LLR Alliance. Operational Plan Second draft

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1 LLR Alliance Operational Plan Second draft 1. Introduction The remit for the NHS in England is clear: implement the Five Year Forward View to drive improvements in health and care; restore and maintain financial balance; and deliver core access and quality standards. The mechanism through which this will be delivered is the local Sustainability and Transformation Plans. The purpose of this operational plan is to describe how the LLR Alliance will support the delivery of the LLR Sustainability and Transformation Plan (STP) over the next two years. 2. Background The Alliance took over the provision of elective community services in April We are a partnership of the main health organisations in Leicester, Leicestershire and Rutland, who have come together to deliver better planned care services in community and primary care settings. We operate within, and support a culture of collaboration and are made up of the following organisations: East Leicestershire and Rutland Clinical Commissioning Group (ELRCCG) West Leicestershire Clinical Commissioning Group (WLCCG) Leicester City Clinical Commissioning Group (LCCCG) Leicestershire Partnership Trust (LPT) University Hospitals of Leicester NHS Trust (UHL) Leicester, Leicestershire and Rutland Provider Company Limited (LLR PCL) Alliance contracting offers an innovative approach to delivering care through a multi-agency partnership, and is also a relatively new approach to contracting for care within the NHS. This Alliance is unusual in that it is a collaboration of commissioners and providers, rather than reflecting the purchaser/provider split which the NHS internal market is based on. The Alliance is based on the principles of collaboration across the health system and collective risk and reward across the commissioners and providers making it well placed to support and enable the transformation required in the LLR Sustainability and Transformation Plan. Through the Alliance s contract, a range of elective health services are provided in the eight community hospitals in LLR including diagnostics, outpatient services and day-case surgical procedures, however there is still so much more that the Alliance has to offer the LLR system. Our overall aim is to deliver high quality, effective and sustainable elective care services, and to continually improve the range and quality of services provided outside acute hospital settings. 1

2 3. The Way the Alliance Works in LLR The Alliance was established to enable the organisations in LLR to work in collaboration rather than silos and to enable a system-wide approach to the redesign of services. As a result the Alliance partners committed to adopt a set of principles and values to achieve these aims and to work together on a Best for Project basis in order to achieve the Alliance objectives. The key values, which underpin the way that the Alliance operates, are: Trust Collaboration Innovation Mutual Support Clinical participation in all we do Transparency Collective ownership of risk and reward The governance structure was created to ensure that the Alliance is driven by engagement with clinicians, patients and the public, whilst also being accountable to its partners. The partners are represented through having senior representatives on the Alliance Leadership Board, which is responsible for the overall strategic direction of the Alliance and the delivery of the Alliance objectives. Three years on, there is clear evidence that the system is working in partnership, for example during 2016/17 a Transformation Fund was established by the Alliance Leadership Board and investment was made to fund a project manager to drive forward the transformation of diagnostics services across LLR, there is now a single integrated plan for the delivery of diagnostic services and implementation will commence from April The Alliance has a small core team of management staff, who are responsible both for the operational delivery of contracted services and for taking forward the planned changes to elective care. There is also a small team of project managers, funded through the Transformation Fund that work with a range of specialties to move services out of the acute setting and also with primary care to reduce acute demand. The Alliance governance structure interfaces with the governance structure of the Sustainability and Transformation Plan as well as that of each of its partners. 2

3 There is an overarching agreement between all parties the Alliance Agreement, which commits the partners to achieving the Alliance s strategic objectives. The three provider organisations each has a standard NHS contract (known as pillar contract) which is applicable for the services they provide within the Alliance. The Financial Framework underpins the contract which encompasses the principles of risk and reward for all partners. Currently the majority of our activity is provided through the acute provider pillar contract (UHL) although in the last 12 months some progress has been made in moving activity into the primary care (LLR PCL) pillar contract. It is our aim over the next two years to increase the activity delivered via the LLR PCL and LPT pillar contracts. 4. Strategic Priorities We have made great progress in creating operational stability in the Alliance and have started the process of delivering transformational change for the population of LLR. Over the forthcoming two years the Alliance will seize the opportunity that it has to change how elective care is delivered outside of the acute setting. The focus 2017/18 will be to 3

4 consolidate those services where the activity transfer from UHL has already been agreed and to transfer activity into primary care where this is appropriate to do so. Our key priorities for the next two years are: Priority 1 Improved Access To improve access to services across Leicester, Leicestershire and Rutland (LLR) in line with the Sustainability and Transformation Plan (STP) priorities, while maintaining high levels of performance and quality standards. Our key areas for service transfer are: - Rheumatology - Ear, Nose and Throat - Medical day case procedures - Orthopaedic Surgery (minor hand surgery) Priority 2 Lift, Redesign and Shift into Primary Care Priority 3 Lift, Redesign and Shift into LPT Priority 4 System Wide Service Redesign To develop services offered within primary care settings by transferring activity into the LLR Provider Company Limited (LLR PCL) pillar contract. To explore opportunities with Leicestershire Partnership Trust (LPT) to transfer services into the LPT pillar contract. To work in partnership with the system to undertake a review of key services to ensure long term sustainable provision across LLR including the following areas: - Diagnostics - Musculoskeletal (MSK) Physiotherapy - Cardio-respiratory - Hearing services - Any Qualified Provider services (AQP) Priority 5 Clinical and Financial Sustainability To support service reconfiguration by enabling the left shift of acute activity and increase the range of treatments that we offer. To implement a programme of productivity that reduces our cost base and delivers services in a lower cost setting To support the STP programme for planned care by working towards: - A reduction in the level of new and follow up outpatient appointments. 4

