Operational Plan Burton Hospitals NHS Foundation Trust

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1 Operational Plan Burton Hospitals NHS Foundation Trust

2 1 BOARD STATEMENT EXECUTIVE SUMMARY THE SHORT TERM CHALLENGE Background Commissioner Challenges Quality Performance/Challenges Financial Performance Challenges QUALITY PLANS Trust Vision Goals & Objectives Clinical Model Partnership Engaging with Our Staff Quality Strategy Consistently Safe Consistently Effective Positive Patient Experience Commissioning for Quality and Innovation (CQUIN) National CQUINs Local CQUINs Board Assurance Risks to Quality and Mitigation OPERATIONAL REQUIREMENTS AND CAPACITY Activity Capacity Changes to key service lines PRODUCTIVITY, EFFICIENCY and CIPs How the Cost Improvement Programme is Managed CIP Work streams Quality Impact Assessment Review Cost Improvement Projects Life-Cycle CIP Schemes Work stream Delivery Programme Key Issues FINANCE Introduction I&E Summary INCOME CHANGES Central Funds and Initiatives Allowance for Fines and Challenges Non Clinical Income Non Recurrent EXPENDITURE CHANGES CIP Schemes Additional assumptions for 2015/ Capital Plans... 40

3 7.12 Balance Sheet Cash flow CoSRR Downside scenarios considered Implementation plan Governance APPENDICES

4 1 BOARD STATEMENT This document completed by (and Monitor queries to be directed to): Name Job Title address Helen Ashley Chief Executive Officer Tel. no. for contact ext 4151 Date 30th June 2014 The attached Operational Plan is intended to reflect the Trust s business plan over the next two years. Information included herein should accurately reflect the strategic and operational plans agreed by the Trust Board. In signing below, the Trust is confirming that: The Operational Plan is an accurate reflection of the current shared vision of the Trust Board having had regard to the views of the Council of Governors and is underpinned by the strategic plan; The Operational Plan has been subject to at least the same level of Trust Board scrutiny as any of the Trust s other internal business and strategy plans; The Operational Plan is consistent with the Trust s internal operational plans and provides a comprehensive overview of all key factors relevant to the delivery of these plans; and All plans discussed and any numbers quoted in the Operational Plan directly relate to the Trust s financial template submission. Approved on behalf of the Board of Directors by: Name (Chair) Chris Wood Signature Approved on behalf of the Board of Directors by: Name (Chief Executive) Helen Ashley Signature Approved on behalf of the Board of Directors by: Name (Finance Director) Jon Sargeant Signature

5 2 EXECUTIVE SUMMARY The Trust is within a financially challenged health economy. To balance budgets commissioners are targeting significant reductions in activity through initiatives such as integration of care pathways for frail elderly and long term conditions. The Trust supports these initiatives and seeks to be a lead provider of such services, though some of the target activity reductions are considered ambitious in the light of a growing and aging population. The Trust is continuing to work on improving quality following the Keogh report. The Trust was inspected by the Chief Inspector of Hospitals on 23rd, 24th & 25th April 2014 and expects a final report and outcome from the inspection within the next few weeks. In the meantime the Trust is addressing the matters raised during the visit. In the light of the challenges described above the Trust has refined its vision, goals and objectives. This vision implies it will need to be a very different type of organisation within the timeframe of the five-year strategy. Specifically it will be far more proactive at engagement with the system, operating along more of the patient pathway (in a lead integrator role), enhancing its capability and capacity to deliver change by partnering with others in joint ventures where it makes clinical and/or financial sense, maximising market share of the catchment population and reducing the estate footprint for core services only. Since last breaking even in the Trust has incurred income and expenditure deficits. Audited Income and Expenditure Accounts show these have reduced year on year to only 1.8m in following a period of turnaround the previous year. However after two month s performance the Trust s forecast deficit for is 10.6m compared to a plan of 3.0m at the start of the year. Independent financial advisors have investigated the reasons for the deterioration and concluded: Whilst the Trust s financial position on the face of I&E has been improving since FY12, once the deficit is adjusted for non-recurrent items the financial position reverts to a year on year increasing deficit Although the Trust is achieving high levels of CIP, these have not been sufficient to offset reduced levels of clinical income and increasing cost pressure. In addition CIP programmes are not 100% achieved thus creating further pressure to the financial performance The Trust is experiencing high employee costs pressure due to Keogh review since early FY14 and been having difficulties to recruit permanent staff thus high number of agency is used There may be opportunity for big ticket savings in length of stay for non-elective frail elderly patients, reduced use of agency staff and improvement in day case ratios. Capacity and Capability to deliver the 2 year plan Over the course of the last 6 months the Trust has invested in additional capacity to address both internal and external challenges. With the exception of the addition of the Director of Governance role, the Executive Team is established with a core set of skills and competencies to be able to address the current challenges. Moving forward and over time the team will be complemented through the use of more commercial skills, either on an ad hoc basis or via a strategic partnership approach. The capacity and capability challenge for the 2 year period broadly breaks down under two headings; addressing the delivery of the 2 year plan and laying the foundations for the longer term 5 year strategy. The Trust has refreshed its Programme Management Office in the last few months in order to take account of the challenging CIP programme for the next two years, and will be key in supporting the 2 year plan to drive efficiencies through the organisation. Specialist skills on Estates and Facilities and creating theatre opportunities are already in place to support the programme. At the same time, there is significant work to be undertaken in order to ensure that the Trust is well placed to respond to Commissioning Plans and much more fundamental changes to its operating model. Whilst these changes might not take effect until the second half of the 5 plan, the Trust must be in a position to capitalise on opportunities in a proactive rather than reactive way The Trust recognises that transformational change and much greater capability and capacity is required to maintain the improvements in quality and make a step change in financial performance. The Trust s five year strategy sets out how it proposes to do that. 5

6 In the meantime the scale of the projected deficits mean the Trust will require distressed trust funding during the two years of this plan. 6

