University Hospitals of North Midlands NHS Trust

Transcription

1 University Hospitals of North Midlands NHS Trust Summary of Operational Plan 2016/17 April

2 1. Introduction This Operational Business Plan brings together the plans of University Hospitals of North Midlands for 2016/17. It forms part of the Trust s Integrated Business Plan 2016/ /21, which sets out how we will deliver the objectives we set and meet the needs of our funders. The plan is supported by strategies the Trust has agreed for the quality of its services, for the clinical services it will operate, for the workforce it will use, for supporting services it will provide, for the management of risk and assurance in its work and for its estate. It also demonstrates how UHNM will deliver its financial obligations. 2. Approach to Activity Planning Our vision is to be a world-class centre of clinical and academic achievement, where staff work together to ensure patients receive the highest standards of care and the best people want to come to learn, work and research. This is set out in 2025Vision statement. In order to achieve this we need to address the following key strategic issues: Achieve faster flow through the Royal Stoke University Hospital (RSUH) site in order to not only hit A&E targets but also to protect elective capacity, which generates a positive financial contribution. During 2015/16 the local health economy has been supported by ECIST (Emergency Care Intensive Support Team) visits and has been advised by Dr Ian Sturgess. This has been enormously helpful in sharing national good practice and helping set stretching but achievable KPIs (key performance indicators). The initiatives below have been informed by this work. We are working with local commissioners to achieve this. From 1 December 2015 UHNM has assumed responsibility for the step down pathway from acute care in order to reduce the number of medically fit for discharge patients in the acute hospital. In addition, UHNM has also been appointed the prime contractor for respiratory, heart failure and diabetes in the local health economy with effect from the same date. The Trust must realise the benefits we planned from these in 2016/17. The Clinical Commissioning Groups (CCGs) are considering proposals to move to a fully integrated urgent and emergency care network through the Staffordshire Strategic Review currently underway. To continue to successfully integrate County Hospital into our operations, developing it as protected capacity for day cases and short stay planned work along with specialist rehabilitation services, not just for UHNM, but for also for other providers of health and social services to the population. This will ease pressure on the RSUH site and enable us to bring back into Staffordshire treatments for the local population which are currently done elsewhere, along with the associated investment. Spending the Staffordshire pound in Staffordshire! In order to stay up to date and deliver the best possible services to our patients we need to continue to expand our tertiary capabilities and capacity to service the population of the North West Midlands, Derbyshire, Wales, South Manchester and the northern suburbs of Birmingham. This will be supported by the clinical networks we are developing with Leighton and the Royal Wolverhampton Hospitals, which deliver benefits to all partners and their patients. We will ensure that the vision is taken forward by ensuring a clear thread from the overall vision to the strategic objectives derived from the vision. The five strategic objectives that we have set for the period of this Business Plan are: 2

3 Delivering quality excellence for our patients Delivering our obligations to the taxpayer To achieve excellence in education, training and research Create an integrated, vibrant Trust and develop strategic alliances with neighbouring trusts and partners Create a resilient Urgent and Emergency Care System through increased integrated healthcare and social care provision In summary, this strategy means that UHNM will be a much more integrated and flexible provider within the local health economy and beyond by 2020/21 than currently. Service Development Plans 2016/17 Having undertaken an analysis of our market it is clear that the demographic changes over the next five years are: The local population has been projected to grow by 5.5% between 2012 and 2022 There will be a 24% increase in population in the age group 5 to 9 For older age groups there will be a 29% increase in the 65 to 74 age group and an 18% increase in the over 85 age group. This growth is expected to continue for the next 10 years Stoke-on-Trent is ranked as the 8th worst nationally for health deprivation, with 70% of the population living in areas classed as the 20% most health deprived in England This means that the Trust will need to expand its capacity to meet increased demand driven by the ageing and expanding population it serves. The key growth areas are: Trauma and orthopaedics 15% Neurology 13% Cardiology 13% Medicine 2.76% The demand for diagnostics has risen faster than activity over the past few years and we anticipate this will continue Community Services From 2015/16 the Trust has been awarded the contract to manage step-down services in order to give it greater leverage in reducing the number of patients who are in acute beds but who are medically fit for discharge. It is proven that unnecessarily long stays in an acute hospital result in deterioration in the health of elderly patients and therefore the key challenge is ensuring a home first culture across the health system. Over the next five years, the Trust will need to work with its partners in the community services and the local authority to expand the availability of domiciliary care packages and care home packages to ensure that there is flow through the whole system and the home first culture can be realised. The assumptions and key enablers to realise this vision are enumerated below: Assumed responsibility on the 1st December 2015, 16 month pilot Original plan was 110 beds, contract negotiations underway with CCG s to increase to 166 beds, due to the growth in demand and delays in implementing the agreed model of care, which should disappear now UHNM have direct control Early stage discussions with the CCGs and Staffordshire & Stoke-on-Trent Partnership (SSOTP) about UHNM taking responsibility for all community beds 3