5 - Compliance with the low value treatments policy. Priority 6 Workforce Development Priority 7 Improve the Alliance Profile Locally Priority 8 Organisational Development Priority 9 Getting the Enablers Right To deliver better value care, including achieving financial balance. To implement our workforce development plan, so that we are developing the right workforce to deliver our priorities. To improve the Alliance s profile locally by demonstrating a collaborative approach to delivering health care across LLR and to be a positive choice for more patients. To continue to develop the organisational culture of the Alliance, to support collaborative service improvement and transformation with all Alliance provider partners. To develop an IM&T Strategy that joins up the system. To develop an Estates strategy that addresses our key risks and opportunities. 5. The Scale of the Challenge The Alliance partners have set a high level of ambition for their collaboration. Delivering the level of change represented by our strategic priorities will be a significant challenge. It represents a step change in the pace of change compared to that which has been achieved to date. The Alliance s structure, values and ways of working provide a fantastic opportunity to tackle those challenges, but we must not underestimate the complexity of the task. The level of system-wide collaborative working is essential to deliver on our objectives and to support the STP work programme. Delivering on our plans will require the Alliance to develop a clear approach to service improvement and the shift of activity into primary and community settings. This approach will need to be worked up in partnership with the Alliance s partner organisations and embedded throughout those organisations, so that there is both a pull and push towards change. Some of the risks and barriers to change will need to be addressed at both a strategic and an operational level. The rest of this document sets out in more detail how we will work to achieve the Alliance s strategic priorities over the next two years. 5

6 6. Our Approach to Activity Planning 6.1. Demand Activity Planning The demand activity plans have been developed by our Alliance Management Team with the support of the Business Intelligence and Finance teams. We are also working closely with LLR CCGs and our provider partners to agree the activity for next year and ensure alignment with the STP, which remains work in progress. Our activity modelling has been based on the following assumptions: 2016/17 forecast out-turn activity levels Baseline growth assumptions of between 1.0 and 1.7% (dependent on service) Known business case developments for example in dermatology, endoscopy and urology A summary of the indicative changes between 16/17 activity (the forecast outturn ) and 17/18 expected demand are shown in table 1 below. Table 1 Activity Type PbR Actual Management 15/16 Outturn (Activity) 12 Months Rolling (Activity) 16/17 Plan (Activity) 16/17 Straight Line Forecast Please note these have not been finalised and 18/19 activity figures are yet to be agreed. Adjusted 16/17 FOT (Activity) 17/18 Planned Changes (Activity) 17/18 Indicative Activity Plan IP Day Case 9,441 8,818 12,192 7,448 10, ,860 IP Total 9,441 8,818 12,192 7,448 10, ,860 OP New Outpatients 30,604 30,441 30,927 29,043 29,219 (30) 29,188 Follow Up Outpatients 61,364 61,375 64,123 60,148 62,268 (584) 61,684 Outpatient Procedures 15,753 15,575 17,077 15,069 17,711 (2,247) 15,464 OP Total 107, , , , ,198 (2,862) 106,336 CQUIN CQUIN CQUIN Total DA Direct Access (Diagnostics) 60,119 61,406 59,768 63,683 64,916 (5,624) 59,292 DA Total 60,119 61,406 59,768 63,683 64,916 (5,624) 59,292 DI Diagnostic Imaging 8,787 8,907 8,935 9,043 9, ,504 DI Total 8,787 8,907 8,935 9,043 9, ,504 Other 9,266 9,741 9,287 10,142 10,756 (1,403) 9,353 Other Total 9,266 9,741 9,287 10,142 10,756 (1,403) 9,353 UB (1) - UB Total (1) - Grand Total 195, , , , ,395 (9,051) 195, Delivery of Operational Performance Standards We will work with partners across LLR through the STP programme to continue to deliver operational performance standards in the short, medium and long term. The Alliance provides the opportunistic vehicle to change how elective care is delivered in community settings; however this relies heavily on the support and enablement of the Alliance partners to make this happen. 6

