OPERATIONAL PLAN 2016/17

Transcription

1 1. Operational Context OPERATIONAL PLAN 2016/17 University Hospital Southampton NHS Foundation Trust (UHS) provides high quality, innovative care to more than 1.9 million people living in Southampton and South Hampshire. The Trust provides nationally renowned specialist services such as neurosciences, cardiac services and children s services to more than 3.5 million people in central and southern England and the Channel Islands. It has a workforce of over 10,500 and a turnover of almost 700m. The Trust is a major academic centre for teaching and research and enjoys strong relationships with the University of Southampton and a number of national institutions. The NHS continues to work within a financially challenging economy with a predicted 20bn national affordability gap, this requires new ways of working to deliver affordable services that meet patient need and quality. The Autumn Spending Review settlement has committed 8.4bn investment into the NHS, over the life of the Parliament, to support the Five Year Forward View and help re-stabilise the provider sector. The funding is significantly front loaded into 2016/17 and the 20bn efficiency gap still remains. For 2016/17 provider plans are to include actions to deliver: The 9 Must do s (see appendix 1) Further improvements in efficiency which are recognised as requiring system-wide change via collaboration rather than continue mainly at organisational level The expected tariff arrangements (whereby the specialist tariff changes implemented in 2016/17 have been suspended) Deployment of the Sustainability & Transformation Fund (STF) to support the delivery of an aggregate financial balance nationally 2. Approach to activity planning Baseline growth alignment The first step of the Operational Plan process for 2016/17 was the submission of activity and financial baselines from Providers and Commissioners on the 26 January This gave an opening position for each organisation. Since this time contract negotiations have taken place but have not yet been concluded with all commissioners. At this stage of the planning and contractual process the Trust has reached agreement with Southampton City Clinical Commissioning Group (SCCCG), West Hampshire Clinical Commissioning Group (WHCCG) and all associates on a contract baseline and QIPP expectations. However, the Trust received the first financial offer from Specialist Commissioning on the 29th March which was substantially below expectations, indeed substantially below the 15/16 outturn. The offer is based on QIPP schemes which represent 10% of the contract value for which no firm plans have been received. The Trust has rejected this offer and remains in negotiations with the specialist commissioners. If a reasonable agreement can t be reached the Trust will work through the arbitration process as per the national guidance. 1

2 All contracts are cost and volume contracts using the Payment by Results tariff. Nationally, via the NHS Call to Action the following activity growth assumptions have been shared locally: Demographic 2016/ / / / /21 Southampton 1.5% 1.5% 1.0% 1.2% 1.1% West Hampshire 1.1% 1.3% 1.6% 1.6% 1.6% Specialised 1.6% 1.7% 1.7% 1.7% 1.6% Non Demographic Acute 0.5% 0.3% 0.3% 0.3% 0.3% Specialised 3.4% 3.2% 3.2% 3.3% 3.3% In 2015 the South West Hampshire health system tasked Deloitte to create a SW Hampshire system capacity plan and for the base case used the above. This model will support discussions and planning for the Five Year Sustainability & Transformation Plan (STP). The Trust has seen growth in emergency activity of 2.8% when compared to the same period (M11) last year. Underlying the emergency rate is an 7.8% increase in Specialist Commissioning emergency activity. At the end of month 11 elective activity is broadly similar to the position last year. Currently the Trust is prudently planning on 1.7% income growth, including the full year effect of 2015/16 (excluding IPPPDs) and forecast population/non-population growth. Specific service developments will be included as they are agreed with commissioners Demand & Capacity Planning Whilst the overall rate of growth has declined, the acuity of patients has been increasing due to nationally recognised drivers including an older population, long-term conditions and emergency demand. These factors impact on the capacity needs of the Trust. The Trust recognises balancing the flow of demand with capacity, together with acuity changes, is fundamental to delivering high quality safe services together with excellent patient experience and performance. The Trust has been reconfiguring services to reflect the principles laid out in the 5yr Forward View. On any given day, 42 patients are cared for in the virtual ward and in addition support is given to patients on home ventilation, chemotherapy at home, complex feeds at home and patients who need respiratory care. This principle of Hospital without Walls is also applied to the outpatient settings with an increase in the number of patients supported by telephone based or internet based outpatient interactions. The Trust has invested significantly in capacity to build the infrastructure required to provide complex specialist services and care for our local population. The Trust recently invested in a significant number of additional beds, including critical care beds, however it has also seen increased complex delayed discharges impact capacity (c. average 100 formal sitreps). Managing the reduction in complex delayed discharges is a key priority for the Trust and one of the top 10 KPIs. Part of this demand could be eased with increased nursing home capacity or alternative models of step down care. Local CCGs have prioritised Better Care Fund investment on plans supporting independent living in order for patients to stay at home. However, the rise in elderly population also means demand is increasing. To improve capacity the Trust has successfully implemented healthcare at home (circa 42 bed equivalents), implemented pathway changes and is working with partners via the System Resilience Group. The Trust is a partner on the SW Hampshire Estate Strategy Group reviewing system assets to improve utilisation and rationalisation. The Trust will continue to rely on outsourcing some elective work (circa 15 bed equivalents) to the private sector to maintain a capacity balance 2