4 For step up services, the Trust has taken responsibility for delivering long term condition contracts for diabetes, respiratory and heart failure on a pilot basis. The idea is that by removing barriers between, for instance, consultants, specialist community teams and GPs, we can ensure that patients can be treated as close to home as possible and admission is avoided wherever possible and length of stay reduced. Target admission/re-admission and length of stay reductions are being developed through the business case, service transition plans and the new clinical pathways. Activity Plans 2016/17 The Trust has plans to increase the size and scale of its services further, as outlined above, and the activity will continue to grow over the next five years in accordance with the service development plans. These figures and the assumptions have been shared with our CCGs. The activity for the 2016/17 plan is set out in the table below. 2015/16 Forecast Outturn 2015/16 Non Recurrent Actvity 2016/17 Service Developments 2016/17 Other Developments 2016/17 Plan AandE 235,467 - (7,800) 12, ,775 AandE 172,352 - (7,800) 12, ,660 Type 2 63, ,115 Elective 99,719 (2,952) 6,397 1, ,057 DC 81,674 (2,606) 4,402 (899) 82,571 EL 14,918 (345) 1, ,779 REGDC 3, ,752 6,707 Non Elective 104, (3,488) 4, ,475 NEL 80, (3,608) 4,521 81,681 NELNE 23, ,794 Outpatients 693,579 (18,763) 24,526 6, ,696 FOL 394,644 (8,776) 12,532 (4,054) 394,346 NEW 199,960 (6,937) 6, ,255 NFTF 5,128-1,511 7,411 14,050 OPPROC 93,847 (3,050) 4,108 2,141 97,046 Grand Total 1,133,095 (21,701) 19,636 24,973 1,156,003 The figures above include: Growth assumptions and service developments in 2016/17 The removal of non-recurrent activity which took place in 2015/16 (e.g. activity to undertake waiting list initiatives) Other developments include counting and coding changes and productivity improvements Additional capacity as it becomes available for 2016/17 Delivery of operational waiting time targets and reduction of waiting list backlogs during 2016/17, as outlined in the section below The achievement of the TSA Steady State model, which includes bringing forward the transfer of elective orthopaedics from Cannock in July 2016 for the Stafford and Surrounds population The figures above do not include: The impact of the step down services community care model, which will be implemented in phases between December 2015 and March 2017, as outlined above The impact of the long term conditions programme outlined above The impact of any CCG QIPP programmes, which are being discussed with the CCGs and will be implemented in a phased way over the year, once concluded 4

5 National Targets The activity profile described above will deliver the performance trajectories summarised in the table below: Performance Trajectory Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Overall RTT 90.7% 91.0% 91.3% 91.6% 91.8% 91.9% 92.1% 92.1% 92.1% 92.1% 92.1% 92.1% 62 Day Cancer 69.3% 81.8% 85.5% 85.4% 85.1% 85.5% 85.4% 85.4% 85.5% 85.4% 85.2% 85.1% A&E 82.0% 86.0% 90.0% 91.0% 92.0% 93.0% 94.0% 95.0% 89.0% 83.5% 85.0% 89.0% Diagnostics 1.5% 0.7% 0.7% 0.7% 0.7% 0.7% 0.7% 0.7% 0.7% 0.7% 0.7% 0.7% A&E Performance UHNM A&E performance will incrementally build and hit 95% in November 2016 but realistically will not maintain over the winter months and has therefore been reduced over the winter period. In doing this we are taking into account the historical rise in both demand and discharge delays experienced during the winter months. However, we can build upon this level of performance if unmet demand and MFFDs (medically fit for discharge) are maintained through the winter period at the target levels (67 beds at RSUH and 15 at County; current levels are over 150). Cancer Targets UHNM is currently meeting all its cancer targets apart from the 62 day target. As a result of the cancellation of operations in Quarter 4 of 2015/16 the 62 day target will not be met in April and May 2016 but will be met from June 2016 onwards. 18 Weeks UHNM is planning to incrementally build its overall RTT performance to hit 92% in October 2016 and sustain it thereafter. By specialty the plan will achieve sustainable 18 week pathways in all specialties with the exception of the following: Speciality 2016/17 Plan Dermatology Plan achieves by January 2017 Plastics Will not achieve in 2016/17 General Surgery Will not achieve in 2016/17 (Colorectal & Upper GI) Plan to increase performance to 86% by January 2017 Pain Plan to achieve late 2016/17 Neurosurgery Plan achieves by December 2016 T&O Plan achieves by December 2017 Assumes Cannock work transfers in July 2016 Immunology & Allergy Plan achieves by October

