Chief Nurse and Medical Director to ensure the plans are compliant with quality requirements. Underpinning these requirements are a suite of quality KPIs which are integrated into the Trust performance dashboard with finance, performance and workforce KPIs. 10 P a g e

11 4 Workforce Planning Like many community health NHS Trusts, CLCH has a challenge recruiting substantively to all of its nursing posts. The Trust workforce plan addresses this challenge but it has to be recognised that the problems are sector-wide and cannot be resolved by CLCH on its own. 4.1 Approach, support and governance The Trust has a People Strategy developed in partnership with our Joint Staff Consultative Committee (JSCC). This strategy focuses on achieving our vision of Great Care Closer to Home and outlines how its enabling workforce strategies align to Trust priorities and the Carter review. Workforce planning and the assessment of workforce information is built into the annual business planning cycle adjusted throughout the year driven in response to system changes. Specific guidance and advice on legislative conditions, safer staffing, supply market analysis and current professional group developments is fed into the planning cycle with clinical operational management. This in turn drives the short, medium and long term financial planning of the organisation encompassing service and Trust priorities. Service Management Business Management HR & Workforce Financial Planning Long Term Financial Plan Annual Finance Plan Annual Workforce Plan Business Planning Cycle Workforce data is viewable by managers through Qlikview who are able to drill down from a Directorate to Clinical Business Unit to team level. Workforce data is contained in the monthly divisional reports, discussed at divisional meetings and performance meetings with Clinical, Quality, HR and Finance input. The integrated finance and performance report presented at the Trust s Finance Risk & Investment Committee (FRIC) contains workforce, finance and clinical quality information on Trust-wide and divisional performance across key performance indicators. Key projects include developing an apprenticeship strategy for new and existing staff, mobile working, implementing the Allocate Health Rostering tools and the procurement of a new appraisal performance system including: 360 degree job planning and manager feedback. The Trust has successfully outsourced all its HR transactional services to Capita shared services in Belfast for the next six years. As a community Trust in a dynamic contracting environment with significant movements of staff from winning and losing bids, accurate forecasting and performance against plan in the medium to long term is challenging and complex. For instance, in 2016/17 we unexpectedly lost our award winning integrated Community Independence Service which is being transferred to three separate providers. 11 P a g e

12 As the Trust s business planning process is clinically led, it identifies skills gaps through its training needs analysis, led by the Deputy Chief Nurse in conjunction with the Education and Training team. Each CBU discusses their training needs with their teams and completes a Learning Needs Analysis template. The findings are then discussed at the Trust s Education Forum, which enables a Trust-wide understanding of any needs required and where the focus is needed. Critically the Trust is highly dependent on the commissioning of specialist nurse training for roles such as District Nursing, Health Visiting, Tissue Viability, Diabetes, Emergency Nurse Practitioners and School Nursing which remain in short supply. Funding for these qualifications over the next few years is being reduced, there are already significant vacancies and supply is unlikely to meet demand as staff leave or retire. The impact of ending the nurse bursary may lead to a drop in nurse training locally as London is an expensive place to live and train. Nursing Apprenticeship roles will not fill this gap for several years. A key focus for the Trust is on improving retention and recruiting internationally, particularly from the Philippines while immigration rules allow this. The Trust was successful in becoming a partnership pilot site for the new Nursing Associate scheme which should help to develop the skills of the band 3 to 4 workforce that can support new skill mix models in the community. The Trust has a clinical strategy which highlights the growth in demand for our services driven by increases in the older and younger populations that the Trust serves. In all of the local STPs workforce strategy developments, new models of care and pathway redesign are at a very early stage. The challenges in respect of workforce supply for key roles are common to all. The Trust is fully committed to the NWL agency and bank initiative which is aiming to reduce agency spend through coordinating e-rostering, improved agency management and sharing bank staff. The strategic direction outlined in the five year forward view suggests more care will take place in the community, supported by seven day services which would imply workforce growth and investment. However, such growth has not been translated to clear commissioning intentions to date, as this is conceived to be work in progress. The impact of Brexit has been negative for some overseas, EU and British staff who now feel rejected by their local communities and uncertain about whether they will be welcome to stay in Britain long term. The Trust has taken steps to support all staff who report experiencing racism and harassment during their work. Despite our best endeavours in this regard, uncertainty in respect of Brexit and prolonged pay restraint is likely to impact negatively on our health and social care system for several years to come. Agency Staffing The Trust is very focused on reducing its use of agency staff. Regular meetings reviewing performance against devolved trajectories linked to the annual plan are led by the Chief Executive Officer and Chief Nurse to ensure that the Trust is risk assessing plans for a safe reduction in agency usage supported by international recruitment, switching agency staff to bank or permanent roles, tight monitoring and where necessary reductions in service provision. This will continue to ensure that the targeted ceiling for 2017/18 is achieved in a safe fashion and the Trust continues to improve its performance on continuity of compassionate care to patients and financial control. 12 P a g e