3 but aims to repatriate this as soon as capacity is available to improve efficiency, provide care directly to patients and patient choice. Nationally there are expectations of significant shifts of activity moving from acute care into primary and community settings. We support this wherever feasible but this may be relevant for more standard District General Hospitals work but does not necessarily reflect the position of a large specialist (teaching) centre such as UHS. There is also an Independent Treatment Centre in Southampton City which had a significant volume of low complexity work transfer from the Trust when it was opened. The Trust remains committed to delivering high quality specialist care and anticipates further regionalisation, re-designation of units and market shifts eg Neonates, Dorset Clinical Review and Hampshire Hospitals Foundation Trust strategic plans. The reconfiguration of vascular services is being planned for 2016/17. The delay in HRG4+ tariff is likely to be detrimental to the Trust as it should more fairly represent the acuity and specialist breadth of care that is significant for specialist centres to be financially viable. During 2016/17 it will be necessary to manage a programme of bed closures to allow a refurbishment programme. This will need to be managed within the current bed footprint and the financial plan incorporates the impact of the bed closures necessary to enable the refurbishment. The Trust has a managed equipment service for diagnostics which ensures kit is replaced and updated with the latest technologies. This will improve patient care and deliver efficiencies. In 2016 the Trust will build a new bunker to start the Linac Replacement Programme for the Cancer Centre. This is essential for the future of the Trust as the current equipment is all over 10 years old and subject to regular failure and breakdown. The Trust has 34 theatres and continually seeks to optimise the capacity by increased productivity as well as some Saturday working. Again this is an ageing estate and theatre refurbishment will be necessary during 16/17. In the longer term the Trust aspires to build a new elective centre. While a business case is being developed, the Trust plans to create a small minor operations suite to relieve pressure on main theatres as well as decant space to enable modernisations of estate. The Trust s ageing estate was raised by the CQC when they visited in In particular, concerns were raised about the general intensive care unit, which is in estate circa 40 years old and does not meet current HBN Standards. A business case has been developed and the principle of increased tariff costs to support this development has been discussed. Similar cases need to be developed for Neo-natal and Neurosurgical ICU. A charitable investment will support an expansion of two Paediatric Intensive Care beds. For the detail of the 2016/17 capital plan, see section 5 Capital Planning. Performance The Trust is committed to improving the delivery of core access and Constitutional standards set out in the NHS Mandate, which are also part of the 9 must do s. Subject to the caveats set out in section 5 the Trust expects to deliver the RTT 18 week target and all cancer targets (62 day, 31 day and 2ww) in Q3 and Q4 working towards this in Q1 and Q2. This will build on the strong performance in 15/16. The pressures to meet 95% for 4 hour wait in ED are expected to continue. The Trust plans to deliver improvement in the ED performance building on the improved performance in 15/16. There are a number of challenges to the delivery of this target; this is also set out further in section 5: 3

4 UHS is a major trauma centre serving complex (and often multiple) patients through resuscitation, Regular diverts from other hospitals linked to capacity A high level of bed occupancy in the hospital (driven in part by continued high levels of Hampshire DTOCs) A low proportion of minors attendances in the case mix (which are easier to manage within 4 hours) than our peers, and the successful efforts that UHS and partners have made to divert patients away from the ED, whether to the separate MIU or directly to the Acute Medical, Surgical or Oncology Assessment Units. Psychiatric emergency ED attendances are a very high risk patient group, and currently we are not achieving parity of esteem as the proportion of these patients achieving the 4 hour target is substantially lower than the proportion of patients with physical ill-health. The Trust is working with our local mental health provider and commissioners to improve services for this group of patients. Therefore, the forecast below is challenging but realistic and sets a clear improvement trajectory. This trajectory has been shared and agreed with the local commissioners. The Trust is continuing to develop a recovery plan with commissioners. This will include actions that are solely the responsibility of UHS to deliver and actions that are system wide. Quarter Proposed Performance Approximate Year-on-Year Change Q1 91.1% +0% Q2 91.6% +1.3% Q3 90.5% +2.6% Q4 87.4% +3% The supporting Finance & Activity Template has a monthly forecast of the Top 10 KPIs including performance. 3. Approach to quality planning Approach to quality improvement Always Improving is embedded as one of the values in our Forward Vision along with Patients First and Working Together. These are the underpinning values and delivering on quality is the responsibility of Trust Board. The named Executive leads for quality are the Medical Director and the Director of Nursing and Organisational Development. In 2016 UHS are developing a Quality Improvement Strategy, a strand of our wider strategy for organisational development. The executive team have visited leading centres for quality improvement in the UK, e.g. Salford Royal, and have commissioned a national expert to support our strategy development. We already have significant quality improvement activity at UHS, including a training programme and series of projects which will be aligned through this process. 4