6 Diagnostics 6 weeks Diagnostics have not met the target in March 2016 nor in April 2016, but will achieve it from May 2016 onwards. Risks The table below describes the main risks associated with achieving the above planned targets and the steps being taken to mitigate these risks. Performance Target A&E performance 18 Weeks and Cancer Targets Risks Demand for service grows above the level forecast in the activity plans. Medically fit for discharge numbers increase above those experienced in 2015/16, which is the basis on which the plan has been set, and is in excess of the agreed local health economy targets. This will reduce the flow through the bed base, which will impact on the time lag on the admissions from A&E. A key element in this is the ability of the Local Authorities to reduce the unmet demand for domiciliary and care home services for social care. At present Stoke-on-Trent City Council do not have a plan which closes the gap between demand and supply. Staffordshire County Council have not yet shared their draft plans. If the risks described above under A&E are not mitigated, this will reduce the capacity available within the Trust to service routine work. This will result in the cancellation of appointments and operations, which means that the 18 week and the cancer targets will be affected. Any sudden increases in demand as a result of national campaigns, such as for breast cancer awareness, which are not foreseeable, may exceed the planned capacity available. This will adversely affect the performance. Mitigations UHNM is working with the commissioners on a number of QIPP schemes to reduce attendances at A&E and admissions. UHNM is recalibrating the step down services with the CCGs and will directly control the community beds associated with the step down services from 1 April 2016, thus reducing barriers between the service and delays in transfer. UHNM have commented on the draft Stoke-on-Trent City Council plans and are participating in their further development. UHNM also has a seat on the Health and Wellbeing Board, which is required to sign off the Better Care Funds. As above There are no mitigations within the Trust s control. 6

7 Performance Target 18 Weeks and Cancer Targets (continued) Risks The Trust have taken a prudent view on their ability to staff theatre and critical care capacity based on historical performance and the plans going forward to remedy the shortages. If the level of staff losses rises from this current level or the recruitment plans do not come to fruition due to external factors such as Home Office rules, there may not be sufficient theatre and critical care capacity to support the activity planned. Implementation of Medway System across both sites exposes a number of 18 Weeks breaches. Mitigations The Trust will need to take a decision on whether to use a higher level of agency staff, if available, than planned which may breach the agency cap. The Trust is undertaking a validation exercise prior to implementation. Resource implications for 2016/17 Beds The current number of beds is 1,121 at RSUH and 155 at County giving a total of 1,276. As part of the County refurbishment an additional 15 beds will become available in June 2016 and a further 39 beds in November The 2016/17 planned activity generates a requirement for an additional c28 beds. A 2-3% p.a. Length of Stay (LOS) reduction will generate a c30 bed saving. Productivity benchmarking indicates this is achievable if the number of MFFD patients remains at the 2015/16 level or reduces. The continuing inability to discharge patients to domiciliary care (including care homes) is the biggest single threat to UHNM s ability to sustain flow through its bed base in 2016/17. UHNM is informing the discussions the CCGs are having with the local authorities on building community capacity and the BCF (Better Care Fund). Outpatients The current number of outpatient clinic rooms in the main outpatients department is 56 at RSUH and 34 at County. The additional activity in 2016/17 results in a 1.75% increase in appointments this will be managed within existing clinic room capacity through improving utilisation to a target 92%. As part of our plan to increase non face-to-face outpatient sessions (from c5k to c14k in 2016/17) by introducing telephone clinics, the overall number of rooms required will be reduced. Theatres The current number of theatres at RSUH is 27 (including the Poswillo Theatre local anaesthetic, which opened February 2016) with five operable theatres at County. As part of the Trust s plan to increase planned work at County there will be an additional three laminar flow theatres planned for County site, the first of these being built in 2016/17. The level of activity for 2016/17 has been based on the 2015/16 theatre availability and utilisation and therefore, as the productivity improvements outlined below are realised there should be opportunity to increase activity. 7

8 The IBP includes plans to improve productivity for theatres by achieving 80% (for non-elective) and 85% (for planned) utilisation targets. Work undertaken by Newton suggests that 85% utilisation will give capacity for an extra 4,200 cases p.a. Plans are in place to expand the capacity for the preassessment service across both sites. Critical Care The current number of critical care beds at RSUH is 58, with a further two opening in April 2016, and four beds at County. Transformation schemes during 2016/17 and 2017/18 will improve productivity enabling more activity to be undertaken through the existing bed base giving a c1,000 bed day equivalence saving in total. There is sufficient capacity for the additional activity in 2016/17. Workforce A key constraint is the workforce supply, particularly for difficult to recruit areas such as theatres and critical care. This is discussed further in Section 4. Unplanned changes in demand Winter pressures will be handled through using the escalation capacity available at Cheadle Hospital and County, along with Stadium Court as a last resort. Triangulation of indicators As part of the Trust s performance framework access, quality, workforce and financial indicators are triangulated: Monthly, via the Trust performance reports, which are reviewed by the Trust Board Quarterly via divisional performance reviews Copies of the Trust s performance report can be made available upon request. 3. Approach to Quality Planning Approach to Quality Improvement Quality, safety and patient experience remain our number one priority. Our core vision continues to be a leading centre in healthcare, driven by excellence in patient experience, research, teaching and education and our overall ambition is to be among the top 20% of the best performing trusts in England. Key to the Trust s success and achievement is listening to and involving our staff, our patients and the local community we serve. We believe that by doing this we will improve the experience of patients and staff and improve their sense of ownership of their local healthcare services. The Trust underwent its CQC Inspection in April 2015 and has been given a rating of Requires Improvement. The Trust s registration with CQC has no restrictions or conditions and has been assessed as compliant with all the standards. The Trust developed a detailed action plan to address the different issues identified in the CQC s Inspection Report and this has been used as the drive to improve the quality and safety of the services provided by UHNM along with 8