7 6.2.1 Referral to Treatment (RTT) the 92% standard The Alliance has continued to achieve the national 92% RTT target standard and has therefore contributed to the overall performance figures for UHL week waits We have not reported any 52 week waits in 2016/17 year to date and our commitment is to maintain this in the forthcoming years Diagnostics We have continued to deliver the diagnostic target in 2016/17 and have contributed to the overall performance figures for UHL. We aim to continue with this level of performance in the forthcoming years Cancer The increase in cancer prevalence and the evidence of unmet needs will require a transformation in the way that NHS cares for people affected by cancer. This will move away from the emphasis on acute and episodic care to a holistic personalised approach that is co-ordinated and integrated. There is a piece of work at the moment working with MacMillan and UHL on a bid for project manager and Macmillan support to redesign cancer pathways. The Alliance is a perfect vehicle to enable this transformation and we are scoping what can be done. The Alliance will work with our UHL partner in redesigning patient pathways to enable an LLR achievement of the cancer targets. In particular, we are working closely with UHL to review endoscopy pathways for care closer to home. 6.3 Productivity to Maximise Capacity Use of utilisation targets The Alliance will deliver a suite of reports to measure utilisation and productivity across all of our points of delivery. This data will then be used to set utilisation targets Day case units Some of the active projects from 2016/17 will continue to deliver increased benefits, such as the improvements in scheduling linking in with the upgraded ORMIS and linking into UHL s Unisoft system (so that clinicians can seamlessly access relevant patient reports), review of preassessment processes and improved control and escalation systems to reduce wasted time in theatres. A particular focus will be on reducing unnecessary variation within the way different Theatres and their teams practice. Across LLR there continues to be, as part of the STP, the movement of day case and endoscopy work from UHL to the Alliance providing surgery within community hospitals and within GP practices, outside of the acute setting Outpatient units The Alliance will work with UHL as part of the outpatient work stream to improve booking processes particularly around ERS (e-referral service) and electronic referral. This will continue 7

8 into 2017/18 to support the reduction in conventional face to face follow-up appointments to improve efficiency and outcomes for patients. All elements of the outpatient work stream will overlap with technological developments and will link in to the IM&T strategy. There will be a significant focus on reducing variation by ensuring the standardisation of clinic templates across the specialities with particular focus on DNA s, hospital cancellations and robust monitoring of both consultant attendance and productivity against the SLA contracts held Utilising a more cost effective care setting The Alliance remains committed to transferring activity out of the acute setting and into primary and community facilities. In addition we know there is some activity currently carried out in our community hospitals that may be better suited to clean room facilities within primary care. By moving this activity into primary care, it will free up theatre capacity to allow us to transfer further services from the acute hospitals and into the community, closer to where patients live. 7. Our Approach to Quality Planning Our senior leads for quality improvement are the Head of Nursing and Clinical Governance and the Clinical Director Patient Safety and Quality Improvement Our commitment to safety and quality remains unwavering. With an increasingly diverse range of procedures and specialties being delivered in the Alliance and within an exceptionally challenging financial environment, there is a greater need than ever to focus resources and actions to ensure the best value for money and a material decrease in avoidable death and harm. We will continue to focus on safety measurement and improvements in our collection, analysis and use of safety information and data. This will enable us to identify safety themes, trends and clusters. Internally, our safety priorities for the next two to three years will mirror those of the East Midlands Patient Safety Collaborative and will focus on:- Improving organisational safety culture from board to ward ; Growing leaders for safety and quality improvement; Building capability in safety and quality improvement; Undertaking improvement projects and effective evaluation Improving organisational safety culture The safety culture of the Alliance in the next two years is really going to be a challenge as we transform how and where services are delivered. Robust focus will be on suitability of environments for delivering care ensuring the patients experience and safety is not compromised as we adopt new ways of working. This will involve working closely with our partners on developing robust governance and quality measures in all pillar contracts and seeking assurance on safety, experience and outcome data. 8

9 We will continue to work on principles and actions around promoting a safety culture, specifically focusing on transparency, visible-felt leadership, and learning and improvement. We will continue to work in collaboration with our partner organisations on projects aimed at improving the safety culture across the Alliance. We will learn from our local and national leaders and support further work on the effect of Human Factors in incidents. Reporting and investigating incidents will follow national and local standards and we will learn from the new Healthcare Safety Investigation Branch in terms of national learning. We will continue to share the learning from patient experience and incidents across organisational boundaries Growing leaders for safety and quality improvement We recognise that inspiring and enabling staff to be leaders is critical to our success in terms of credibility, reputation, impact and outcomes. Collaborating with Health Education England (HEE), the East Midlands Leadership Academy (EMLA), the Leicestershire Innovation and Improvement in Patient Safety (LIIPS) unit and academic partners, we will use local expertise to coach, train, develop and support leaders and potential leaders in safety improvement. The newly developed role of Clinical Quality and Safety lead in the Alliance will help to embed a safety culture and Quality Improvement methodology in practice across the Alliance. In addition we will implement leadership development programmes for our clinical and operational leaders for band 6 and above. We will build succession planning in to the roles of our senior leaders to promote a culture of organisational development and system leadership. This will; be monitored through appraisals and personal development plans Building capability in safety and quality improvement We will continue to build safety and quality improvements capability by the ongoing development of the senior leadership team and specifically the Alliance Clinical and Quality Safety Lead. This role will support staff within the Alliance by attending recognised quality improvement study programmes, including the Institute for Healthcare Improvement Open School, the Health Foundation improvement modules or relevant degree courses. Senior leaders will be encouraged to attend the LIIPS measurement master classes. Where possible we will collaborate with our partners in the use of improvement experts from other safety industries to support our work Undertaking improvement projects and effective evaluation The purpose of the Alliance is to deliver better elective care services in community and primary care settings. As these new models of care are implemented, the Alliance will use nationally recognised improvement methodology for example PDSA, Appreciative Inquiry and Lean thinking during planning and of implementation of business cases. The effectiveness of new ways of working will continue to be evaluated to ensure improved experience and outcomes for patients. 9