5 Quality Improvement is just one element of a co-ordinated and organisation wide approach to quality. Each year the Trust defines our quality improvement priorities through the development of a Trust wide Patient Improvement Framework (PIF) with priorities set against outcomes, safety, experience and performance. We consult and agree on these priorities with our staff, our patients and key stakeholders and agree the measures against which we will monitor the improvement. Progress is monitored monthly through our Key Performance Indicator report with alternate quarterly progress reports to the Board. Each of the PIF domains are underpinned by strategies on safety, experience and quality which set out our longer term aims. The results of our priorities are also published in the Trust s Quality Account. In addition to the above and to embed the qualities at ward and department level the Trust has introduced a Clinical Accreditation Scheme where wards and departments demonstrate their standards of care and the improvements they have made on an annual basis. The process for wards gaining this accreditation is through the submission of information on the key performance indicators, patient complaints and compliments to a senior clinical panel with patient representatives who also undertake an unannounced visit of the ward. Wards attaining accreditation are awarded with a certificate, which is presented to them by the Director of Nursing. This year the Patient Improvement Framework has been modified to reflect the CQC domains of well-led, safe, effective, responsive and caring. Improving responsiveness focusing on home before lunch and the emergency access pathway are priorities. The Trust Patient Improvement Framework is shown below. The Trust values outlined in our Forward Vision support the organisation being well-led at every level. An organisational development model is being developed for 2016/17, to support the implementation of the vision and move to a future organisational state of excellence. This will encompass having the right culture and behaviours, innovation and people development. As a Board, visibility is vital to role model behaviour but also to listen and respond to frontline staff. This is achieved through regular Board and Executive walkabouts. The Board also receive regular presentations from the Divisions on their quality, performance, successes and challenges. 5

6 At the last CQC inspection, which took place in December 2014, the Trust was judged as Requires Improvement, although it was acknowledged by the CQC that the Trust was well led and that staff were resoundingly felt to be caring and compassionate. Since the inspection we have been monitoring and implementing a plan of action developed from the recommendations made by the CQC. In October 2015 Monitor and the CQC held a risk summit with our key stakeholders. Good progress was noted against the plan, with no concerns raised and it was agreed that the Trust was open and transparent in its management and oversight of quality and challenges. The outstanding actions are primarily around estates, which have been agreed through the capital planning process, together with an improvement to the environment in General ICU where we are seeking an uplift in tariff from our Commissioners to support this going forward. The Trust is now working towards achieving a good or outstanding rating for the next inspection through assessment and monitoring against the CQC Key Lines of Enquiry, Executive walkabouts, internal reviews and ensuring that we communicate to frontline staff all the actions that have been undertaken. The inspections are based on the Keogh and CQC reviews and have been undertaken in all Divisions. This year Divisions proposed areas where they wanted the reviews to be undertaken and, reviews will have been undertaken in dermatology, radiology, end of life care and the pathway of care for patients with a learning disability. The Trust s quality improvement governance systems are through the Divisional structure from Care Group governance groups reporting into Divisional Governance Groups, reporting into the Trust Quality Governance Steering Group (QGSG) which reports into the Trust Executive Committee and ultimately to Trust Board. There are number of other sub groups and feeder groups of QGSG, which are the Patient Safety Steering Group, the Patient Experience Group, Corporate Health and Safety Committee, Infection Prevention and Control Committee, Vulnerable Adults Steering Group, Clinical Effectiveness and Outcomes Steering Group, Education and Strategy Committee and Children Safeguarding Committee. This infrastructure ensures that the Trust Board has the appropriate oversight of its governance and quality improvement arrangements A further sub-committee of the Board is the Quality and Performance Committee with membership from the Non-Executive and Executive Directors of the Board. The purpose of this committee is to provide robust challenge and scrutiny to both operational and quality performance in further detail and on behalf of the Board. The Trust has an established Internal Medical Examiner Process. This has reviewed 91% of all adult deaths over the last eighteen months and is now reviewing 100% (previously deaths in the NHS Hospice were not subject to review). We have completed the national NHS self-assessment questionnaire and are pleased that this indicates that we are already identifying the expected proportion of deaths with avoidable factors. The Trust has a Mortality Board aligned with the best practice guidelines forwarded by Monitor. The Trust has processes and assurance that we are identifying avoidable mortality and will be able to publish this data. The top three risks to quality identified are: - Failure to deliver the 4 hour ED target, which affects both patient experience and safety. There is a recovery action plan in place formally reviewed by our Commissioners. The main focus for 2016/17 is working with partners to reduce delayed transfers in care, improving the numbers of discharges that occur before midday and improving processes for emergency patients between the Emergency Department and inpatient teams Capacity and Occupancy, which impacts on patient flow and timeliness of care. Increased risk in 16/17 through unplanned transfers in service from other local providers and support for 6