9 improving patient experience. Implementation of the actions is monitored via the Trust Compliance Steering Group. In March 2016, an internal audit was commissioned to seek assurance that actions identified as having been implemented (rating of green) had robust evidence to support that rating. The internal audit report confirmed that 91% of those actions had sufficient evidence to support that rating. This plan can be made available upon request. The Trust participates in all the required national audits and reports outcomes of these to the Quality Assurance Committee and Trust Board to allow learning and benchmarked performance to be reviewed and shared. The Association of Medical Royal Colleges guidance has been fully taken into account by the Trust. The Quality Assurance Committee is one of six key committees, each chaired by a Non-Executive Director, which report directly to the Trust Board. The named executive leads for quality are our Chief Nurse and Medical Director. In 2015/16 we set five core patient safety, outcome and experience priorities to drive our improvement goals set above. The priorities for 2016/17 are: 1. To improve our patients experience 2. To reduce avoidable harm 3. To improve staff experience 4. To consolidate and harmonise the integration of clinical pathways to improve the patient flow through UHNM and deliver efficient admission, diagnosis, treatment and discharge 5. To improve communication with patients and stakeholders In line with the national timeframe for publishing the Quality Accounts the priorities for 2016/17 are in the process of being agreed in conjunction with stakeholders, including local community, public and staff. These workshops will take place throughout the months of April and May Patient Care Improvement Programme This is now our fourth year of intense focus on quality improvement with our Patient Care Improvement Programme (PCIP) setting out clearly our priorities, namely: Patient experience will be in the top 20% of all NHS hospitals by 2016/17 and sustained thereafter: o For inpatient survey to be ranked as in the top 20% of all trusts nationally. o For the Friends and Family Test to be consistently over 75. Reduce avoidable harm will be in the top 20% of all NHS hospitals by 2016/17 and sustained thereafter: o o A zero tolerance of outliers. A reduction of 10% in those patients remaining in hospital past their medically fit for discharge date. Hospital Standards Mortality Ratio (HSMR) will be in the top 20% of all NHS hospitals by 2016/17 and sustained thereafter: o For all patients who are identified with sepsis to be compliant with the sepsis care pathway. To support the delivery of the PCIP the Trust has now established a Quality Academy and has recently recruited a Programme Manager to co-ordinate its function. The purpose of the Academy is 9

10 to expand the scope of quality improvement into every aspect of care across the two sites and empower staff to deliver improvements themselves. This will be achieved through the facilitation of huddles which have now been piloted in three wards. The Clinical Assurance Framework has now been adapted into the Care Excellence Framework (CEF), which refocuses from assurance and compliance to quality improvement and achieving excellence. The CEF expands to incorporate ward self-assessment, ward rating and reward. The rating will reflect the Excellence In Practice Accreditation Scheme of Platinum (comprehensive evidence), Gold (substantial evidence), Silver (significant evidence) and Bronze (limited evidence). It is proposed that any ward achieving gold or platinum are invited to the Trust Board to be presented with a certificate. Trust Top 3 Risks Risk Patient quality and safety issues associated with A&E and emergency flow MFFD patients having unnecessarily long stay in an acute hospital bed resulting in the deterioration of health for elderly patients Failure to recruit staff for hard to recruit to areas, resulting in failure to deliver new service models or planned capacity Mitigation UHNM is working with the commissioners on a number of QIPP schemes to reduce attendances at A&E and admissions. UHNM is recalibrating the step down services with the CCGs and will directly control the community beds associated with the step down services from 1 April 2016, thus reducing barriers between the service and delays in transfer The Trust will need to take a decision on whether to use a higher level of agency staff, if available, than planned which may breach the agency cap. See Section 4 for further detail Sign up for Safety priorities for 2016/17 Following development of the Patient Care Improvement Programme in 2014/15 the Trust is continuing to consolidate and expand the initial Sign up to Safety Projects, which were a falls safety project and hot x-ray reporting project. These have both had initial success in reducing patient harm and improving patient experience. As part of UHNM's commitment to improving patient safety and the Sign up to Safety Campaign, at all levels of the organisation, our priority for 2016/17 is the exciting launch of our Quality Academy, planned for June Pilot multidisciplinary huddles across the Trust have already given rise to improvement projects around medication safety and nursing shift handovers. Seven Day Services UHNM delivered an SDIP (service delivery implementation plan) in 2015/16 that targeted full compliance with eight of the 10 national clinical standards across both sites (the remaining two, standards 7 and 9, relating to mental health provision and community transfers are largely influenced by factors external to the Trust so require a whole economy approach). The 2015/16 10