10 We will collaborate across the health sector and with academic partners and improvement teams regionally and nationally to achieve this. We will continue to undertake formal evaluation of improvement projects. In collaboration with UHL we will liaise with Health Education England and the Academic Health Science Network to seek funding for improvement and to seek opportunities for upscale and spread Quality Improvement The Alliance will work with any of our partners and ensure the learning from organisational external inspections is shared. This will include the learning from 2016 Care Quality Commission (CQC) visits to LPT, UHL and relevant GP practices. The aim of CQC inspections is to check whether the services that we are providing are safe, caring, effective, responsive to people's needs and well-led. Whilst the inspectors did not visit any of the Alliance departments or services, the principles of the recommendations are applicable Quality and Safety Performance Reviews and departmental quality visits were introduced in 2016, led by the Head of Nursing and Clinical Governance, and these will continue on a regular basis going forward. Data from the quality visits will continue to inform decisions regarding quality improvement across the organisation. In line with CQC guidance around the care of the deteriorating patients, the Alliance has introduced the use of an adapted Early Warning Score chart in all day case areas. The plan is now to extend this to include invasive procedures carried out in all outpatient settings. An ongoing programme of quality visits covering both wards and non-ward clinical areas has been incorporated into our 6 monthly ward review tool. This is an interactive ward based process underpinned by the CQC key lines of enquiry and the five core domains; safe, effective, caring, responsive. These reviews give the Head of Nursing, Quality and Safety the opportunity to: spend quality time with the Matron and Ward Sister to discuss ward performance data and agree actions using a checklist to prompt the discussion with documented agreed actions for improvement; interview staff with some CQC style questions (using the CQC intelligence we have); have a discussion about what staff are proud of and opportunities to celebrate; and finally, meet patients and discuss their experiences to gain real time feedback. The review also involves an inspection of the ward environment, agreeing actions and improvements required. The Alliance will use the headings of the UHL 2017/18 Quality Commitments to help drive improvements. The Alliance will include the following objectives to achieving the broad aims and KPI s: Clinical Effectiveness Screen all deaths within 30 days Implement robust pre-assessment of all patients requiring day case procedures Ensure all business plans include SMART objectives for monitoring implementation and outcomes for patients 10

11 Patient Safety The timely recognition, escalation and treatment of the deteriorating patient Use of EWS and sepsis screening for the community To undertake thematic reviews of patient safety data across the pillar contracts Patient Experience To continue to improve the patient booking process to minimise on the cancellations and improve our DNA rate To undertake thematic reviews of patient experience data across the pillar contracts Through our Quality Commitment we aim to: Improve patient outcomes and provide effective care by delivering evidence based care/best practice Reduce harm to patients and improve safety by reducing the risk of error and adverse incidents Provide care and compassion and improve patient experience by listening to and learning from patient feedback In developing our plans to improve quality we have taken into account both local and national priorities across the three domains: patient experience; clinical effectiveness; safety. Our CQUIN Scheme for 17/19 is currently being agreed with commissioners. The full 2.5% of annual contract value remains on offer to the Alliance. 1.5% will be assigned to deliver against mandated CQUIN indicators. The mandated CQUINS will have a minimum weighting of 0.25% and are currently being agreed. The remaining 1% is to be assigned to support engagement and commitment to the Sustainability Transformation Plan (STPs) and is subject to further discussion. There are currently 19 Indicators in the Quality Schedule for the Alliance in 2017/18 but most have more than one metric where performance is monitored (for example Clinical Effectiveness Assurance includes both Clinical Audit Programme and NICE compliance) and some have a suite of metrics (for example Infection Prevention includes CMG Self-Assessment against the IP Toolkit and reporting of other Infection rates). We continue to use patient feedback (from sources such as patient survey results, complaints, message to matron, NHS Choices) to identify areas for improvement. Increasing our Friends and Family coverage remains a key focus in the forthcoming year. Achievement of our quality objectives are monitored through a number of groups including the Alliance Leadership Board, Alliance Management Board, Alliance Elective Care Governance Group and Alliance Elective Care Clinical Audit Group. Additionally, the Alliance reports to UHL through Nursing Executive Team (NET) meeting, Executive Quality Board (EQB) and Trust level meetings such as Infection Control Committee Quality Impact Assessment Process and Risk Each month the Alliance Elective Care Governance Group meet and an agenda item at this meeting will continue to be the review of the quality impact assessments for any new or resubmitted Cost Improvement (CIP) schemes. Where the impact on quality is felt to be of 11