7 3 THE SHORT TERM CHALLENGE 3.1 Background Burton Hospitals NHS Foundation Trust is the principal provider of acute hospital services for the residents of Burton upon Trent and surrounding areas including South Staffordshire, South Derbyshire and North West Leicestershire. The Trust serves a population of approximately 360,000 people and is committed to delivering high quality patient care. The Trust was formed in 1993, going on to obtain Foundation Trust status in 2008, whilst continuing to work in partnership with a multitude of different agencies for the benefit of the local population. The Trust provides a wide range of services accustomed to a general district hospital and has a number of outreach and community based clinics, all of which are supported by a dedicated team of clinical staff and senior managers. The Trust recognises the importance of working in the community, providing patients with the choice to access services in a setting that may be more amenable or comfortable for them. Since acquiring the Samuel Johnson Community Hospital in Lichfield, the Sir Robert Peel Community Hospital in Tamworth and the Midlands NHS Treatment Centre based on the Queen s Hospital acute site in 2011, the Trust has continued to develop and reconfigure the services provided at these facilities in order to meet the needs of the local population. The Trust also provides a full complement of Accident and Emergency, outpatient and direct access services. All specialties are supported by a comprehensive range of clinical services in therapies, pharmacy, pathology, and radiology. In addition, we provide facilities to other NHS providers for specialties such as orthopaedics, phlebotomy and obstetrics. The Trust is committed to delivering sustainable and viable services in order to meet the needs of patients, building on the Trust s vision of being the local healthcare provider of choice, and delivering the best patient experience. 3.2 Commissioner Challenges The Trust s main commissioner is East Staffordshire Clinical Commissioning Group (ESCCG) which falls in the Staffordshire County Council area and is predominately covered by the area governed by East Staffordshire Borough Council with a small part of its population falling under Lichfield District Council. The CCG serves a population of 134,200 residents and has been formed by the 19 general practices within the East Staffordshire Borough Council Boundary which includes Burton on Trent and Uttoxeter. The member practices together have had a strong identity, based on historical use of Queen s Hospital in Burton and have a long track record of working effectively together. Using the national allocations funding formula, ESCCG is lower funded per head of population than other CCGs in the Staffordshire area; this equates to a potential shortfall of 2.1 million per year based on the fair shares toolkit formula. ESCCG is 12 million below fair share allocation in 2014/15. The six CCGs in Staffordshire and Stoke on Trent have produced their own five year strategic plan. The key themes affecting BHFTs plan are: (a) (b) (c) There is one key aspiration that we have for Staffordshire and Stoke-on-Trent and that is to integrate care so as to connect people with the care they need, when they need it. This aspiration works across organisational boundaries and is shared by the whole workforce. To achieve our ambitions for a sustainable health and social economy, we have to bring our citizens on the journey with us so that prevention and self- care become the norm. The importance of safety, positive experience and quality outcomes are clear. This is especially pertinent to people following the tragedy and harm to patients at Mid- Staffordshire. 7

8 (d) (e) (f) (g) (h) The projected financial situation across Staffordshire and Stoke-on-Trent is bleak. This will also be compounded if there is no change to how services are delivered, and if demand is not controlled and decreased. The Better Care Fund (BCF) agreements will be a key driver for developing integrated commissioning and transformational programmes, which will integrate the whole system of delivery of care and support. The model of primary care at scale links to and has a coordinating role for integrated care, urgent care, elective access, prevention and maximising self-care capability of citizens. 7 day working, to provide a seamless wrap-around service, is an expectation for delivering sustainability of the health and care system in the next 5 years. The urgent and emergency care system across our area is at risk of failure if the ever increasing demand is not addressed. This strategy sets out ambitious intentions to reduce A&E attendances by 40% and emergency admissions by 15%. CCGs and local providers are working together to deliver the national requirement of a 20% productivity improvement in elective care by 2019/20. A step change in the way that planned care services are organised and managed aims to improve access, decision making, recovery times and eliminate errors whilst improving productivity. This will mean using alternative settings of care and stopping some activities. BHFT supports the direction of travel indicated by the commissioners plans but locally believes the non-elective and A&E reductions to be ambitious in the timescales indicated given the demographic projections and historic performance in delivering change to the level targeted. The activity analysis undertaken be the Trust below therefore assumes lower levels of contraction in these services though by taking an active role in the move towards more integrated pathways it will make a significant contribution to managing demand down from trend. The Trust has recently agreed some high level targets for joint work with its host commissioner. This agreement focuses on a desire for both organisations to work in partnership to change the local service provision for Burton residents by providing top decile performance. This will involve significant changes in the care model particularly for elderly and frail patients. A copy of the areas of agreed partnership principles is included as an appendix. 3.3 Quality Performance/Challenges On February , the Prime Minister announced that he had asked Professor Sir Bruce Keogh, NHS Medical Director for England, to review the quality of care and treatment provided by those NHS trusts and NHS foundation trusts that are persistent outliers on mortality indicators. A total of 14 hospital trusts were investigated as part of this review. After the reviews, 11 of the 14 trusts, including BHFT, were placed into special measures by Monitor and the NHS Trust Development Authority. The Trust welcomed the review as an opportunity to improve the quality of services that it offers to patients and was accepting of all findings and recommendations that resulted from the review. The Keogh Review made six urgent recommendations for BHFT in July 2013 which if implemented would improve the quality of our services to patients through the delivery of consistently safe and effective care. Since then the Trust has been working constantly to implement the recommendations and achieve the improvements in outcomes required. In doing so, we have benefitted from the support of our nominated buddy, University Hospitals Birmingham NHS Foundation Trust, and wish to continue this relationship in the longer term. The Trust was inspected by the Chief Inspector of Hospitals on 23rd, 24th & 25th April The Trust expects a final report and outcome from the inspection within the next few weeks. In the meantime the Trust is addressing the matters raised during the visit. A Quality Summit will be held following which the CQC report will be made public. 3.4 Financial Performance Challenges Since last breaking even in the Trust has incurred income and expenditure deficits. Audited Income and Expenditure Accounts show these have reduced year on year to only 1.8m 8

9 in following a period of turnaround the previous year. However after two month s performance the Trust s forecast deficit for is 10.6m compared to a plan of 3.0m at the start of the year. To get a better understanding of the causes of the continuing financial challenges the Trust commissioned independent financial advisors to review its historic financial performance and identify key drivers of the deficits it is incurring. The advisors concluded that: Whilst the Trust s financial position on the face of I&E has been improving since FY12, once the deficit is adjusted for non-recurrent items the financial position reverts to a year on year increasing deficit. Although the Trust is achieving high levels of CIP, these have not been sufficient to offset reduced levels of clinical income and increasing cost pressure. In addition CIP programmes are not 100% achieved thus creating further pressure to the financial performance. The Trust is experiencing high employee costs pressure due to Keogh review since early FY14 and been having difficulties to recruit permanent staff thus high number of agency is used. There may be opportunity for big ticket savings in length of stay for non-elective frail elderly patients, reduced use of agency staff and improvement in day case ratios. The independent reviewers recommend that financial governance controls be strengthened in the light of these findings and there be more robust activity and workforce forecasting systems put in place. These are key deliverables within the early months of the operating plan. The implications for productivity, efficiency and CIPs are described later in this plan. 3.5 Capacity and Capability to deliver the 2 year plan 9

10 The Trust recognises that transformational change and much greater capability and capacity is required to maintain the improvements in quality and make a step change in financial performance. The Trust s five year strategy sets out how it proposes to do that. Over the course of the last 6 months the Trust has invested in additional capacity to address both internal and external challenges. With the exception of the addition of the Director of Governance role, the Executive Team is established with a core set of skills and competencies to be able to address the current challenges. Moving forward and over time the team will be complemented through the use of more commercial skills, either on an ad hoc basis or via a strategic partnership approach. The capacity and capability challenge for the 2 year period broadly breaks down under two headings; addressing the delivery of the 2 year plan and laying the foundations for the longer term 5 year strategy. The Trust has refreshed its Programme Management Office in the last few months in order to take account of the challenging CIP programme for the next two years, and will be key in supporting the 2 year plan to drive efficiencies through the organisation. Specialist skills on Estates and Facilities and creating theatre opportunities are already in place to support the programme. At the same time, there is significant work to be undertaken in order to ensure that the Trust is well placed to respond to Commissioning Plans and much more fundamental changes to its operating model. Whilst these changes might not take effect until the second half of the 5 plan, the Trust must be in a position to capitalise on opportunities in a proactive rather than reactive way 10