11 SDIP was informed by a gap analysis against a self-assessment of compliance with the 10 standards in each of the nationally identified high risk specialties. For 2016/17 UHNM is negotiating a further SDIP which will follow up actions from the 2015/16 plan and incorporate actions following the March/April 2016 audit against Standards 2, 5, 6, 8 mandated by NHS England. The Trust is working with Combined Healthcare, who are the commissioner of mental health services, to use increased funding to ensure compliance with parity of esteem which will include 24/7 presence of a mental health liaison service in A&E. Quality Impact Assessment (QIA) Process The UHNM process for undertaking QIAs on CIP plans is aligned to National Quality Board guidance and covered by an internal Trust policy. All schemes require an initial QIA. Scheme owners are responsible for assessing impact and providing a risk score on the three domains of quality: patient safety; clinical effectiveness; and patient experience. Schemes with potential to impact adversely on quality will require a more detailed risk assessment (full QIA). The threshold for full QIA is set according to our contractual requirements with commissioners. For 2015/16 this currently requires exception reporting for all schemes with an initial risk score of nine or above. Where possible, schemes are not implemented without QIA approval. However, there will be instances in which schemes are opportunistic in nature and savings have already been realised before they are verified for inclusion in the CIP. In these instances, savings are not transacted in the general ledger until a QIA has been approved to remove the associated budget. It is important that there are on-going measures in place to monitor the potential impact of schemes on quality. The QIA process provides an indication of risk before implementation. However, this will not be a one-off process and risks will be reviewed throughout the life of a project. Scheme owners are required to review all initial and full QIAs on a quarterly basis and record whether the original assessment remains valid. Any changes will be treated as a new scheme and presented to the Medical Director and Chief Nurse for approval. Quarterly reviews will continue until implementation is complete and schemes become business as usual. Information on the quality risks identified and outcomes of the QIA panels is reported: Internally on a monthly basis to the Divisional Senior Management Teams Internally on a quarterly basis to the Quality Assurance Committee and the Executive Performance Reviews Externally to the commissioner Clinical Quality Review Meeting (CQRM) During 2015/16 the services at County Hospital all emergency and inpatient surgical, trauma, obstetrics and some medical were safely transferred to RSUH after a thorough QIA process using our tools and process 11

12 4. Approach to Workforce Planning The Trust is developing as a clinically led organisation and has communicated its clear vision to be a world-class centre of clinical and academic achievement, where staff work together to ensure patients receive the highest standards of care and the best people want to come to learn, work and research. The workforce underpins achievement of all the strategic objectives set out in Section 1 with some key critical success factors identified: To be seen by Health Education England, Keele University as the top performing postgraduate medical teaching and undergraduate teaching organisation by 2017/18 and sustained thereafter 80% of staff rate their teaching and education as excellent by 2016/17 and sustained thereafter Improve employee retention from 86.66% (December 2015) to 90% by 2020/21 Achieve a year on year reduction in agency costs and live within the national cap Increase number of staff recommending the Trust as a place to work from 60% to 80% over three years and then sustain thereafter Developing our Workforce Plans Workforce planning is integral to the Trust s business planning cycle. Divisional business plans, comprising activity, finance, CIP and workforce plans, are subject to confirm and challenge sessions to ensure consistency and alignment. Professional confirm and challenge of workforce plans has been carried out by the Medical Director, Chief Nurse, Chief Operating Officer and HR Director. Workforce plans, based on operational need and safe staffing levels, are built up from the service level by each directorate. The plan for 2016/17 is set out below and compared with the activity growth plans: FTE by 31 March 2017 % Growth April 16 to March 17 Medicine Medical and Dental % Non-medical Clinical % Non Clinical % CWD Medical and Dental % Non-medical Clinical % Non Clinical % Main areas of workforce growth Business Cases: EAU, County Chemo Unit, Brachy expansion, Specialist Nurse, Therapies staffing Activity 2016/17 Plan % 2.76% Predicted growth in diagnostics of about 10% not reflected in activity plans % 0.48% 12