12 significance (high) the scheme will continue to be referred to the Alliance Management Board and Alliance Leadership Board for refinement or rejection. Key Performance Indicators are determined for each scheme and these are recorded as part of the scheme details on the CIP tracking system. The Alliance will continue to maintain a live risk register which will be updated and reviewed every month at the Alliance Elective Care Governance meeting, the Alliance Management Board and bi-monthly at the Alliance Leadership Board. Risks identified through the Quality Impact Assessment process will be added to the risk register along with all other risks identified for the organisation. Strategic risks will continue to be reported to the commissioners as part of the monthly Performance Dashboard reporting to the commissioning contracts team and via the Alliance governance structure Top 3 Risks and Mitigation Our Board Assurance Framework (BAF) sets out a list of principal risks to the achievement of our strategic objectives, their current mitigating actions and internal and external assurance sources. The BAF also identifies further mitigating actions to be taken for each principal risk. The following table summarises our three significant risks to quality and their mitigations. Strategic Risk Medical workforce limitations Mitigations Workforce Development Plan developing and use of extended workforce i.e. Nurse Endoscopists, Surgical Care Practitioner at Melton. Organisational Development Strategy Service Level Agreements and monitoring arrangements in place between UHL (and other suppliers of clinicians) and the Alliance. Transformation fund identified for GP training. PCL leading engagement with primary care / GPSI's. Strategic Risk Implementation of business cases Mitigations Alliance Business Plan. Business case tracker in place to monitor and report on progress which has recently been re-prioritised. Decision making process for business case approval. Progress reporting to Planned Care Board, Alliance Management Board and Alliance Leadership Board. Alliance Implementation Group oversees delivery. 5 project managers (working with Planned Care team). Alliance Financial Framework in place. Clinical Reference Group supports pathway redesign. Weekly liaison with senior UHL managers to address progress issues. Strategic Risk Financial disincentives for Alliance providers to transfer activity to the 12

13 Alliance Mitigations Business Plan, priorities agreed for service transfer to the Alliance. Decision making process for business cases in place. Alliance funded project managers (working with Planned Care team). Alliance Financial Framework in place. System leaders on the Board of the Alliance. Regular reporting of Alliance progress to UHL Finance and Performance Committee to keep profile high. STP and Planned Care Board supporting delivery of left shift. 8. Our Approach to Workforce Planning / Clinical Engagement 8.1. Workforce Planning Methodology The Alliance Strategic Workforce plan is closely aligned to the 5 year Forward View and the emerging LLR STP and it builds upon the strategy outlined in the former Better Care together programme. The Alliance has developed its workforce plan principally based on demand and capacity assumptions and has also been linked to our Cost Improvement Programme and the recommendations contained within the Carter review for maximising efficiency. Using the forecasted WTE (whole time equivalent) and pay bill out turn position for month 5 16/17 (less premium spend and adjusted for vacancies) as a baseline, the following process has been adopted: 1. Derive baseline WTE position 2. Determine revised establishment position based on activity and capacity requirements (which will be driving any increases/ decreases in bed or theatres or outpatient capacity, any newly designed models of care, safe staffing levels, service changes and cost improvement assumptions 3. In deriving revised establishment consider new roles as an alternative where there are risks to the supply of workforce and establish any double running requirements in the development of such roles with a particular emphasis on apprenticeships 4. Determine recruitment / reduction trajectories and based on revised establishment. 5. Where significant gaps between establishment and in post arise, forecast non-contracted WTE and pay bill to meet gap and identify premium expenditure required ensuring no overall breach. Triangulate outcomes of this process by comparing: 1. Forecast pay bill (financial plan) to WTE plan to ensure affordability. This has been aligned to the financial plan described in section Forecast WTE percentage change to activity percentage change with a broad assumption that increases in activity will not necessarily translate into further staffing demand. The overall WTE change (for 17/18) is: 13

14 Outturn 16/17 WTE 17/18 WTE WTE Change % Change 18/19 WTE ALL STAFF % Bank % 8.22 Overtime % 3.94 Agency staff (including, (2.00) -100% 0 Agency, Contract & Locum) Substantive WTE % We have predicted changes to our workforce based on a number of principles: Managing left shift activity through current workforce Changes arising from volume changes Changes arising from acuity reviews Anticipated shifts in agency and bank usage as a result of NHS Improvement initiatives Understanding of turnover and predicted vacancies. Taking account of the ageing workforce and intention to retire and return on more flexible arrangements. Cost improvement measures including such interventions as skill mix review and reduction in average cost per whole time equivalent Alignment with the LLR sustainability and transformation plan The processes above generated an internal draft workforce and financial plan, which was then adjusted to account for activity and capacity shifts associated with the LLR STP (at the broadest level) to create a revised workforce model and aligned to the assumptions in the finance and activity models. This methodology has been applied in the context of an overarching workforce plan which has six pillars of delivery: 1. Increasing community provision and supporting the left shift 2. Creating a sustainable workforce 3. Seven day service delivery 4. Increased role for Primary Care services 5. Grow our contracted Workforce and reduce our dependency on the non-contracted workforce 6. Developing new ways of working via the OD plan It is recognised that workforce plans need to align to evolving left shift business cases linked to service transformation and the LLR Better Care Together Planned Care work-stream programmes. In addition, plans have needed to consider supply and demand challenges as this has an impact on the ability to create capacity for the delivery of services. The Alliance workforce plan highlights key workforce challenges and the Alliance s response with specifics reference to: The Medical Workforce The Nursing Workforce 14