11 4 QUALITY PLANS 4.1 Trust Vision In the light of the challenges described above the Trust has refined its vision, goals and objectives. When the people in our community need healthcare they will look to Burton Hospitals NHS Foundation Trust This vision means we will: Be a provider that our community recommends not just for hospital care, but for healthcare - because we are offer high quality and easy access to specialist capability Understand and listen to our community this includes the public, our patients, our staff, our carers and our GPs Evolve with the changing landscape of healthcare and take a lead on innovative approaches to delivering care Accept where we cannot sustain a specialist service and ensure our community trusts us to bring it the best alternative provider from our partners This vision implies we will need to be a very different type of organisation within the timeframe of this strategy. Specifically we will be far more proactive at engagement with the system, operating along more of the patient pathway (in a lead integrator role), enhancing our capability and capacity to deliver change by partnering with others where it makes clinical and/or financial sense, maximising our market share of the catchment population and reducing our estate footprint for core services only. 4.2 Goals & Objectives The goals and objectives have been designed to ensure we demonstrate our progress with achieving this vision. Goals Objectives 1. To completely transform our approach to engaging with and understanding our community 1.1. A wholesale change in our approach from passive, reactive engagement with public, patients and GPs (i.e. waiting for them to need help) to conscious, proactive engagement 1.2. A continuous and live understanding of our markets a radical change from annual contracting and a reactive culture to a richer and continuous understanding of what our community needs, the issues our commissioners are facing and what our competitors are doing to allow us to adapt our strategy and services far more quickly 2. To deliver an evolved clinical model Independent assessments demonstrate a recognised transformation in the way we engage with key stakeholder groups public, patients and GPs Implemented and embedded with demonstrable outputs, a new process to continuously update our understanding of our community s healthcare needs and the issues with healthcare provision 2.1. Have the ability to continuously examine the sustainability and clinical viability of our services 2.2. Have a working and commercially effective partnership model for clinical services to deliver clinical viability and support change 2.3. Have an outward looking culture that seeks out best clinical practice, learns from the wider system and understands what its competitors are doing well 2.4. Implement key changes to our clinical services Renewed acute model of care that emphasises proactive care and rapid access to specialist support with lowered non-elective admissions and reduced dependence on A&E Top decile performance on PROMs in year 5 Top decile performance on relevant clinical outcome measures vs our peers Best in peer group on Family and Friend Testing Top decile non-elective admission rates & readmission rates (vs. 2012/13 benchmarks), outpatient first to follow up ratios Top decile performance on key operational and quality measures 18/52s, 4 hour A&E targets (vs. 2012/13 benchmarks) 11

12 Goals Objectives A well developed and innovative set of out of hospital services that offer proactive support for the elderly frail and those with long term conditions A top decile elective centre for quality and efficiency 3. Implement a radical new and efficient business model 3.1. A significantly smaller estate footprint to lower running costs and new, fit for purpose, estate where required 3.2. Effective, recurrent delivery of cost improvement schemes, year on year 3.3. Partnerships including joint ventures and outsourcing arrangements to deliver all non-core services and functions wherever we can get better value and/or to deliver new revenue streams 3.4. Integrated IT and technology that supports a healthcare provider with services in a hospital, in primary care and in community care 4. To create a step change in our delivery capability and organisational effectiveness 4.1. Governance that assures the future as well as the present 4.2. A strategic culture amongst the leadership for the Board and our Clinical leaders 4.3. An effective programme of staff development and a workforce willing and able to deliver change 4.4. Fully developed, integrated service line reporting and service line management 4.5. Alignment of strategic and operational priorities with performance management 5% surplus from clinical services and a positive underlying surplus Proportionately lowest estate running cost and back office function cost in our peer group Material performance improvements where partnerships are implemented 100% appraisal rates 100% of identified clinical and managerial leaders to have been through a new development programme Top scores on independent governance assessments e.g. vs. QGF and BGAF We believe delivery of these goals will enable us to exploit the opportunities we have through: Building on our strong local presence with support from the CCGs and residents in our catchment Exploiting our key strategic assets such as the elective treatment centre and community hospitals Changing our delivery models to meet the increasing demand for healthcare in more innovative ways Repatriating patients flowing out of area as our reputation for quality improves as identified by the distressed health economy review Engaging our staff in the vision for a vibrant and successful future for the Trust The operational plan represents the first two years of this journey. 4.3 Clinical Model For Acute Services we plan to continue offering a very warm site. This incorporates a full suite of District General Hospital (DGH) services, 24/7 accident and emergency services and some specialist services. However a range of specialist services are acknowledged to be not clinically viable for BHFT to provide and these have been offered to other partners to provide as shown in the figure below: e.g. vascular surgery to University Hospital North Staffordshire NHS Trust (UHNS). 12

13 For Community Services the Trust intends to focus on elderly and vulnerable people as this closely matches the future commissioning strategy. The service would consist of a broader range of services than BHFT currently offers and mean working in partnership with other providers NHS, social care and third sector to deliver the full range of required care. 4.4 Partnerships The Trust Board is in discussions with University Hospitals North Staffordshire NHS Trust to enter a strategic partnership, to share expertise, provide cross organisational support on patient safety and efficiencies and also to provide capacity and workload to allow UNHS to concentrate of tertiary work whilst Burton uses its spare elective capacity to free resource at UNHS. Currently discussions are at an early stage, however the Trust Board has set a timeline for there to be a heads of terms in place by September 2014 and the partnership to start in April In addition to the strategic partnership with UNHS the Trust will investigate setting up a joint venture with the private sector to provide support to the Trust in terms of management capability and potentially access to capital. This support is being reviewed with an expectation that it will cover commercial support (e.g. market share enhancement, bidding for contract), estates planning and reconfiguration, care pathway development and delivery of change. The Trust is currently engaged in soft marketing, but anticipates starting a tender process by the end of August 2014, with commencement of the contract being dependant on the form of tender (e.g. EU open procurement or based on national framework agreements). The sort of tender will ultimately depend on the extent of the support, this decision will be made once the soft marketing is completed. 4.5 Engaging with Our Staff In support of the Trust s objective to engage and empower its staff, there are two significant work streams that will underpin the Trust s two year operational plan. The first is in respect of internal communications, having established a plan to improve communications across the Trust and its three sites. Through its Keogh Action Plan the Trust has taken a number of actions to improve visibility and communication at both Board and Executive level. The focus going forward will be to empower both senior and middle managers to achieve a greater consistency and flow of communication. The second work stream specifically relates to Listening into Action and the Trust s ambition to fundamentally shift the way that we work and to put staff at the centre of its change programme. 13