13 FTE by 31 March 2017 % Growth April 16 to March 17 Main areas of workforce growth Activity 2016/17 Plan Surgical Medical and Dental % Non-medical Clinical % Non Clinical % Colorectal/UGI and Urology Business Cases, plus JOSM - County Theatres Specialised % -0.15% Medical and Dental % Non-medical Clinical % Non Clinical % Clinical Divisions Total Medical and Dental % Non-medical Clinical % Non Clinical % ARTU; Heart failure and rehab; Neurology Stroke service developments % 4.85% Corporate Services % 2.14% Medical and Dental 0.00 Non-medical Clinical % Non Clinical % Central Functions % Medical and Dental % Non-medical Clinical % Non Clinical % Trust Total % Medical and Dental % Non-medical Clinical % Non Clinical % % 2.14% Step Down Business Case Total including Step Down A Trust level workforce plan is also prepared from the corporate perspective, based on the overall pay envelope i.e. a top down model (affordability model). The figures above do not include CIPs which are still being developed for 2016/17. There is an expectation that some of the planned growth will substitute for agency use. The operational workforce plans are compared to the top down" model to ensure that operational (safe staffing) requirements are also affordable. The overall aim is to ensure that an affordable workforce with the right skills and competence is in place to support achievement of the Trust s vision. 13

14 The Trust s Workforce Plan is reported to Trust Board and assurance against plan is provided through monthly workforce reports to the Finance and Efficiency Committee. These plans also inform the workforce submissions to the Local Education and Training Board plans to ensure workforce supply needs are met. The Trust has set out four goals for the Workforce Plans to support the IBP: Goal 1 to improve the productivity of our workforce by 90m over five years, or 18m pa. Goal 2 to tailor the activity plans to a realistic view of the workforce supply. Goal 3 to secure operational capacity, the workforce solution must be based on the workforce need not current roles. Goal 4 the workforce supply must be deliverable and affordable over each year in IBP. These goals will be achieved through the following opportunities: a) A professional confirm and challenge of the divisional annual and five-year workforce plans. b) Centrally driven initiatives on workforce productivity, supply et al, with central co-ordination, support and action to drive workforce change. These initiatives will contribute towards to Trust s 90m cost improvement programme over five years by aligning workforce to service needs, creating more efficient processes and realising productivity gains through: Changing skill mix Improving workforce productivity by using technology Implementing the apprenticeship strategy Reviewing unfunded posts Creating high performing teams Outsourcing/backroom shared service Introducing new roles Specific initiatives identified to date include: Introduction of 50 practitioners at band 3/band 4 in the areas of ED, elderly care, general medicine and rehabilitation Introduction of new roles: physicians associates in medicine division commencing with support for the placements of five physicians associate; 17 scrub assistants at band 4 in theatres by July 2016; clinical fellows via the MIT programme Introduction of apprentices in all divisions (80 nursing apprentices in four cohorts) Converting 34 HCA (health care assistant) overseas nurses onto register Increase numbers of ANPs by four (Health Education West Midlands) and a further 12 places for MSc programme at Staffordshire University The Trust has a staff turnover rate consistently below its target maximum level of 11%. The Trust turnover rate was 7.25% at February 2016, comparable to the latest available benchmark data for the 12 months to September 2015, showing turnover rates as: Total NHS Excluding Bank, Locums and Trainee Doctors - 8.8% Whilst some degree of turnover is considered beneficial, excessively high levels are costly in terms of potential disruption to services, especially when some skills are in short supply. 14

15 Quality, safety and workforce indicators Staff Engagement The staff engagement score is used as an indicator of the direction of travel regarding the quality of care being delivered to patients. The indicator is made up of scores for staff job satisfaction, motivation, levels of involvement and willingness to act as an advocate for the organisation by recommending it [measured via the NHS Annual Staff Survey]. The Trust recognises that there is an important link between staff wellbeing and the quality and safety of care delivered as evidence suggests that NHS trusts prioritising staff health and wellbeing perform better and have improved patient satisfaction. Staff Wellbeing The sickness rate target is 3.39% and actual performance as at February 2016 was 4.28%, split by staff group as follows: Staff Group Actions to improve include: Absence % (FTE) Add Prof Scientific and Technic 4.61% Additional Clinical Services 6.74% Administrative and Clerical 3.89% Allied Health Professionals 2.76% Estates and Ancillary 3.20% Healthcare Scientists 2.57% Medical and Dental 0.98% Nursing and Midwifery Registered 4.38% Trust Rate 4.28% To contribute towards a reduction sickness absence: o o o Development of a portfolio of wellbeing/support offerings. A focus on compassionate leadership and engagement, supporting positive leadership approaches and wellbeing. Implementation of the national CQUIN s to improve health and wellbeing for staff, including providing the opportunity for staff to access schemes and initiatives that promote physical activity, and provide them with mental health support and rapid access to physiotherapy where required. To contribute towards a reduction in the percentage of staff saying that they had suffered workrelated stress in the previous 12 months. Counselling and occupational health services are being market tested. A range of workforce indicators are reported to Trust Board in the monthly performance report, which is published on the Trust website. 15