15 The Administrative Workforce Non-Medical /Other Clinical Roles New Roles CIP/Pay bill There will be a collaborative approach between Alliance, UHL and the Planned Ambulatory Care Hub (PACH) including workforce planning 8.2. Underpinning Workforce Strategy In addition to the five year workforce plan, we have a number of workforce strategies which will support the six key strands of delivery, examples include: - Shift of activity from acute to community and from community to primary care: The Alliance has agreed with UHL to drive forward the activity shift of a number of speciality areas through the successful development and implementation of business cases. Current priority left shift business cases include Gastroenterology, Dermatology, Urology and lumps and bumps. - New Roles, up-skilling and re-skilling of existing staff: Development of Assistant Practitioners using a competency framework to support career progression for the non-qualified staff has commenced with two band three staff appointed within endoscopy, the training and use of nurse endoscopists, ODPs and ESP s. - Specific issues in relation to the Alliance workforce e.g. Age profile, flexibility: Creating a workforce which allows room for the Alliance to grow and develop its care pathways. Up skilling our workforce, enabling our workforce to gain experience from our partners on a rotational basis, ensuring staff have access to training and development opportunities and a review of our staffing structures. - Recruitment and Retention-addressing occupational shortages: In support of the reform programme set out in the Future of Apprenticeship s in England; Implementation programme (published in October 2013). In order to positively attract a younger workforce the Alliance can provide opportunities of traineeship and apprenticeships in administrative services, healthcare support workers, sonographers and optometrists. - Workforce Redesign: The Nursing structure has been redesigned in order to strengthen its leadership and to provide capacity for activity shifting out into the Alliance. Future plans include developing nurse leadership, providing more flexible shift options, aligning patient mix and staffing, providing mentorship and professional development and developing staff engagement activities. The Alliance is currently in the process of reviewing and restructuring its administration service to support both day case and outpatient activity. - Reducing the reliance on off payroll arrangements to support sustainable services: The Alliance has significantly reduced its number of Medical staff on off payroll arrangements converting them to be paid and employed by UHL strengthening the substantive workforce. 15

16 - Culture new ways of working and working across boundaries: Joint appointments with GP Practices looking at developing GP s with a Specialist Interest (GPSI) through education and training. - Education and training: This will include up skilling our GPSI s in their specialist interests to enable them to offer a wide breadth of advice and treatments to patients supporting Primary Care. This will be linked to relevant Consultant mentorship and support. Each of these strategies support delivery of the workforce plan and ensures that innovative approaches to supply and demand are adopted Governance To ensure ongoing triangulation with activity and finance, the workforce plan has been reviewed at all stages of development by the multidisciplinary Alliance senior team. The plan is managed through a range of work streams including the Better Care Together LLR Strategic Workforce Planning Group, Planned Care Board, the Reconfiguration Business Case Work streams, Nursing Executive, the Seven Day Services Project Board, The Alliance Left Shift Implementation group and the Alliance management board and Leadership board Achievement of Efficiency - Capitalising on Collaboration The Alliance plays a key role in the LLR Strategic Workforce Planning group which aims to develop a system wide approach to workforce planning to maximise efficiency across the system. This stream works in conjunction with other LLR workstreams to ensure opportunities are maximised in attracting high quality workforce to LLR/ensuring the right behaviours and skills are in place to work in a collaborative context, ensuring systems and processing are in place to enable staff to move readily across different care settings. Therefore, growth in demand will be offset by a more efficient and specialised workforce in taking the workload away from the nonspecialist practices across LLR and achieving efficiency. The Alliance has already converted its Waiting List Initiatives (WLI s) into substantive posts in collaboration with UHL which includes Gastroenterology and Ophthalmology. The Alliance will next be progressing this forward with the growth of its Rheumatology and Dermatology services Workforce Transformation, New Care Pathways, Specific Staff Group Issues The Alliance will be working collaboratively across LLR on a range of workforce development initiatives including: ODP s - developing Operating Department Practitioners in conjunction with UHL. Clinical placements - offering the opportunity to all learners across LLR including students and apprenticeships. Collaborative work on placement capacity and the development of mentors is already established and utilising the Alliance s dedicated practice learning lead to find new and innovative placements in order to attract and retain leaners. Trainee Assistant Practitioner (TAP) roles and Nurse Associate roles - working with partners to develop the best workforce solutions at all levels but the development of the band 4 role, with a pilot likely in UHL from January The approach to TAP roles and 16