14 During March and April the Trust the Executive Team will undertook a number of staff conversations from which a programme of work will be established that will support, either directly or indirectly, the delivery of the Trust s objectives. 4.6 Quality Strategy The Review of Quality of Care and Treatment by Sir Bruce Keogh in May 2013 represented a sobering call to action and we have already put in place all of the work highlighted by the review as needing immediate attention. Much of this focussed on workforce planning, improving training for ward nurses and healthcare assistants, reducing the need for agency and bank staff and improving the experience of junior doctors and student nurses. However, we are committed to going far beyond the remit of these specific recommendations. As part of this programme the Trust refreshed and re-launched the Quality Strategy of the Trust. The key strategic objectives of the Quality Strategy 2013/15 are: Consistently Safe ensuring that essential patient care is safe, effective, positively experienced and delivered to a consistently high standard Consistently Effective ensuring high quality of care for all people using the service and reducing the variation in clinical practice Perceived in a positive way by patients continued development of the patient experience, with particular focus on the patient journey, and ensuring effective communication between staff and all patients and carers. Our approach is built on: Developing real time patient feedback in all wards and departments and acting on it locally (including a rating of whether the patient would recommend the hospital) Developing the range and quality of public and patient information in consultation with patients and carers Defining the values and behaviours that we expect from our staff and embedding these through recruitment, induction, development and appraisal Using all forms of feedback to influence how are services are developed, delivered and evaluated Embedding our patient promises in the way we work with patients, families and carers. 4.7 Consistently Safe While acknowledging that healthcare environments inevitably carry risk of harm to patients, we have clearly asserted that any incident of preventable harm is unacceptable. We have put in place appropriate measures to minimise the risk of harm, set up robust systems to ensure that any incidents are identified, reported, escalated and monitored, and established processes to ensure that learning from incidents is embedded and shared to support the reduction in variation in practice. We are also committed to being transparent with our patients when harm has occurred in a manner that is timely and open. In order to achieve this we intend to minimise the risk of harm to patients by reducing or eliminating: Pressure ulcers VTE Healthcare acquired infections Avoidable Incidents And by enhancing: Management of Acute Kidney Injury Management of the Acutely Ill /Septic Patient 4.8 Consistently Effective 14

15 The Trust is focussing on three particular elements of patient care to reflect and facilitate the changes needed to address the short term and longer term challenges identified in our plan, these are: Mortality monitoring trends and performance, and demonstrating lessons learnt Learning from Serious Incidents and incidents Building on ward assurance through the introduction of the ward toolkit. 4.9 Positive Patient Experience The Trust is consistently delivering performance in excess of 70% for the Friends and Family Test. In 2013/14 the Trust was one of the highest achievers in the region for operational performance in the Emergency Department while maintaining amongst the highest patient experience scores in that Department. In keeping with our strategic intention to move well beyond the minimum standards expected we have set ourselves challenging stretch goals in this area, including: Consistent and positive patient discharge procedures Reduction in formal complaints Wider engagement with patient groups Focus on delivering compassionate care, embracing the 6Cs at all levels and introducing the touch point methodology Engagement with minority groups within our community. Patient Promises: We will always be approachable and acknowledge that you are there We will treat you in the way you would expect to be treated with consideration and respect We will be polite, professional and courteous We will listen to what you tell us your opinions are our opportunity to improve We will admit our mistakes and do all we can to put them right We will talk to each other so that we can care for you better We will be caring and kind Commissioning for Quality and Innovation (CQUIN) Commissioning for Quality and Innovation (CQUIN): 2014/15 Guidance issued in December 2013 notes that CQUIN monies should be used to incentivise providers to deliver quality and innovation improvements over and above the baseline requirements set out in the NHS Standard contract, whether this be incremental improvement or radical service redesign. It is recommended that there is a maximum of 10 local CQUIN goals per contract. CQUIN is set at 2.5% value for all healthcare services commissioned through the NHS standard contract, excluding high cost drugs, devices and listed procedures. As a minimum one fifth of this value (0.5% of the overall contract value) is to be linked to national CQUIN goals. Variations are acceptable if three principles are followed the best interest of patients, promoting transparency, and constructive engagement of Providers and Commissioners National CQUINs Goal Number Indicator Number Indicator Name Indicator Weighting (% of CQUIN scheme available) Expected Financial Value of Indicator 1 1a Friends and Family Test 1.50% 47,866 implementation of staff FFT 1 1b Friends and Family Test early 0.75% 23,933 implementation 1 1c Friends and Family Test 0.75% 23,933 increased or maintained response rate 1 1d Friends and Family Test 2.00% 63,822 increased response rate in acute inpatient services 2 2 NHS Safety Thermometer 5.00% 159,554 15

16 Goal Number Indicator Number Indicator Name Indicator Weighting (% of CQUIN scheme available) Expected Financial Value of Indicator improvement 3 3a Dementia Find, Assess, 1.67% 53,291 Investigate and Refer 3 3b Dementia clinical leadership 1.67% 53, c Dementia supporting carers of 1.66% 52,972 people with dementia 4 4a Safe and effective management 56.00% 1,787,006 of non-elective patient s 4 4b Supporting effective discharges 9.00% 287,197 within a hospital setting 4 4c Improved communication 10.00% 319, Medication safety thermometer 5.00% 159, Sepsis care pathway 5.00% 159,554 TOTAL % 3,191, Local CQUINs At least 2% of the total contract outturn is attributable to local CQUINs. There is a national pick list of validated indicators to assist Commissioners in deriving an agreed CQUIN. CQUINs must be agreed and validated before contracts can be signed. Templates for any new local CQUIN must be published to the NHS England site. The Commissioners have identified 3 local CQUINs. Local CQUIN negotiations continue and the Trust has rejected the safe and effective care proposal from the CCG which does not appear to fulfil the quality aspirations of CQUIN. The Trust would favour local CQUINs directed to the priorities noted in this Annual Plan, namely Mortality, Patient Safety, Frail Elderly Care and End of Life care. It is noted that the NHS England pick list contains a number of CQUINs of this description Board Assurance The Trust received a Board Quality Governance Assurance Framework assessment from Deloitte in The Trust is addressing the action plan that arose from that report. It is the intention of the Trust to commission a follow up scored assessment in the summer of 2014 to confirm that the actions taken have addressed the issues raised and that the Board of Directors is able to take assurance that the Quality Governance framework of the Trust is operating effectively. The Trust has been working with the Good Governance Institute to review Governance and Risk Management structures and has appointed an interim Director of Governance with a view to seeking a permanent appointment in this role in 2014/ Risks to Quality and Mitigation The Trust maintains a comprehensive risk register and key risks to the achievement of Trust objectives are recorded and monitored through the Board Assurance Framework. The following risks have been identified for the purposes of this 2 year operational plan: (a) (b) Failure to provide patients with a positive patient experience from our services. The risk is mitigated by ensuring that mechanisms are in place to both capture and act on patients feedback, and that standards of privacy, dignity and respect for all service users are at the forefront of all operational planning The Trust s Governance, Risk and Assurance Committee retains oversight of this risk on behalf of the Board Failure to improve patient safety and eliminate avoidable harm. 16

17 The risk is mitigated by have the appropriate staffing levels across all departments, the ongoing focus on reducing healthcare acquired infections, and the utilisation of recognised pathways, protocols and guidelines The Trusts Governance Risk and Assurance Committee retains oversight of this risk on behalf of the Board 17