7 emergency flows. The Trust has mitigated this by minimising the bed closures refurbishment programme, focusing on 7 day service, improving patient flow e.g. home before lunch, developing a hospital without walls, investing in a capital programme to improve capacity (surgical robot, hybrid theatres and minor ops rooms) and reducing length of stay. Staffing, plans are in place for both recruitment and retention. To mitigate this risk we will continue to recruit from overseas, work with universities to increase student nurses, develop band 4 posts and apprentices, a new brand think UHS, enhance overseas fellows posts, review all junior rotas in light of the new contract, use flexible and temporary staff when needed, create different roles linked to our research agenda and review training and education to enhance retention. The Trust was one of the first of 20 in signing up to safety in January Our safety priorities are outlined in the Safety Strategy and include a 20% reduction in falls and pressure ulcers, recognition and management of Acute Kidney Injury, recognition of sepsis and delivery of antibiotics within an hour and improving CTG monitoring. The Trust was successful in being awarded funding following a bid to the NHSLA and sign up to safety on improving CTG monitoring. Implementing our Forward vision The Trust has invested in developing professional quality improvement skills and capacity across the organisation for a number of years. There is a formal four day training programme in quality improvement techniques and have hosted a number of quality improvement fellows for Health Education Wessex. Training provides staff with a range of recognised tools and techniques they can apply in appropriate context. As well as training our own staff we sell training to partner providers across Wessex. In our recent staff survey The Trust has scored in the upper quartile for staff reporting engagement in change and improvement. In 2016 we will publish our first organisation wide Quality Improvement Strategy. We have a board overseeing the process including the Medical Director and the Director of Nursing and OD and the Director of Transformation. We also have a clinical reference group guiding the process. Quality impact assessment process Ownership of the Cost Improvement Programme (CIP) at ward and department level is the key to success with clinical input from the very outset. This helps to ensure quality/safety considerations are taken account of before CIPs are agreed. We also have a local Divisional review processes which should deal with quality/safety issues in any schemes that are still of concern. Combined with delegated responsibility we have a system of tight central controls to ensure consistent and robust governance of the overall process. We operate an annual cycle of scheme identification, development and delivery. In the second quarter of the year the Medical and Nursing Director will review the entire CIP programme when we conduct a dedicated quality review with each Division. We conduct a second review later in the year to ensure CIP schemes have not had a quality impact. Major schemes are subject to a formal written review and sign off process as described in published CIP rules. In addition to the annual cycle there is an on-going process of challenge and review. Members of the Executive Team meet the Divisions on a monthly basis to review their progress with CIP. Corporate quality monitoring and metrics are also in place to assure cost improvement doesn t negatively impact on quality, for example the monthly staff status reviews and risk registers. 7

8 Triangulation of indicators The Trust has an Integrated KPI Report, which the Board monitors, that includes the key KPIs. This includes quality, performance and financial KPIs. The Trust has also completed the supporting Financial Templates for this plan which triangulates the corporate planning of the organisation. Please refer to the KPI section of the Finance & Activity Schedules. In parallel the Trust works with partners to triangulate assumptions and also negotiate contracts. 4. Approach to workforce planning Planning the workforce The Trust s approach to workforce planning has been refreshed this year to include initial strategic discussions with Divisional Management teams. It is an iterative process, with ideas and solutions from the Care Groups and Divisions that align with their service and activity plans, feeding into the final plan. Facilitated meetings with each Division have reviewed historic trends, demographic data and initial forecasts and using a mind map encouraged debate and discussion of the many schemes. Key members of divisional management teams together with HR Business Partners, Training and Development Leads, Directors of Medical Education and Strategy & Business Development Managers were engaged with the process. Further follow-up in the Specialties is planned, and will involve medical and non-medical clinicians to develop detailed plans. The 5 year forecast will be presented to TEC prior to submission to the Trust Board for approval. Key workforce planning themes The Trust is in the early stages of plans in response to the Five Year Forward View. However, as new workforce initiatives are agreed with partners it will see an evolving workforce to be fit for purpose for new models of care and a modern health service. The proposed changes to the bursary system and the removal of the caps for nursing and AHP undergraduate students creates both opportunities and threats to the supply of students and ultimately qualified staff to the trust in these professional groups. The Trust is already working closely with both existing and potentially new HEI partners to review the impact and capitalise on the opportunity to increase the programmes available, and the supply of nurses in both adult and child fields. A particular focus is the maintenance of the widening participation agenda and ensuring mature entrants are maintained by further linking the existing apprenticeship pathways into undergraduate training. This will require continued work with community partners and HEEW to maximise the available placement capacity to manage any increase in the numbers of students. The Trust s substantive workforce will continue to grow in 2016/17 with recruitment plans for additional consultants, nurses and other clinical staff aligned to initiatives, including: 8