13 5 Financial Planning An analysis of CLCH financial delivery over the last five years in terms of QIPPs and income & Expenditure (I&E) shows a strong track record, of which we are proud. We are cogniscent, however, that in common with many other NHS providers the low hanging fruit has largely disappeared and both the operational and financial climate is far harsher for organisations like ours, which has consistently delivered surpluses, year-on-year. Equally we recognise the need for a viable NHS that can live within its means and so we strive to innovate, improve and engage as we take forward our transformation programme over the next two years. The Trust is planning for a surplus of 5.0m for 2017/18 and 5.0m for 2018/19 in line with the control total set by NHS Improvement (NHSI) which the Trust is planning to accept. Within the budget the Trust has planned for national inflation pressures for pay and non-pay. To achieve the target surplus further work is needed in relation to fully identify the QIPP programme for the next two years as well as manage identified cost pressures and investments to an affordable level. The Trust income plan is based on historic contracted levels with adjustments made for agreed impacts of contracting intentions of commissioners. Significant change is anticipated over the next two years as a result of the STP initiatives and significant transformation is anticipated in Inner London services to meet the reduced funding envelope by 18% over the next two years. Over previous years the Trust has invested considerable capital in technological development as well as estate and equipment. This investment is now benefiting service delivery and realising value for money for the Trust. However, the investment in the next two years is planned to be lower and will concentrate on invest-to-save estates and service reconfiguration schemes including some technology developments. The Trust also anticipates that as a result of STPs significant investment will be required in community services to support the out-ofhospital strategy leading to increased income in future years. Plans are underpinned by robust financial forecasts and modeling and are consistent with the strategic intent of the STP as we understand them at this stage. 5.1 Financial forecasts and modelling The Trust s financial plan has been informed by our five year Integrated Business Plan, which drives the Trust s activity, workforce and finance plans. CLCH s financial strategy focuses on the following key priorities: Delivering continued future income and expenditure surpluses through achievement of a net surplus margin over the two year planning period; In 2017/18 and 2018/19 the target is 2.6% due to stretch targets. Delivering consistently good levels of EBITDA. Maintaining segment one status in NHSI Trust segmentation analysis. Delivering a significant contribution to QIPP through clinical and corporate transformation programmes. Investing in estates and service redevelopment schemes and building on existing IMT investments to continue achieving significant improvements in clinical quality, service cost reductions and service transformation to ensure we provide a sustainable service to our patients & commissioners. 13 P a g e