17 Advanced Clinical Practice has been developed collaboratively with LPT to ensure a consistency of standard across the STP footprint. Medical workforce and training - work is already underway in establishing medical training programmes. The Alliance is currently establishing a postgraduate medical training programme in its Rheumatology and Dermatology services in collaboration with HEEM and LLR and is looking towards expanding JAG accreditation to include training status for endoscopy in the three units with current JAG accreditation.. Apprenticeships - using apprenticeships to employ more young people within UHL, to address our future ageing workforce challenges and to help reshape our workforce. This approach helps mitigate the ongoing challenges we face in the supply of staffing across a number of staff groups and specialties New Initiatives as part of Five Year Forward View Each of the LLR strategic teams has received an allocation from HEEM Five Year Forward View monies. This will be used to fund initiatives such as: 1. Use of complex workforce modelling techniques to develop system wide views of workforce demand across the system SWPie (Strategic Workforce Planning (integrated and evaluative). System uses a principle of high level functions for determining workforce skill levels in order to understand how workforce demand may shift in the system 2. Use of functional mapping for redesigning workforce in conjunction with care pathway development 3. Investment in workforce analytics skills to develop a numeric system wide plan 4. Investment to support an LLR wide attraction strategy with a specific focus initially on apprenticeships 5. Investment in Advanced Clinical Practice 6. Investment in Seven Day Service project management to develop ways of introducing seven day workforce models at minimal cost 7. Investment in mental health and learning disability training software 8. Investment in Organisational Development including expertise in transformational change and the development of an LLR Way 9. Investment in a Workforce Planning expert to support the Urgent and Emergency Care Vanguard in the delivery of revised models of care e.g. Clinical Navigation Hubs, tiered approaches to Urgent Care 8.6. Support for delivery of Workforce Plans in conjunction with Local Workforce Action Boards We have been actively engaged with the Local Workforce Action Boards in developing local bids for education and training support which support Health Education England priorities. A significant numbers of bids have been jointly submitted with STP partners to ensure education and training programmes support such ambition of left shift and improved discharge processes. Bids include the use of functional mapping / workforce profiling to support new workforce models; support for further development of the advanced clinical practitioner unit; support for improved infrastructure for delivering the national apprenticeship ambition; implementation of nursing rotational programme through community and acute settings; a range of skill enhancement 17

18 initiatives to support up skilling of community based staff; support for the implementation of an overarching LLR Attraction Strategy; investment in infrastructure support to understand the impact of plans to remove bursaries for nursing and Allied Healthcare Staff 9. Engagement Plans 9.1 Engagement with stakeholders As a vehicle for system change, it is vital that the Alliance engages well with the widest possible group of stakeholders across LLR. Key stakeholders are well represented in our business structure and meetings such as the Clinical Reference Group, Patient and Public Partnership Group. We hold an annual stakeholder engagement event to collaborate with key stakeholders from across LLR including our most important stakeholders our patients. At the last event more than 60 people attended. Alliance staff are also members of key system redesign groups such as the STP Delivery Board, Planned Care Operational Group and Clinical Senate. The Alliance s plans for elective care will feed into the system wide public consultation plans. Following consultation, the Alliance will also contribute to the business case which will set out in detail the overarching plans for change and improvement to elective care. We have an active communications and engagement plan which has already delivered some key achievements in the last 12 months. Plans for the future include: Increasing understanding of what the Alliance does Raising awareness of the patient benefits of Alliance services Generate reassuring messages around the longer term benefits Listen, collate and share patient experiences Ensure that patient feedback and stories are used to continually improve Alliance services and are used in shaping new services 9.2 The Alliance Patient and Public Partnership Group Patients and members of the public are seen as core members of the Alliance partnership, and we seek to involve local people in our decision making and our work to change the way that services are provided in community settings. To help make this happen, there is a wellestablished Patient and Public Partnership Group (PPPG), which has the role of giving voice to patients and the public and feeding into the decision making of the Alliance. The PPPG is made up of local people drawn from different Patient Participation Groups (PPGs) in localities in Leicestershire and Rutland, working with the Alliance Management team and the Clinical Reference Group. It is responsible for leading on the Alliance s engagement activities, aiming to ensure we are listening to as wide a group of patients as possible. This includes surveying patients and holding engagement meetings with patients and the public and making sure that important lessons from what patients tell us are used to improve our services. The PPPG also takes a role in helping to monitor the quality of our services. To ensure that we are truly involving the public in the way that we run the Alliance, PPPG members are also members of the other key Alliance meetings include the Clinical Reference Group, the Alliance Management board and the Alliance Leadership Board. 18