9 A small increase in ITU beds Increased acuity and dependency of patients in hospital Filling nurse vacancies and reducing dependence on agency workers Further potential growth from other tertiary work Further extension of seven day working, including an evening ward clerk service A small number of extra beds Delivery of the patient improvement framework, including; o referral time to treatment (RTT) and all cancer waiting times for patients o Changes to patient pathways o Early supported discharge building on new model implemented in 2015/16 o Enhance medication safety for in-patients and those preparing for discharge and invested in the team to improve patient flow especially on the day of discharge o An improvement in performance against the four hour standard in the Emergency Department: In particular the Trust has invested in improvements in the Acute Oncology Service to extend the hours and reduce pressure on ED, created a new team to manage frailty in a younger cohort of patients to reduce length of stay, 7 day working for Pharmacy and made permanent the funding available to support more consultant presence at night and at weekends and the nursing pitstop model. An increasing range of services, including acute oncology and acute surgery have nurse specialists and doctors working together. In other settings and for patients with long-term conditions we will equip staff to train patients to do their own interventions/care e.g. line flushing. All our tertiary services are developing multiprofessional teams with advanced skills. In children s services there will be a focus on rehabilitation and re-ablement. The Trust provides complex tertiary highly specialised care but will outreach into Community Services. Continuing development of expanded roles in nursing, AHPs and pharmacists for case management and support to junior doctors including prescribing, will continue in 2016/17. Further refinement of the major trauma service will see changes to the workforce as we recruit or train multi skilled staff for the multi-trauma ward. Changes to spinal, stroke and plastic surgery services will particularly impact on the medical workforce with cross-organisation working to enable centralisation of highly specialised care across the network. Seven day working The Trust already performs well in this area and has been identified as a national leader. We regularly review our mortality rates using Dr Foster HSMR and both weeks and weekends are within the expected range. All Divisions have now reviewed themselves for compliance against the clinical standards published by Sir Bruce Keogh. Specific plans for 2016/17 include: Further review of physician input to frail elderly patients in surgical beds Hospital at night team needs to be more consistent across the Trust to improve the timely identification and care of the deteriorating patient Expansion over seven days of imaging services, pharmacy and therapy services, but these will be subject to investment decisions Some increase in ward clerk cover during evenings & weekends 9

10 Deployment of staff HealthRoster, an e-rostering tool, is in use for all AfC staff. It is the primary source of management information for safe staffing, staff utilisation and absence reports. Work will continue to embed and maximise the functionality of the system in managing the staffing resource trust wide. One Division utilises the electronic interface with our managed bank provider, NHSP, and is piloting the use of SafeCare, a module that enables patient acuity data to be recorded and compared with planned and actual staff on duty. In line with the recommendations from the Carter review, SafeCare also records and reports Care Hours per Patient Day (CHPPD) in real time and will enable the Trust to effectively review this aspect of staff utilisation. Roll out to all ward areas is prioritised for 2016/17. A monthly report is provided to the Trust Executive Committee on vacancies in ward-based nursing, midwifery, medical, AHP and theatre staff. Quarterly divisional workforce meetings, jointly led by the Director of Nursing and Associate Director of HR, are in place to regularly review and address workforce hot spots, including a review of vacancy trajectories and recruitment pipelines. Incident reports that involve staff are reviewed alongside this data by the Nursing and Midwifery Staffing Review Group and Strategic Workforce Group. Staff Development Systems are in place to ensure staff are registered and/or licensed to practice where this is mandated. Staff are required to have the appropriate skills, education and experience for the roles they provide. All staff are required to do mandatory training and continued professional development, to ensure they are appropriately trained and have ongoing development plans. Training targets will also ensure all staff will meet the regulatory requirements expected by the Trust. The Trust s approach to management and leadership development is being reviewed during 2016/17. Joint work to enhance appraisal, talent management, personal development plans and succession planning is ongoing. Temporary and permanent resourcing The Trust is building on the success of its 2015/16 recruitment strategy for non-training grade doctors and is working in partnership with other organisations and recruiting overseas, looking at options to extend to more specialties. The proposed new contract for Doctors in Training presents some risks as we are unclear on the impact of fill-rates for August, which could further impact on existing vacancy rates in some junior and middle grade rotas. There are 344 WTE (16.4%) ward-based Registered nurse vacancies. In 2016/17 the Trust will continue with its successful programmes for international recruitment to reduce registered nurse and theatre staff vacancies, and run local programmes to attract health care assistants and nurses, to reduce reliance on temporary staff. Reductions in spend on non-framework agency staff was achieved in 2015/16, and we will continue to focus on further improvements during 2016/17. Turnover is a key issue for the Trust and trends are regularly reported. Overall turnover rate for all staff excluding junior doctors rose to 13.3%, during 2015/16 and we are seeking to reverse this. The Workforce Project Management Office (PMO), established in 2015, is working with Divisions to use improved turnover 10