18 5 OPERATIONAL REQUIREMENTS AND CAPACITY 5.1 Activity The Trust has seen an overall increase in Non-Elective admissions over the past 3 years, mainly driven by the General Medicine and Care of the Elderly sub-specialties. July 2011 to March 2012 compared to July 2013 to March 2014 saw an increase of 3% in activity. (Obstetrics admissions have declined by almost 5% over this period). Elective admissions have reduced significantly over the 3 years (5681 in 2011/12, 4557 in 2013/14). This trend is across all the main surgical specialties, with significant numbers of procedures moving from inpatient to day case. Until July 2011 the majority of Day Cases were contracted to the independent Treatment Centre. However, a comparison of the last two years (2012/13 and 2013/14) shows a 9% increase in activity on the main site, (although the declining activity in the Community Hospitals reduces this to 4.4% for the Trust as a whole). Again the increase is across most surgical specialties, particularly ENT and Ophthalmology. Urology day case activity has decreased in recent months because Flexible Cystoscopies have moved to an outpatient setting. The biggest increases in new out-patient attendances are in Medical specialties (Gastroenterology, Neurology, Respiratory, Neurology, Rheumatology) and Paediatrics. Follow-up attendances rose in line with new during 2011/12 and 2012/13 but have since reduced in 2013/14, representing an improved new to follow up ratio. Outpatient procedures have risen significantly over the last 3 years (from 23,698 in 2011/12 to 42,108 in 2013/14 on the main site), mainly in Urology, ENT and Ophthalmology. A large part of this increase is due to greater coding of outpatient procedures. The Trust opened an acute assessment centre (AAC) on 27th August This has had an impact on A&E attendances in that there has been a reduction in the number of GP referrals to A&E (a reduction of, on average 367 a month) as these patients now go more appropriately to AAC. Over a three year period the number of patients arriving at either A&E or AAC has remained relatively static seeing only a very slight upward trend, however since March 2014 there has been a large increase in the number of A&E attendances, up an average of 458 per month in March, April and May compared with the three previous months. The baseline plan assumes that activity continues in accordance with current plans and known developments in individual service lines. It is upon this baseline plan that the implications of this strategy are modelled. The baseline plan defines the following key growth factors: - 2.8% growth in Non-elective General Medicine and the AAC, compensating for a relatively low growth rate of 1% in A&E attendances (following an underlying historic trend) - 0% growth in Obstetrics driven by a strong trend of reducing birth rate and reducing impact of immigration - Growth of 2.5-3% in General Surgery (to reflect the Bowel Scope Screening Programme), ENT, Haematology and Ophthalmology day-cases driven by strong underlying growth - Growth in Cardiology as the catheter laboratory becomes further established and the range of procedures offered increases - Continued shift in point of delivery from elective inpatient to day-case, and from day-case to outpatient procedure. Applying the strategic opportunities identified above to the baseline plan generatd the activity for the Trust s strategic plan. Furthermore, a downside scenario assumes that commissioner plans to reduce activity at BHFT are achieved more quickly and more fully than the Trust s strategic scenario. It is important to note that the downside scenario mirrors commissioners intentions, but does not fully the activity shifts proposed. 18

19 Capita were engaged in order to model the capacity requirements resulting from each of the scenarios. The table below sets out the three scenarios: Scenario 1 Baseline Plan Scenario 2 - Strategy Scenario 3 Downside Underlying activity trend The baseline plan (as identified through modelling and division discussions) The baseline plan (as identified through modelling and division discussions) The baseline plan (as identified through modelling and division discussions) Commissioner Plans/Reducing non-elective admissions and follow-ups to create capacity Non-elective growth/ Follow-up growth at current trends Mirroring commissioner intentions, with non-elective reduction over years 3, 4, 5 to 8% in year 5 (vs. 14/15 plan) Follow up ratio reduction from 1.8 to 1.3 Large reduction in nonelectives (12% reduction by year 5 vs. 14/15 plan), which is considerably less than CCGs are suggesting (24%). It has also been assumed, unlike the CCG modelling, that these changes are back, not front, loaded. It is also assumed that A&E attendances reduce by 27% (55% suggested by commissioners) Community expansion No expansion assumed Long term conditions PIN is won resulting in 11m additional income from 16/17 PIN not won no community expansion Margin growth on the additional income to 8% by year 2 Repatriation of activity and partnerships with other providers Nothing assumed Elective/ Day-case and outpatient procedure growth in years 2, 3, 4 with the same margin assumed, due to repatriation of activity (based upon the triangulation of separate information from CHKS, Dr Foster and KPMG) Elective/ Day-case and outpatient procedure growth halved from years 2, 3, and 4 with the same margin assumed. This is either because CCGs do not support share gain or the growth is more difficult to achieve than anticipated Capacity implications No expanded treatment centre assumed. Sale of building in the short term No expanded treatment centre assumed. A decision will be made in year 3 of the analysis. Sale of building in the short term No expanded treatment centre assumed. Sale of building in the short term Community hospitals No change dependent upon outcome of public consultation No change dependent upon outcome of public consultation No change dependent upon outcome of public consultation The table below sets out summarised activity levels within each of the scenarios, as expected in the year 2018/19, including community hospital activity: 19

20 Point of Delivery (PoD) 2014/15 Plan Activity (2018/19) Scenario 1 Baseline Scenario 2 - Strategy Scenario 3 Downside Elective inpatients 4,137 4,157 4,491 4,420 Elective day-cases 27,367 29,561 29,874 29,574 Non-elective inpatients 32,065 33,882 32,075 29,755 Outpatients (first) 80,851 83,539 83,539 82,275 Outpatients (follow-up) Outpatient procedures 172, , , ,358 53,632 56,353 56,879 56,879 A&E attendances 56,689 58,991 58,991 44,222 The table above demonstrates the effect of the Strategy scenario, reducing non-elective admissions and outpatient follow-ups from the baseline through the delivery of the PIN and working to achieve commissioner intentions, with this being replaced by elective and day-case repatriation resulting from the partnerships formed, and from work with GPs to address gaps in market share. This elective work is delivered at a better margin, with no stepped increase in capacity as space is reused. The downside scenario (which moves closer towards commissioner plans) reduces non-elective admissions further, as well as significantly reducing A&E attendances. Although growth in elective and day-case work is achieved, this is insufficient to fill the capacity created by the loss of such a significant level of non-elective work. The trends for each of the scenarios for outpatient procedures, day-case and elective combined and non-elective admissions can be seen in the chart below: The effect of the downside scenario can be seen most clearly in its impact on non-elective admissions, with the reducing rate assumptions causing a sharp decline from 2016/17. It should be noted that this assumption is based upon commissioner intentions, however it does not reflect the full reduction in non-elective admissions that CCGs have suggested. 20