16 The application and monitoring of quality impact assessments for all workforce CIPs The Trust s Transformation Office reports on delivery of the CIP programme via workbooks, which are RAG rated as appropriate. Ensure appropriate QIA s are undertaken and monitored. Assurances and risk assessments are provided to the QIA. Maintain financial trackers in conjunction with divisional business advisors, including validation and assessment in line with CIP rules and principles; and Provide support and challenge to all areas of the organisation to ensure that CIP schemes are fully worked up and thought through. Balancing of agency rules with the achievement of appropriate staffing levels In response to the Agency Cap the Trust is reviewing the management of the temporary workforce and finding new solutions to attract our own staff to work on the Trust bank with the right reward package. We are working closely with the agency supply chain to ensure that we can balance complying with the caps with the delivery of safe patient care. We are reviewing all our temporary workers to ensure that they comply with framework requirements. Operationally, managers are challenged with ensuring that effective rostering is in place to minimise the need for temporary/agency workers. Price caps, being the maximum total hourly rate payable by a trust to an agency, have been set for different grades of staff and different shift types. An annual limit for agency nursing expenditure as a percentage of total nursing staff spend has been set as follows: Q3/4 2016/ / / /16 Trust ceiling 8% 6% 4% 3% For 2015/16, the Trust is expected to spend circa 48m to 50m on agency staffing. The impact of the Agency Cap is that this spend must be reduced to circa 28m in 2016/17, which is challenging. Although the Trust has been required to breach the cap in the interests of patient safety and quality of care, actions taken to address the impacts and reduce spend on agency staffing include: Divisions are to ensure they have clear plans in place to reduce agency costs and this will be managed through the Trust s Performance Review process Areas that are breaching the caps and engaging non-framework agencies are required to provide a clear rationale for the breach, requiring approval by the Executive Management Team The Trust is investigating the potential for a new model for the delivery of temporary staffing solutions 16

17 Systems in place to review and address workforce risk areas. At a strategic level, the key workforce risks identified are: Risk Workforce supply where a failure to recruit staff in key shortage areas, such as theatres, nursing, critical care, and therapies, will result in a failure to deliver new service models or planned capacity, and which also impacts on delivery of teaching, research and service requirements Mitigations Application of the Recruitment and Retention Strategy. Recruitment Plan developed and linked to workforce plans. Recruitment and retention introduction of innovative solutions, improving process flow, introducing recruitment and retention premia, e.g consideration of loyalty bonuses, golden handshake s etc. Rolling advert for nurse recruitment. Developing new training models, although benefits will take time to realise. Extra training and support has been introduced into the Recruitment Team. Rolling recruitment plans for OPD s / Theatre Nursing - phased to match staff capacity to train/mentor new staff. Overseas recruitment. Skill mix. Short term agency and overtime. Specific and targeted recruitment campaigns / recruitment fair. Demand exceeding capacity - A high level of activity has historically been delivered by Treatment Initiatives, which is not sustainable Workforce planning aligns the Trust s Integrated Business Plan, People Strategy and finance plans to ensure that a workforce with the right skills and competencies is in place to support achievement of the Trust s vision. The overall aim is to: ensure the workforce has clarity of purpose, shared goals and values, and is empowered to make a difference Productivity efficiencies built in to capacity plans for some specialties. For 2016/17 examples of this are the introduction of: Practitioners at B3 or B4 levels, physician associates, scrub assistants in theatres, clinical fellows via the MIT programme and apprentices across all divisions. Productivity opportunities identified as part of the transformation programme are assumed to meet an element of the gap between capacity and demand, although this is based on assumptions regarding resource utilisation. LOS Reduction and Admittance Avoidance Schemes. Implementation of the recruitment and retention strategy and develop further options to improve Trust recruitment Identification of ways we can support our existing staff to maximise their potential Development of a long term workforce supply plan to ensure delivery of service activity plans A review of opportunities for workforce transformation/role re-designs particularly in areas where there are hard to fill posts 17