11 information and exit survey data, and a retention helpline has been established for staff who are considering leaving. Productivity Increasing productivity is core to the UHS cost improvement programme, a consequence of year on year growth in activity. A focus on improving booking processes and reducing DNAs in the outpatient departments has delivered a substantial gain in each of the last two years, from 9.5% in 2014 to below 8% in 2016 (rolling 12 month average). A similar focus on improving surgical flow and theatre productivity by improving booking processes, start times and turn-around times has allowed us to deliver an increase in operating time of 2%. Productivity improvement is supported by the UHS Transformation Team and Performance teams through the publication of productivity information and direct project support. The Trust will review the recommendations in the Lord Carter Review and Model Hospital data and respond accordingly, e.g. targets to cap total management and administrative spend. The Trust also has a continuous improvement culture to drive productivity and had focused initiatives on theatres and outpatients as examples. Currently the Transformation team have reviewed outpatient bookings and system in order to release unbooked clinics for Trust-wide utilisation to optimise capacity and throughput. Agency The Trust has made significant progress in achieving compliance with NHS Improvement s agency rules. The use of non-framework agencies has reduced from 770 (Sep 15) to 62 shifts per month (Dec 15) and nonframework agencies are only used when other bank, framework agency options have been exhausted but failed to provide staff. For the on-framework agencies, we have requested their rates to be reduced in line with the revised 1 April 2016 limits however early feedback in the first week of April is that several agencies are refusing to lower their prices either at all, or sufficiently, to be compliant with the new rates. Again, we are prioritising the use of bank and rate-compliant framework agencies and only using non-rate compliant agencies in exceptional patient safety situations. We therefore expect to incur some agency costs above the new limits in year 2016/17 but are committed to minimise, and then eliminate, these exceptions as soon as possible. The Trust has very detailed plans to monitor and control the use of agencies. For example, senior nurses will minimise breaches in ward-based areas by careful review of rosters and the continued operation of the 'Golden Key' for bookings made to high-cost agencies. The Trust will design and develop our long term approach to temporary agency spend for Medical locums, AHP and A&C staff. This may include growing our internal bank. Apprenticeships In line with the expected changes to the national apprenticeship targets for the public sector (currently in consultation), the Trust plans to double the number of apprenticeships in 2016/17. This includes plans for therapy assistants, more ward-based opportunities, administrative staff and opportunities to offer apprenticeships in occupations within our Trust headquarters. We will work with local schools, colleges and Universities to market opportunities for career progression and educational opportunities to attract young people to the Trust with a clear career path. There are plans to increase the number of Band 4 practitioners and this will include working with local colleges to support students completing the advanced BTEC in health and social care to progress into the Higher Apprenticeship/Foundation Degree in Health and Social Care at Southampton Solent University. During 2016/17 the Trust will plan for the introduction of the new Health Trailblazer apprenticeships at all levels so that we are able to offer these once they are available. We will also plan for the introduction and 11

12 impact of the Apprenticeship Levy and Digital Apprenticeship Voucher system that is expected to be in place by April Engaging and motivating the workforce Staff Engagement During 2016 the Trust will respond to results of the 2015 National Staff Survey. It will focus on areas of required improvement identified by staff and work with Divisional partners to put in place plans to respond. The Trust aims to continue to be ranked in the top 20% for staff engagement in the NHS. Information identified in the staff survey will be used to continue to develop staff retention and recruitment programmes. Health and Wellbeing The Trust has been selected as a national pilot site for the NHE England (Simon Stevens) Healthy workforce project. THE TRUST will pilot a number of health and wellbeing initiatives aimed at staff with the hope of reducing sickness absence and also increasing engagement. The CEO, supported by HR and Occupational Health, will lead a local wellbeing group with key stakeholders from across the Trust to implement the project. Partnership Working Working closely with the trade unions is at the heart of our workforce values at the Trust and to deliver local changes including our corporate workforce priorities. The Trust ensure that Trade Union representatives are part of all major strategic workforce/hr groups to ensure a staff side voice to our planning and implementation will be a year of unprecedented change for medical staff contracts with the planned implementation of a revised contract for consultants and the new Junior Doctor terms and conditions. Despite the significant challenges nationally to these contracts, the Trust has continued to work extremely closely with its local BMA members to ensure disruption to services is minimised during periods of national industrial action. Once the final details of the contracts are agreed nationally, the Trust will work closely with staff-side representatives to implement the new contract. The Trust meets regularly with the Wessex office of Health Education England and actively contributed to their consultation about education commissions in the 2015/16 planning round, which concluded with increased undergraduate commissions, particularly for Registered Nurses. Discussions have started about the impact on changes to bursary schemes for nursing and AHP graduate programmes. The Trust aims to maximise new qualifier recruitment in all professions, and works with higher education institutions and local colleges to achieve this. The Trust works closely with NHSP, our managed bank provider, and Allocate software to ensure we optimise use of systems to support workforce decisions. Equality and Diversity Driving a culture of equality, diversity and inclusion is key the Trust. A strategy has been set out to address important areas of our workforce composition. This includes schemes to try to increase the diversity of our job applicants, particularly for more senior roles in the Trust. The Trust is mandated to publish annual data under the national Workforce Race Equality Standard (WRES) which focuses on aspects such as recruitment and selection. The Trusts Equality and Diversity Steering group oversees the delivery of these plans. The Trust will also continue to work closely with its Network groups who each are focused on a protected Characteristic (Race, Religion, Sexual orientation). 12