21 Although the Strategy scenario does not facilitate large scale increases in total activity, it does include the creation of a new service providing out of hospital care as part of a Lead Provider contract. The recent PIN issued by commissioners is likely to create immediate opportunity for the service to be developed, with future growth in these types of services and contracts providing a key element of BHFT s plan for sustainability, and supporting the reduction in non-elective activity seen in the chart above. The Strategy scenario also enables the Trust to operate on an increasingly planned cost base, with the reduction in non-elective activity and growth in repatriated elective are. This will facilitate the organisation s required improvement in productivity and efficiency, with an increase in planned work leading to better flow through the hospital and, for example, fewer cancellations, a reduction in waiting list initiatives and less of a reliance of agency staff. This will therefore support the Trust in improving the margin made on activity, thereby facilitating the achievement of CIP targets. 5.2 Capacity The capacity analysis identifies, that should current length of stay performance be maintained, the baseline activity projections would require an additional 48 beds. The strategy scenario, despite the growth in more profitable work, would require only an additional 23 beds. Moving to upper decile in length of stay in the Strategy scenario achieved through the improvements in flow identified above would in theory allow a reduction in beds from the current establishment (by 14 beds). On this basis, the Trust is not planning on expanding its bed base as part of this strategy. 5.3 Changes to key service lines Each Clinical Division has written a Plan for the Operational period 2014/16 in order to inform this Trust Plan. Changes to key service lines are summarised in the table below. Service Frail Elderly Care Pathway and Intermediate Care services - Growth Change The Trust Length of Stay project includes implementation of a new frailty team, joint redesign of the complex discharge pathway with our partners in the Staffordshire and Stoke on Trent Partnership Trust (SSOTP), closure of Ward 44, and a review of alternative models of care closer to the patient s home. The closure of Ward 44 to new admissions is planned for the spring of The phased closure of the Ward over the summer requires action from partners to put in place services to maintain the cohort of patients on the ward in Community or home settings. In addition, it is likely that some 50% of the current cohort of patients will need to be absorbed within the main site bed stock. The Trust has commissioned an audit of the patients to identify the clear pathways required. The plan will require some estate reconfiguration to accommodate the acute rehabilitation beds noted. The decision will also impact upon the income received by the Trust for rehabilitation. The plan will be developed for submission to the Better Care Fund as a key project for the frail elderly priority. Funding will be sought to bridge the transition of the service to a final frail elderly care pathway which we believe should be supported by a locally modified pathway tariff. It is anticipated that the transition will take at least two years to complete. In 2012 the Board of Directors agreed a strategy to refocus Community Service provision on the most vulnerable group of patients. Commissioners have signalled an intention to tender services for both intermediate care and long term conditions, although at the time of writing there is little detail available of how this tender might impact the Trust or be presented. The frail elderly care pathway programme is intrinsically linked with the Trust vision for Community Services. The Trust has undertaken a significant engagement exercise drawing on the views of staff, service users, non-statutory sector partners, commissioners, Borough Councils and other NHS providers through engagement events. The Trust is seeking, in the short to medium term to utilise space in the Community Hospital in Tamworth by leasing ward space to the Mental Health provider for South Staffordshire and Shropshire, leasing theatre space to Cross City CCG for their new assessment model, and to reconfigure the remaining bed space to meet the anticipated needs identified for intermediate care. 21

22 Service Change The Trust is seeking to reconfigure the space in the Community Hospital in Lichfield to meet the anticipated requirements of the Intermediate Care and Long Term Conditions tender. The Trust is currently building a strategic shortlist in order to develop more detailed proposals. The intention is to build the volume and value of Community services closer to the patient home, sustain the use of the Community Hospital assets, increase the margins in service lines within this Operating Unit and consolidate service lines where margins are weak and unlikely to recover given the scale of the services offered. This project is led by a senior project lead and the Board of Directors will consider first options in April 2014 with a view to full Business Cases after discussions with local stakeholders, for purposes of the plan implementation has been assumed as post the General Election in be 2015/16. Long Term Conditions Growth and Partnering Commissioners have undertaken a market research exercise to establish the willingness of providers to deliver a horizontally and vertically integrated and multi-agency Long Term Conditions service. Services are currently provided by a combination of primary, community and scheduled and unscheduled secondary care providers. There is some involvement of third sector providers. Commissioners for East Staffordshire, Stafford and Surrounds, and Cannock Chase have combined for this exercise. The model envisaged is a lead/prime provider model to ensure effective integration across the statutory and nonstatutory sector. The Commissioners wish to move to an outcome based commissioning agreement for these services, informed by the NHS Public Health and Adult Social Care outcomes framework, particularly outcome 2: enhancing quality of life for people with long term conditions. The model envisaged by Commissioners relies increasingly on assistive technology and the use of direct payments and personal health budgets. The prime provider model is seen as a means of increasing the critical mass of the Trust, however, the Trust will need to assess whether the service represents integration or diversification and whether there are true economies of scale from the possible tender. The Trust does, however, plan to explore the resultant contract tender and is currently working with Commissioners to support changes to the Long Term Conditions services provision in our catchment area. Hyper Acute Stroke Service Partnering and divestment The Local Health Economy plans to create a Hyper Acute Stroke service at Derby Hospitals NHS Foundation Trust supported by stroke services at BHFT and Stroke Rehabilitation services at Staffordshire and Stoke on Trent Partnership NHS Trust have been significantly delayed. The Trust plan assumes continuation of the current service model in 2014/15 and 2015/16 although it is anticipated that the longer term service plan will identify this area as one of particular focus. Endoscopy - Growth Derbyshire Screening Centre (covering both Derbyshire and East Staffordshire) was in the first wave of the Faecal Occult Blood tests (FOBt) screening programme for bowel cancer. A new screening programme utilising a one-off flexible sigmoidoscopy (FS) is currently being rolled out across the country. This is initially being targeted at centres with successful age extension of the FOBt programme and proven resilience. Derbyshire Screening Centre has recently been approved for the programme by the national office following a Quality Assurance visit in January The second wave of the programme roll out commences in April It is anticipated that this will result in increased demand of between 6000 to 8000 examinations per 1 million population. The catchment area of Derbyshire and East Stafford is approximately 1.13 million. 5% of examinations are expected to result in the need for colonoscopy. The activity increase for colonoscopy has been built into the Trust baseline assumptions in partnership with our neighbouring acute providers. Radiology Services The Trust has undertaken a number of reviews of its radiology services both in terms of efficiency and sustainability and has concluded that a strategic 22

23 Service Partnering Implementation of Electronic Medical Record Transfer of Fertility Services Pathology Services - Partnering Theatres Growth and Partnering Change partnership for the future provision of radiology services is the preferred option for the delivery of this service. The Trust will therefore develop a series of options, for formal evaluation, for moving the service by the end of 2014/15. The enquiry of the market will be framed to move the Trust towards the longer term objective of ensuring optimum care no matter the hour or day of delivery ( 24/7 ). The Trust has recognised that it needs to strengthen the management of its ICT, information and performance regime and will be recruiting a Chief Information Officer to provide specialist skills to lead this function, reporting to the Director of Finance. During 2014/15 an updated IT strategy will be created. This strategy will address not only the Trust s IT infrastructure, but also an information strategy and the proposed upgrade to the Meditech system. The Burton Clinic for Reproductive Medicine is a small IVF service with a mixed market of NHS and private fertility work and primary care testing. The Board of Directors has considered a business case for the transfer of this service to a private supplier. The Business Case notes that future growth of the service requires considerable capital investment in laboratory assets and the regulatory framework which can only be supported through increased scale. The case concluded that transfer to a private supplier would preserve the local service and mitigate the capital and future sustainability risks of the service. The private provider has guaranteed the contribution to Trust overheads for a two year period and will continue to purchase services from the Trust while the service is located at Queen s Hospital. The Service with an annual turnover of 0.6 million will transfer in April The Trust has agreed to partner University Hospitals Coventry and Warwick NHS Trust for pathology services, the anticipated start date for the transfer will be April The Trust has significant physical capacity in terms of available Theatres. We have identified that current activity could be consolidated into a reduced number of Theatres. The realisation of this efficiency, through improved scheduling, opens up immediate opportunities to either close capacity or to apply this capacity to activity not currently undertaken. Initial discussions with partner organisations are exploring the concept of an elective partnership model similar to the South West London Elective Orthopaedic Centre model or the Avon Orthopaedic Centre where a number of organisations utilise a cold elective site to repatriate activity from the private sector or from premium sessions within their own organisations. A senior Programme Manager is attached to the Surgery Division to implement the plans. Those plans identify efficiencies in 2014/15. Further development of partnership models will follow when it is clear that the Trust can vacate the capacity required to support a partnership model. Plans for 2014/15 recognise the efficiency target noted but do not include the partnership model which will require a Business Case by September 2014 to implement in 2015/16. 23