14 The Trust budget for 2017/18 and 2018/19 will achieve a surplus of 2.6% of turnover ( 5.0m and 5.0m). ' / / /19 Trust Financial Statements outturn plan plan Income 212, , ,125 Operating Costs (201,035) (179,429) (177,527) EBITDA 11,714 11,976 12,597 EBITDA % 5.5% 6.3% 6.6% Capital charges (6,334) (6,963) (7,584) Surplus 5,380 5,013 5,013 Surplus % 2.5% 2.6% 2.6% Net assets 53,627 58,657 63,670 Cash 11,346 7,983 9,827 The Trust I&E, cash flow and balance sheet has been modelled based on assumptions and provisions laid out in this paper. The Trust currently scores 1 against financial metrics under the Single Oversight Framework (1 is highest score and 4 is lowest): Ratio 2016/ / /19 Single Oversight Framework Outturn plan plan Capital service capacity Liquidity (days) I&E margin Distance from financial plan Agency spend Overall Rating The planned stretch surplus for 2017/18 and 2018/19 has increased by 0.6m to 3.2m in 2017/18 and 2018/19 as a result of the control total set by NHSI. The Trust has submitted various business cases to commissioners for funding for investments of demand driven cost pressures. Income: CLCH has reached agreement on all five of our NHS contracts requiring signature for These are Barnet, CWHHE (Inner London CCGs), Herts Valley, NHSE Specialised Commissioning and NHSE Public Health. The only material income change relates to our CWHHE contract where a reduction in value of 9m over the next two years has been agreed, with an associated programme of transformation schemes. The remaining NHS services such as Merton and Harrow are already covered by multi-year contracts. Local Authorities have not started contract negotiations as they do not follow the NHS timeline. Tariff inflator: we have planned for 0.1% increases in tariffs, which reflect 2.1% cost inflation (allocated to specific reserves as per section below) minus implied efficiency requirement 2.0%. 14 P a g e

15 Business Cases: The Trust has submitted various business cases to commissioners. In reality a significant proportion of these cases will not go ahead without commissioner approval so the Trust would not incur costs; however there is a risk that medical supplies related costs pressures may require internal funding if commissioners do not approve these cases. Summary Planning Assumptions: The planning assumptions identified in the table below reflect the Trust s long term financial plan based on the planning guidance published in October 2016: Implied Efficiency 2017/ /19 Tariff 0.10% 0.10% Pay and pensions (including drift) 2.10% 2.10% Non Pay (excl. drugs) 1.60% 1.60% Capital costs 3.50% 3.10% Drugs 2.90% 2.70% Implied Efficiency -2.00% -2.00% Committed Expenditure: Pay award 1% (of pay budget) Pay inflation has been based on the commitment of the Chancellor of the Exchequer to hold public sector pay inflation at 1%. The national pay awards for 2017/18 and 2018/19 are planned as 1% per annum in our two year plan. Incremental drift 0.9% The Trust has calculated 0.9% of total pay budgets as per the establishment at the end of September Apprenticeship levy This is the national initiative and the Trust has calculated the impact as 0.7m. Non-pay 2% The Trust has assumed 2% of non-pay budgets in line with the planning guidance issued by the NHSI. Revenue consequences of capital investment The Trust has based its assumption on the anticipated cost of financing the updated Trust Capital Investment Programme including the IT Strategy. The Trust is able to finance the investment from internally generated cash surpluses and is not relying on central NHS funding. Risks There are several risks relating to the draft budget for 2017/18 and 2018/19: i) QIPP under delivery This risk will be mitigated through further detailed work on those identified schemes as well as further work by the Director of Transformation and operations directors to identify further schemes. ii) Commissioning delays All our NHS contracts are now agreed however there are risks with delays in implementation with Inner London where the contract includes a transformation program to reduce 2017/18 income by 9% and a further 9% in 2018/19. To mitigate this risk the CHWEE contract contains implementation risk share provisions where responsibility for risk sits with the party who controls that element of the program. iii) Liquidity risk QIPP under delivery may present a risk to the Trust s liquidity. This will be mitigated through detailed management of debtors and creditors and cash forecasting to identify if external financial support is required which could place the Trust into a higher risk category with NHSI. 15 P a g e