18 Risk improve productivity through transformation, and ensure all staff groups fulfil their potential, and are equipped with the skills and knowledge to provide safe, high quality and compassionate care Mitigations A review of Trust- wide plans to enhance the retention of staff 5. Approach to Financial Planning The Trust is submitting a plan with a deficit of 29.6m and a cash requirement of 59m ( 23m Public Dividend Capital (PDC) and 36m PDC Revenue). The planned deficit figure takes into account the fully delivered requirement of 38m CIP and Synergies in 2016/17. This position was discussed and approved at the Trust Board on 12 April 2016 subject to the refinement of the asset revaluation, NHS Improvement confirmation of the CNST support assumption and the investigation of a potential capital to revenue transfer. Sustainability and Transformation Fund The Trust is unable to achieve the proposed control total of 15.8m surplus and therefore the 20.9m Sustainability and Transformation funding has not been included in the final plan. The Trust is working with NHS Improvement to develop a proposal for an adjusted control total reflecting the Trust s outturn position in 2015/ /16 Forecast Outturn For 2015/16 the Trust has reported a 26.9m deficit. The Trust has been under significant operational pressure resulting in additional capacity being commissioned within the Trust and in the Community to meet the demand. The Trust s position includes fines and penalties of 10.1m relating to national target performance and failure to meet Remedial Action Plan performance trajectories. The Trust s efficiency programme is a significant part of the Trust s plans to return to a break-even position. The 2015/16 CIP programme of 36m is in addition to 10m of Synergy saving identified in the Acquisition Business Case (ABC). The Trust is reporting the delivery of 31.8m CIP in 2015/16, but this includes a significant non recurrent element. The recurrent savings carried forward in to 2016/17 are 22.9m. The synergy performance is circa 1.5m below plan due to the slippage of synergies related to theatre utilisation. These synergies are expected to be delivered in 2016/ /17 Financial Plan The financial plan has been based on the forecast outturn adjusted for non recurrent income and costs. Modelling has been completed at a directorate level within the Trust by clinical and corporate support functions. The assumptions in the modelling take into account both national expectations and local assumptions. The plan reflects the technical adjustment of transferring from the Default Tariff Rates (DTR) to Enhanced Tariff Option (ETO). 18

19 CIP The 2016/17 plan includes a 5% CIP on total costs of 38m. The 5% includes the national tariff assumption plus additional savings for productivity improvements taking advantage of the opportunities identified in the: Synergies planned in the acquisition business case Lord Carter work programme Shared Services benchmarking reducing back office costs Revised agency rules Further Procurement opportunities The Trust is currently working on 2015/16 Patient Level Information Costing System (PLICS) data to verify the opportunity identified in the Lord Carter productivity work as this was based on 2014/15 data, which included a part year income and costs relating to the County Hospital integration. Risks The main risks to the achievement of the 29.6m planned deficit in 2016/17 are: Delivery of national performance and quality targets below the planned performance trajectories. Local authorities fail to contract for sufficient domiciliary care from July Any in year consequence from the agreement of the health economy Sustainability Transformation Plan, which is still in development. Delivery of the CIP target, currently only 1m of the 38m planned savings, has been categorised as fully identified developed having gone through the QIA process. Delivery of CQUIN below the planned level. Recruitment and retention of the Trust s workforce, particularly relating to the medical workforce, and the nursing workforce in theatres and critical care. That the deficit support and integration funding will not be received in full in 2016/17. Opportunities The plan excludes a number of opportunities that are being progressed: Capital to revenue transfers as a result of the asset valuation increases. Local authorities contribute to domiciliary care costs in Q1. Ambulatory Emergency Care tariff agreed at a higher rate than planned. Achievement of national performance and quality targets better than planned trajectories. Capital The Trust s 166m capital programme over five years (from 2016/17) is based on the assumption that it will be funded by: 116m - depreciation on Trust funded assets 27m - new Public Dividend Capital (agreed in the Acquisition and the Contingency Business Cases) 22m - PFI additions 3m - donated assets 19

20 The 2016/17 Capital Plan assumes 23m of PDC capital funding. The table below shows the IHSS funding and reflects the 3.5m agreed slippage related to the ward refurbishment programme at County Hospital into 2017/18. IHSS PDC funded Capital Funding Funding ' /15 22, /16 33, /17 23, /18 3,500 Total 83,200 The capital plan from internally generated funds had been prioritised to deliver essential capital replacements to ensure delivery of safe care and support productivity developments. As a result of additional deprecation being generated due to the asset revaluation the Trust Board has requested a review of the capital programme and to work with NHS Improvement to investigate any capital to revenue opportunities. Cash implications The annual plan includes a requirement for PDC Capital funding of 23m for the IHSS work stream. The financial plan also requires additional revenue cash support of 38m to cover the Income and Expenditure deficit of 29.6m and for the repayment of the PFI borrowings. The plan includes the interest repayment on the Interim Revenue Support Facility (Loan) received in 2015/16 and forecast as required in 2016/ Link to emerging Sustainability and Transformation Plan (STP) The Trust is a full participant in the local health economy s sustainability and transformation plan. In Staffordshire there has been a Staffordshire Sustainability Review Programme Office since mid-2015 which is defining the case for change, spelling out the options for implementing this case and then carrying out the necessary consultation as required to put the preferred option into action. Our understanding is that this has the same footprint as for the STP. The Trust s work on an integrated business plan (IBP), which is referenced throughout this return, forms a key element in this and elements of the IBP such as the activity schedules and the assumptions underpinning these have been shared with the programme office and the constituency CCGs. The Trust is currently a leading participant in the work streams to plan specialist services, planned care and estate, IT and back office efficiencies. In addition to taking a leading role in these groups, the Trust is also a key participant in the unplanned care working groups. More details of progress on this work can be obtained from the SSR Programme Office or via NHS England. 20