24 6 PRODUCTIVITY, EFFICIENCY and CIPs 6.1 How the Cost Improvement Programme is Managed The Chief Executive has established a fortnightly CIP Monitoring Group Programme Board, this is attended by project sponsors, lead clinicians and project leads. The PMO supports the Chief Executive and the CIP Monitoring Group providing oversight of the programme with regular monitoring and exception reports. The CIP Monitoring Group provides Executive and Clinical level scrutiny, assurance and delivery support for the programme. This meeting has a duel role of scrutinising the delivery of existing schemes and commissioning new schemes via a project gateway process. Project workbooks are developed for all schemes to pass through Gateway One, a summary of the project and an outline QIA is presented. To get through the Gateway Two approval process a full workbook must be completed which would mean the development of a full brief, a project plan with key milestones, finance and KPIs, risk register and a QIA approved. The group also provides peer challenge to schemes to assist the Chief Executive to hold the organisation to account. The group will receive progress reports on the delivery of the programme, challenging and supporting where schemes are off track and ensuing corrective action takes place. Actions and decisions are logged, risks/issues are reviewed and change control is in place to ensure the overall delivery is in a controlled environment. 6.2 CIP Work streams The programme has five work streams: Clinical Effectiveness Corporate Commercial Workforce Divisional Efficiencies* The work streams have been established and meet fortnightly steer the delivery of a portfolio of CIPs. The work stream his chaired by and Executive Director, the group is consists of a clinical lead, projects leads supported finance, HR, Information and PMO. It is the responsibility of the workstream to deliver their savings targets. The group will drive the delivery of projects and report to the CIP Monitoring Group. Responsibility for the delivery of Divisional Efficiencies rests with Divisional Associate Directors and their managers. 6.3 Quality Impact Assessment Review All schemes are required to be supported by a Quality Impact Assessment (QIA) to be completed by the relevant project lead with full engagement of clinical colleagues as appropriate. The QIA will need to be approved by the Medical Director and Director of Nursing with support from a member of the PMO team before it can be signed off at Gateway 2. At this point the start of implementation of the project can take place as there is surety that there is no adverse impact on quality and/or patient safety. This process will report into Governance, Risk & Assurance Committee. 6.4 Cost Improvement Projects Life-Cycle The CIP Life-Cycle typically goes through a process as described in this section; Identification, Planning, Delivery, Monitoring and Evaluation. Identification The Trust has identified opportunities and projects through central analysis of data, the input of external support, the input of the Programme Management Office senior lead and project plans within the library of schemes collected over the last 3-4 years. The Trust has also used benchmarking from sources such as: Better Care Better Value 24

25 Estates and Facilities Management Information Systems (ERIC) Payments by Results Benchmarking Tool Albatross patient level costing benchmarking system A range of external reports from other areas by agencies such as NHS Benchmarking Club, Dr Fosters, CHKS and CIPFA. Areas of variation have been identified for further analysis and development. Schemes are developed to Project Plan level using the Trust Programme Management Office workbooks. Planning The planning process makes use of a project work book and the commissioning of the projects follows a gateway process. Gateway One requires a project summary and an outline QIA. This is taken to the CIP monitoring group who will approve or reject the scheme. If the scheme is accepted the project lead will complete the project workbook fully which will include: Project Plan with key milestone Financial Plan and savings profile Full QIA and approved by Medical Director & Director of Nursing Executive Sponsor and Clinical Lead Assessment of resources required to deliver Once the above criteria has been met the project will be taken through Gateway Two and once approved the scheme will be delivered as a stand-alone project or has part of a portfolio nested in a workstream. The larger schemes are supported by additional programme management resource that is either protected within existing Trust resources or is purchased through interim or consultancy support. This additional resource is placed as close to the operational service delivering the scheme as possible. Delivery The Trust supports the delivery of the CIPs through the establishment of a Programme Management Office and placing resource as close to service lines as possible. Dedicated programme management support is provided for a range of schemes where appropriate. Cost improvements are tested with Divisions and service lines and when the savings opportunity has been tested and accepted the budgets are removed from Divisional budgets. Divisions are then held to account for benefits realisation through the existing performance management arrangements of the Trust. Divisions have been asked to identify a basic efficiency saving of 1.5% in 2014/15 to reflect the net efficiency requirement of the tariff deflator as a basic business as usual target. A similar process will be in place for the following years. The cross-cutting CIPs are delivered with the support of an Executive Sponsor who chairs a work steam group that steers the delivery of portfolio of schemes. Delivery for the first two months has been disappointing and the Trust has forecast that of the 11m planned CIPs there is only 7m of CIPs where there is a degree of confidence of delivery. The Trust is continuing to develop a range of fora to help identify additional CIPs to add to the programme and to create a pipeline of CIPs for the future. Monitoring The Programme Management Office meets with workstreams to assist the leads to self-assess progress (RAG rate) and to provide the Chief Executive with an independent view on progress (process and financial). The CIP Monitoring Group meets fortnightly and reports exceptions (Red schemes) for escalation. Escalation for Red rated schemes is initially through the Director of Finance and appropriate Executive Director and ultimately to the Chief Executive. CIP leads are required to identify mitigating savings for schemes that have been accepted but where benefits are not being realised as planned. The detailed reports from the CIP Monitoring Board are summarised and reported 25

26 through the monthly report to Finance and Investment Committee. A summarised version of the monthly report is taken to the public Board meeting on a monthly basis. Evaluation The Trust has developed a post project evaluation model that is applied to all material projects and to any schemes where the respective governance bodies wish to seek assurance. The Trust Internal Audit Plan contains dedicated resource to assess effectiveness of the Cost Improvement Plan. 6.5 CIP Schemes The table below illustrates the portfolio of projects and schemes that make up the programme and the savings to be achieved in 2014/15 and 2015/16. The two-year plan of the Trust identifies a target saving of 7m (4.6%) in 2014/15 and a further 7m in 2015/16. The table overleaf demonstrates how the forecasted savings will be profiled during this period. It is can been seen that a number of schemes that have been initiated in the current year have a part year effect and will continue to be delivered in the following year and that some of the more complex schemes that be required to take a procurement route will not deliver savings until 2016/17. 26

27 Since the development of the initial plan, the Trust has undertaken a risk assessment of the current portfolio of CIPs, and coupled with the intelligence gained from two months of delivery, the Trust has re-profiled the programme. All schemes are required to satisfy a gateway process the table below illustrates the current status as at June Work stream Delivery Programme Divisional Schemes Each of the divisions has been asked to identify a basic efficiency saving of 1.5% in 2014/15 to reflect the net efficiency requirement of the tariff deflator as a business as usual target. The Trust will be improving the business planning process for commencing the cycle much earlier in the year (summer 2014) which deliver more robust divisional and cross-cutting CIPs and to proactively influence commissioning intentions and business plans of key partners. The table below illustrates the current range of divisional schemes: Division Surgery Project Summary Non-Pay reductions in dental services, maternity services, critical care and theatres Point of Scale non-recurrent pay savings across a number of services including: surgical medical staff, theatres, surgery ward nursing, surgery management, pension savings Service and Workforce Review: posts are reduced to lower grades without impacting on the quality of service. Services include: Women and Children medical staff, anaesthetics medical staff, theatres, maternity services Other general Efficiencies 27