16 5.2 Efficiency savings for 2017/18 to 2018/19 The Trust has a strong track record in QIPP delivery. A notable achievement is the reduction in corporate costs from the outsourcing of back office functions to Capita. However, the savings programme for the future needs to be reshaped as the task becomes increasingly challenging each year, and our ability to find recurrent savings has reduced. Therefore the approach to delivering QIPP for the next two years will be to: invest in recruitment and retention to reduce our reliance on agency and bank staffing maximise income through rigorous recovery and exploring new income streams release the full benefits of previous investment in technology i.e. mobile working and the Allocate system which will increase the productivity and cost efficient allocation of our staff review all our contracts to ensure they are commercially viable, covering costs and making at least a 1% surplus reduce overheads in line with the expectations set out in the Carter Report build on our partnership with Capita to explore additional opportunities for cost reduction and income generation use our estates rationalisation programme to reduce costs whilst investing in office and clinical facilities for staff and patients develop a comprehensive procurement programme that ensures we can demonstrate best value. Transformation Programmes Efficiency savings are supported by our transformation programmes which are designed to change and modernise our systems, processes and ways of working. They are aligned with the Leading Change, Adding Value framework launched in May 2016 for all nursing and care staff describing the triple aim of better outcomes, better experiences for patients and staff, and better value by making better use of resources. The key transformation programmes are: Technology enabled change including mobile working for clinical staff, assistive technology to support new models of care, and the implementation of a data warehouse to strengthen our business intelligence. New technology will help our staff increase their patient facing time. Estates rationalisation to reduce the overhead costs of our premises and ensure our clinics and office space supports new ways of working. Agile working and a focus on increasing occupancy rates will reduce our need for office space, and the costs of maintaining buildings will be fully reviewed. Workforce including completing the roll out of a rostering system to all staff to increase efficient allocation and reduce the reliance on bank and agency staff. In addition, there is a clear focus on improving the productivity of staff linked to mobile working (as described above); and new roles including apprenticeships Continuous improvement to train and support staff throughout the Trust to review their systems and processes, and track changes and lead service improvements 16 P a g e

17 Key benefits from the programmes are set out below: Transformation programme Workforce Technology enabled change Estates Continuous improvement Examples of efficiencies Efficient Rostering Recruitment (agency reduction) Retention/Good place to work (agency reduction) Sickness absence (agency reduction) Succession Planning (agency reduction) New roles/skill mix (cost reduction potential) Safe Staffing (accurate budget setting/agency reduction) Increased productivity through mobile working (e.g. increased number of visits) Use of technology to increase efficiency/effectiveness of patient contact (e.g. skype consultations) Interoperability/data sharing (avoiding duplication of data entry) Increased occupancy Reduction of estate Energy Savings Costs for facilities management Shared occupancy/one public estate Reductions in Unwarranted Variation (removing unnecessary interventions) Process redesign/lean (increased patient facing time) Culture of improvement (identification of savings) Clinical Outcomes (e.g. cease non-effective intervention) We are also developing two further key workstreams: Corporate transformation which will ensure we have sufficient capacity centrally to support the effective working of the Trust and that we allocate our resources where they will make most difference. It will help us to strategically shift resources to secure most gain, whilst delivering the savings required. Procurement to deliver savings and ensure our current practices are in line with Carter Report expectations. 17 P a g e

18 5.3 Capital Planning We are planning 3.8m of capital expenditure each year. 6 Link to emerging Sustainability and Transformation Plans (STPs) Engagement with STPs CLCH operates across a large swathe of London and Hertfordshire and our geographic reach means we are involved in four STP processes. We have responded to this potential resource challenge by investing in extra capacity to ensure we adequately input and respond as required across the four, and also that messages from the STP programme are disseminated internally. Table 1: STPs in which CLCH is involved STP Area CLCH Services Hammersmith and Fulham Community healthcare services North West London Westminster Kensington and Chelsea Hounslow Community healthcare services Community healthcare services Diabetes and school nursing services North Central London South West London Hertfordshire & West Essex Harrow Brent Barnet Richmond Merton Hertfordshire Adult community health and school nursing School nursing services Community healthcare services School nursing services Community healthcare services Respiratory and sexual health services To ensure the link between our operating plans and the STPs is maintained we have embedded the main aims and future developments of each STP within the bottom-up planning process that we have adopted. This process requires each of our Clinical Business Units across our four operating divisions to write their own plan and within this, explicitly link their plan to those of their associated STP. These plans are then aggregated into divisional plans and cross-checked with our corporate and quality services to ensure that operating divisions will have access to the support they require. In this way we have ensured that our services at the CBU level are informed by the requirements of the STP and, as the system control totals are agreed this will stretch to include individual budget lines to ensure financial alignment as well. 18 P a g e