13 5. Approach to financial planning Financial forecasts and modelling University Hospital Southampton expects 2016/17 to be another challenging year given the underlying deficit carried forward from 2015/16 and anticipated cost pressures in excess of income for the coming year. Despite this pressure the Board is committed in principle to accept the Sustainability and Transformation fund (S&T) offer. However, there are several limiting factors which will affect the Trust s ability to deliver the conditions associated with the S&T funding, some of which are partly or wholly beyond control of the Trust. We therefore accept the S&T funding on the following conditions: Demand Demand for emergency and elective care is within normal expected levels There are similar levels of referrals to previous years There are no significant reductions in services from other providers (e.g. spinal services, Lymington services, ISTC) either through termination of contracts or operational difficulties at these providers Capacity There is an available workforce with no further industrial action There is minimal knock on from other neighbouring Trusts either requesting diverts of emergency patients or not being able to repatriate patients following initial treatment. Partners across the health and social care community deliver the agreed 26 complex discharges per day, including during school holiday periods Health partners deliver to national standards (e.g. Alliance PET CT contract) Emergency psychiatric care is available as per national standards (24/7) Finances There is a reasonable settlement of the NHSE contract that does not significantly impact on planned Income and Expenditure or on cash flow. The final cost of the new junior doctor s contract is within expected levels. The detail of how the S&T funding will be paid and the value of the capital control total has not been issued. We assume that the S&T funding will be paid in full or that any deduction for failure to achieve targets / conditions will be proportionate to the impact of the failure. The Trust s capital expenditure programme, developed to deliver the capacity needed to be compliant with access standards and patient demand, will be allowable in any capital control total imposed in the future New Rules The new counting rules in place for RTT and Cancer do not significantly impact on performance, in particular patients being able to choose to wait for longer, and the new cancer breach sharing rules. The offer of external support from the (S&T) fund of 17.4m with a control total of a surplus of 16.2m contributes 1.2m towards the underlying deficit and, in conjunction with estimated pressures on income and expenditure, equates to a CIP requirement of 29m. The delivery of another year of a challenging CIP target of circa 4% of the cost base will be the major risk to delivering the financial plan. The Capital Programme for 2016/17 has been partially prioritised and there are a number of schemes that are critical to the ongoing safety, compliance and sustainability of clinical services. There is a high value of schemes funded from external sources such as the national NHS IT fund and commercial agreements with private sector 13

14 organisations to the value of 9m, which when added to internal funding of circa 17m results in a capital programme of 26m for 2016/17. Although the S&T funding will only improve the Trust s underlying deficit by 1.2m, it will provide additional cash of 17.4m which despite an increased capital expenditure programme will improve the liquidity position and results in a FSRR of 3 by year-end. This comprises ratings of 3 on capital service cover, 4 on I&E margin and 3 on I&E variance, with a rating of 2 on liquidity. Underlying financial position Although the Trust is has delivered ahead of the 2015/16 planned deficit of 9.8m, it comprises a higher net deficit pre impairments and donations offset by lower exceptional costs and donations plus reliance on nonrecurrent CIPs which results in a net pressure of 22.9m flowing into 2016/17 as the opening underlying deficit. Income Our draft plan assumes the basis for clinical income plans is 2015/16 outturn with the anticipation of the full year effect of developments commenced part way through the year. The Trust has assumed the 2016/17 tariff uplift of 3.4% (including CNST uplift) less the tariff deflator of 2% and no marginal rate for specialised services will be the basis for payment. No allowance has been made for any changes in the business rules for CQUIN. Discussions with commissioners are ongoing and the Trust expects to reach contractual agreement with its two largest local CCGs. Discussions with NHS England in respect of specialist services however, represents a considerable financial gap. Points of disagreement currently include the approach size and risk to CQUIN, the material expectation of QIPP with very little detail behind how demand will be managed and the arrangements surrounding centrally procured devices. The Trust has assumed a conservative level of growth in activity of circa 1.7% (excluding high cost pass through drugs which are assumed at 10%) which is at the low end of recent trends. The Trust anticipates that commissioners will fund this at tariff levels. Specific service developments will be included once agreed with Commissioners. No allowance has been made in the draft plan for any impact for centrally procuring devices which ordinarily would not be a risk given that the costs are passed through to commissioners. However there is a number of non-pass-through devices where current contract prices are linked to pass-through devices and may increase with the proposed centralised procurement by NHS England. This risk is not reflected in the current plan. Education and Training income assumes a 3.6m reduction relating to a further 1.3m reduction in line with the national transition, removal of both the 0.8m non recurrent funding and it s repayment in 2015/16 and a reduction in leadership income of 0.7m. Costs The underlying basis for the expenditure plan is the full year effect of costs required to deliver the 2015/16 activity less non recurrent items and after the addition of the full year effect of cost base changes. 14