19 Priorities for the PPPG in 2017/2018 include: Expanding its membership to incorporate future virtual members so that it can maximise its reach into local communities Assessing the quality of patient information Surveying patient satisfaction and assessing dignity of care The PPPG will continue to work with the Alliance and other key providers to achieve quality care closer to home. Many of the PPPG members play an active role in the Better Care Together steering groups and the development of STP working relationships. The aim of the PPPG is to act as a real and meaningful conduit and to be seen to engage with patients and public. This process requires ability to inform, seek advice and contribute to new ways of working. As part of this process, work is being undertaken to have a robust working partnership not only with the Trusts and CCGs but also with the newly formed Federations and with local PPI groups within locality GP surgeries. 9.3 Engaging with our Staff Our staff are our most important resource, and engagement with staff is central to our plans to develop the quality of patient care in the Alliance. In order to deliver our vision of high quality, integrated pathways out of hospital, we need to secure a highly motivated workforce that is positively contributing to innovation and service improvement. An overview of our workforce plan is described in section 8. There are some specific challenges associated with a dispersed, community based workforce that we need to respond to in developing the Alliance workforce. We have undertaken a number of listening events in the last 2 years which helped us to identify some of the issues for the community hospital workforce and we have developed a communication plan and an organisational development plan to address these issues. These plans are helping develop the culture of the Alliance as an innovative place to work that values staff development, collaborative approaches to service delivery and quality improvement. The organisational development plan includes approaches to developing leadership within community hospital teams. Listening in Action (LiA) is an important mechanism for engaging our staff positively in improving services and their working lives and we will continue to support LiA as a mechanism for hearing the views of people working for the Alliance and empowering staff teams to address the issues that arise. 10. Our Approach to Financial Planning Financial Forecasts and Modelling In 2016/17, we plan to deliver an income and expenditure deficit of 251k. This represents a 737k deficit to the 486k planned surplus and is predominantly due to activity being below plan mainly as a consequence of delays in shift activity moving to the Alliance. This includes 19

20 delivery of a Cost Improvement Programme (CIP) of 722k. The table below summarises the 2016/17 forecast outturn position. 16/17 Forecast 000 Plan Actual Variance Income 24,965 23,349 (1,616) Pay (12,998) (12,195) 802 Non Pay (11,481) (11,405) 77 Net I&E 486 (251) (737) The recently published tariff and initial offer letters from commissioners have all contributed to the assessment of our position alongside internal factors such as scale of CIP programme and current run rate. A fundamental part of the Alliance s position is the movement of activity from UHL to the Alliance in order to support the UHL s reconfiguration from 3 to 2 sites. Progress was slowed in 2016/17 due to delays in movement of Endoscopy and Dermatology activity. Modelling has assumed this activity transfers in full as well as other agreed shift of activity in 2017/18 (i.e. Gastroenterology 2, Urology Penile Scrotal and General Surgery lumps and bumps). We have a number of cost pressures including the impact of leases and rent charges increases that will need to be managed in 2017/18. There is also significant risk associated with the ongoing contract setting process for 2017/18 and 2018/19 with both NHS England and local CCGs. Initial commissioner offers are below expectations. The strategy and ambition set out in the STP is agreed and appropriate but transacting the financial impact and sharing the risk appropriately still remain a challenge for us and the rest of the local health system. This negotiation remains outstanding as part of the submission of our draft plan but will be resolved by the final submission. The financial plans within the 2017/18 and 2018/19 operational delivery plan are outlined below Activity Our 2 year income plan for is based upon the demand and capacity assumptions modelled for each specialty. This is based upon 2016/17 forecast out-turn plus the following demand movements: Income Growth on outturn due to demographic growth and the revised full year effect of the shift activity commenced in 16/17. New shift activity agreed to commence in 17/18. 20

21 A summary activity plan is outlined in section 6 above Income Clinical Income Our plan has been developed under full PbR rules and the application of the STF. We are currently planning for 22.37m (97% of total clinical income) from local commissioners (Leicester City, West Leicestershire and East Leicestershire and Rutland CCGs) and 0.67m (3% of total clinical income) from specialised activity commissioned by NHS England giving a total clinical income value of 23.04m. We have not agreed the 2017/18 contract associated with these plans and income is therefore subject to change. Our plan uses PbR tariff in line with the guidance and draft national prices as published in October and November This assumes a 2.0% efficiency deflator and 2.1% inflation uplift for all local and national prices. This translates to expected income inflation of 0.1%. This reflects NHS Improvement s and NHS England s assessment of cost inflation. The overall impact of pricing changes in 2017/18 is anticipated to be a 521k decrease in income; this can be separated into tariff inflation of 481k, efficiency requirement of ( 458k), impact of HRG4+ ( 826k) and 282k coding and counting changes Other Income We have additional non-clinical income streams (primarily Urgent Care Centre but also Private Patients) that amounts to 0.338m Expenditure Pay The workforce planning section (section 4 above) details the key assumptions and challenges that have been built into the workforce models. These workforce models describe the number of whole-time equivalents (WTE), the skill-mix and also recognise that some of the workforce will be deployed in different settings. Pay inflation is included at 172k (1.5%) based on national pay structures and includes pay awards and the apprenticeship levy. Increased pay costs associated with delivery of the full year effect of the shift activity commencing in 16/17 as well as shift activity commencing in 17/18 has also been included Non pay Non-pay inflation at 216k is based on drugs at 2.8% and a 1.8% increase generally in line with guidance. 21

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