19 Further, we have created capacity for discussion of STPs between managers at every available opportunity to discuss developments and ensure all the senior team are sighted on updates as they become available. We thus have standing items at our weekly Executive Leadership Team meeting and our monthly senior management meeting as well as an STP item at each monthly Board. We will also ensure that any additional or extraordinary briefing sessions that are required will be prioritised as STPs seek to make rapid decisions to enhance progress. Impact on CLCH Planning The STPs in which we are involved include common themes to which we are responding. Firstly, we note the emphasis on prevention and self-care. This is an area where CLCH is strong and we already run several services which focus upon education and longer term management of health. These include truly preventative services such as health visiting and school nursing through treat and prevent services such as sexual health and weight management to the higher end of acuity such as a series of long term conditions services which focus on educating the patient for them to best maintain their independence. We look forward to supporting our STPs in enhancing this across the system in the future. Secondly we note that each of the STPs recommend a significant enhancement to the GP federations of each area to offer a strong and credible voice for primary care in a system. As a close partner to primary care in all the systems in which we work we heavily endorse this move and have already sought to work more closely with our GP colleagues. To this end we have signed MOUs with some of the federations with which we work and seek to sign similar agreements with all of them over the next six months as we better understand how we can work together toward the STP goals. Finally, each of the STPs considers how systems will progress under the new care models or other organisational forms such as accountable care partnerships. This is another area in which CLCH has remained heavily involved and several of our borough or larger commissioner groups have signaled a clear intent to move toward such a model. CLCH has been working with system partners to understand how we play a key role in such a development and will continue to act as a willing and able partner. In sum, we have put the STP process at the heart of our own internal planning process to ensure that they have the relevant consideration. Further, we have created capacity both in terms of management resource and also time at key meetings to discuss and respond to developments as required. We are confident that as the STP process continues we will maintain our ability to act as core partner in our role as community services expert. 19 P a g e

20 7 Foundation Trust application/membership and elections 7.1 Foundation Trust context After a successful Readiness Review, the Trust took part in a Board-to-Board with the Trust Development Authority (TDA) in November The Trust received positive feedback and was awaiting confirmation of referral to Monitor to commence the final stages of the Foundation Trust (FT) process. Shortly after this the TDA and Monitor announced plans to merge as NHS Improvement, and as a result the process for authorising foundation trusts was paused. Since then, CLCH have continued to meet regularly with NHSI and have kept them informed on our performance, progress and developments. We now have a new chair and chief executive who will, with the Board, consider our strategic intent, including our intention to continue with our FT application, providing the process is nimble and supports our strategic direction of partnering with others and is in the best interests of our patients and staff. 7.2 Membership strategy and engagement, next 12 months Membership recruitment began in 2012 and there are currently 7,663 public members and over 3,000 staff members. Our members are involved in a range of regular activity including 15 steps challenge visits, listening events, patient-led assessments of the care environment, stakeholder panels, quality account priority setting, staff awards and the Annual General Meeting. Participation in these activities is sustained and consistent. All members receive a quarterly keeping them informed of developments and highlighting opportunities for greater involvement. Our public membership represents the diversity of the London. The membership strategy is refreshed annually and approved by the Board who also receive an implementation update mid-way through the year. 7.3 Plans for governor elections, training and development activities for engagement In our previous preparations we undertook competitive quotes for an election supplier, prepared election plans, drafted a governor handbook, prepared literature, drafted induction and training plans and other information on the role of the Council of Governors. We are currently preparing a proposal to consult members and the wider community about a change to our governance arrangements. As the geography of the Trust has grown in the last couple of years we wish to reflect this through our membership constituencies and governor arrangements. This consultation will be part of preparation plans for our FT application. 20 P a g e