15 To this cost base the following has been provided in the plan: Pay awards (including A4C pay progression) An estimate of the junior doctors new pay deal National insurance increases relating to changes in pensions Consultant incremental drift and local Clinical Excellence awards Increased costs for the CNST contributions Non pay inflation expectations Capital indexation Increased interest and depreciation charges Cost of delivering the growth in activity Capital planning A capital control total of circa 17m is the current internal planning assumption. This is an increase compared to recent years but recognises that there has been a significant level of slippage in the 2015/16 programme from delays on the building of a linear accelerator bunker. In addition there is a high value of schemes funded from external sources to the value of 9m. The combination of the internally and externally funding sources results in a capital programme of 26m for 2016/17. Cash A cash flow forecast has been prepared with an opening cash position of 21.8m forecasting to reduce to 19.2m by the end of 2016/17, assuming receipt of the 17.4m S&T funding. The 15m working capital facility is still in place but the plan does not anticipate any draw down is necessary in 2016/17. FSRR The financial plan (assuming the S&T funding of 17.4m) will generate an FSRR of 3 by year-end (Q1 2 ; Q2 2 ; Q3 3 ; Q4 3 ). The year-end FSRR comprises ratings of 4 on I&E margin and variance, with a rating of 3 on capital service cover and I&E margin and a 2 on liquidity. With the performance conditions attached to the S&T funding delivering this Plan will be challenging. Failure on one quarter s performance would result in a loss of 4.4m which would be sufficient to reduce I&E variance to a 3, still leaving the Trust at a 4. Key challenges and Risks Delivery of the CIP programme is a significant risk to achievement of this plan. Whilst track record is good, this continued level of efficiency is increasingly challenging. This is seen from the shortfall in delivery for 2015/16 and the increasing reliance on non-recurrent schemes. Income assumptions, whilst modest compared to recent years may prove to be challenging for commissioners unless wider health economy solutions to ease capacity and patient flow pressures succeed. Failure to deliver improvements system wide may also further impact on the Trusts elective activity and reduce the contribution on those services. Sensitivity Analysis The Trust has assessed the potential downside risks not included in the base plan. These factors include: 15

16 The risk of partial non-delivery of the 2016/17 CIP plan based on the track record of delivery and reliance on income growth ( 2m) Delayed transfers of care worsen and impact on income and margin ( 1m) Commissioners increase their challenges on business rules which impacts on clinical income ( 5m) Risk over meeting the conditions in order to receive the full S&T funding. Given the uncertainties of the final detail of these conditions, the Trust has assumed a likelihood of 0% at this stage The Trust has considered the following mitigations in reaction to the downside risks identified above: Minimise investment assumed in the plan If demand falls repatriate sub contracted activity back in house Further management overhead reductions Efficiency savings for 2016/17 The Trust has a long established approach to cost improvement which has delivered excellent results, 90%+ of our target, for over 5 years. In 2015/16 we will deliver approximately 31m CIP, 94% of our target (extrapolated from 94% M11 delivery). We operate a fully devolved model where our cost improvement target is delegated out to all budget holders. This delegated model results in a large number of locally owned schemes, over 1,000 last year. We operate an annual cycle of scheme identification, development and delivery. Focus on identification begins in quarters three and four, shifting to delivery of schemes in quarter one. As cost reduction has become more challenging we have been promoting a greater focus on clinical productivity and transformational change. For example changing models of care to help patients recover more quickly and leave hospital earlier with a reduced length of stay. Areas that we are proud to include are: Reduced medical and surgical length of stay, working in partnership with community colleagues Early mobilisation of patients in intensive care (HSJ Value Award winner 2014) Enhanced supported discharge (hospital care from home) Perioperative medicine for high risk elective surgery (reducing complications; ICU bed days and length of stay) Ambulatory pathways (for existing inpatients) Frailty pathway, including Discharge to Assess (reducing delayed transfers of care) We estimate improving flow through inpatient beds will deliver over 3m savings in 2016/17. Releasing bed capacity in this way will unlock further theatre and diagnostic productivity opportunities. The CIP target included within the 2016/17 plan is 29m (4.2% of operating expenses). This will be a significant challenge to the organisation. We are currently 95% identified against our target. The teams are currently focused on building detailed project plans for identified schemes and developing new ideas. Lord Carter s provider productivity work programme The Trust has engaged with the Lord Carter review team and is confident the level of recommended cost improvement, 44m over 3 years, will be exceeded by our cost improvement programme. Being a specialist provider some of the identified anomalies with national norms are expected. We will continue to engage with the national team and investigate all recommendations. Responding to the specific areas of focus in the interim report: We have formed a dedicated workforce PMO this year to drive further transformation of the workforce. We have reduced medical agency spend by 1.5m in year 1 and have set challenging targets to reduce nursing agency spend by a similar amount in year 2. 16