28 Division Project Summary Medical Community Services Corporate Divisions A&E Coding: This project changes the from the historic use of two codes to the full 10 codes available for treatment, this will allow for a more accurate description of what has happen to the patient at their attendance in ED Review of capacity and demand in Respiratory allowing the reduction in PAs Capacity and demand reviews for each specialty have provided an opportunity to reduce PAs A number of departments have recruited staff on lower points of scale including Therapies, Radiology, Wards 8,12,&44, Community Hospitals Pharmacy staffing & stock reduction in Community Hospitals, rationalising services across 2 community hospitals A range of other smaller schemes, 17 in total make including: Skills mix review, diagnostic tests, Income Generation MIU, Consistent medical model at both Community Hospitals Estate and Facilities: savings will be made from the following areas: transport, accommodation, catering, general estate, directorate Other corporate services including finance, information, IT, HR, Operations, Headquarters, Nursing and Quality Corporate Schemes The Corporate Schemes are made up of larger schemes such as procurement and coding, and smaller opportunist schemes such as CNST, incremental avoidance, year-end stock take and national pay award schemes. The Table below illustrates some of the detail behind the headline figures: Project Procurement Pharmacy / Healthcare Procurement Coding Other Corporate Schemes Project Summary The Procurement team is working with divisions to pursue a number of opportunities across a range of products and services. NHS Supply Chain to provide alternate product analysis, with projected could save up to 380k Materials Management to deliver their aspect of savings requirement targeting a 250k FYE, which has been phased from October. NHSSC to deliver West Midlands wide Audiology project, estimated to deliver 80k savings Ongoing management of savings work plan which contains detail for all projects Procurement are working in partnership the Pharmacy and Healthcare areas The approach taken to the achievement of savings will clinical engagement in Pharmacy, along with Healthcare, which relates to the work that is undertaken on our behalf by other NHS Trusts or alternative healthcare providers. A new head of Pharmacy starts with the Trust on 7 July Income improvement through coding depth and completeness. The Trust has engaged EPS research and acquired the use of the EPS Engage system to undertake development work with all Divisions on coding. The Coding department has been strengthened and supplemented with support from EPS and a series of workshops will be undertaken to improve the quality and depth of coding. A by-product of this work is likely to be an improvement in income and the average income per spell within the Trust. A Review of month 6 coding identified a gross potential of 1.4 million and net of 0.26 million compared to benchmark groups. A detailed review of month 6 data demonstrated a monthly improvement of 0.1 million Other corporate schemes include: CNST inflationary charge comparison, Incremental avoidance, year-end stock and national pay award Commercial Work stream The Commercial Schemes predominantly focus on a programme of outsourcing and market testing of a selection of clinical and non-clinical support services. There is also some scope to take some efficiency prior to going to market. Project Outsourcing inc. Hard & Soft FM, HSSU Project Summary The project has three stages: 1. Determine the existing suppliers and service specifications and baseline costs for each service. Assess productivity and quality of service of current providers including sub-contractors. Management and strategic decision making; TUPE identify potential in scope employees. 2. Agreeing the preferred operating model, Liaise with all key stakeholders and service 28

29 Estates & FM Efficiencies Outsourcing Pathology & Radiology Estates Rationalisation beneficiaries; Understand current industry best practice and standards; Identify potential internal strategic developments that may influence Conduct a full market research to assess supply market capability. 3. Building the procurement plan. Quantification the current cost, line by line. Identification of current specification and performance and future performance/cost. Market Services, evaluate bids and award contract. TUPE management. Management of change issues, communications, transition and transformation phases. A best practice review of estates and FM services has been undertaken, a number of schemes have been identified. Review of Maintenance Contract management Estates Review of Staff following Retirement Facilities Offensive Waste In Laundry, Stock Controls - smart cabinets, Food Waste, Linen The Trust has begun the process of outsourcing the Pathology Service to a preferred partner. A due diligence exercise is currently underway to understand the full inputs and output of the services ahead of the transfer of the management of the service. The Radiology service has been brought into scope and will follow a similar procurement path. The Trust has a medium term plan to decant services from the Outwoods site and gain capital receipts from land sales and reduce the maintenance costs through Estates Rationalisation. Savings in years 16/17-18/19 Clinical Effectiveness The Clinical Effectiveness Workstream has three substantial change projects: Project Length of Stay/Ward 44 Closure Theatres Outpatients Project Summary The Closure of Ward 44 is dependent on a number of projects. These projects are: (1) Development and implementation of a frailty pathway (2) Redesign of the complex discharge pathway (3) Alternative discharge providers outside of hospital. (1) Development and implementation of frailty pathway, in order to improve care for patients who are over 75 years old. This is a whole system approach and includes joint working between BHFT and SSOTP. A Frailty Team will be created which will be multidisciplinary. This work stream has significant dependencies on ensuring there is sufficient health and social care capacity in the community to care for patients and also on redesigning the hospitals complex discharge process to one which is more efficient. (2) Redesign of Complex Discharge. To redesign the Complex Discharge process within the Trust to ensure patients who are medically fit are discharged as soon as possible. BHFT and SSoTP have agreed to jointly fund and jointly undertake the redesign of this pathway to ensure there is one pathway for complex discharge which is understood between professions and organisations. (3) Provision of alternative discharge providers. To consider the need for and develop a range of alternative discharge providers to ensure all patients who are medically fit for discharge are discharged in a timely fashion. In 2014/15 savings will be made by the temporary closure of beds over the summer months and the closure of Ward 44 is planned for 1 April Based on the Trust requirement to improve performance and utilisation of the theatre asset, this scheme will deliver basic utilisation and efficiency transformation in order to achieve the national benchmark of 85% utilisation of the core components. This will include late starts, early finishes, gaps between cases and over runs. This will ensure that Medical and Theatre staff are all there and ready to commence at the scheduled list time with the correct equipment and staffing. This will be completed by the tested method of a 5 minute pre list "Huddle". Key benefits will be an increase in productivity that with additional cases undertaken, a reduction in workforce expenditure and a reduction in the waiting list initiative payments. There is considerable scope to improve the efficiencies, DNA's are around 10% compared with peer average of 8% and best practice of 6%. New to follow ups are high in some specialities. A work programme has been developed to deliver savings in the following areas. Income capture, ward attenders, improving the utilisation of clinics, N:FUs and DNAs. A three month pilot is being developed in a select number of specialities to introduce text messaging reminders to improve DNA rate. Workforce Workforce is by far the Trust's biggest area of spend. The Workforce work stream is developing schemes that will help to optimise the use of our staffing resource. The key to delivering benefits will be getting our staffing base right, implementing effective controls and protocols, their consistence adherence and intelligence systems to manage the process. Project Project Summary 29

30 Agency volume/bank optimisation Job Planning and Medical Productivity Waiting List Premium The Trust has set aside a budget of 2.7m to address the need of staffing wards at safe operating levels, recognising the requirements of the Francis Review, the Kehoe recovery plan and the national nursing template. In order to meet national standards the Trust like most others has had to rely heavily on paying premium rates to agency/bank staff. To combat this trend, the Trust has undertaken a proactive recruitment campaign, locally, nationally and internationally. Following a successful campaign attracting candidates from Portugal a fresh cohort nurses will be in Burton in July 2014, this will be followed by newly qualified nurses arriving in September As the newly recruited nurses are in place, the need for agency staff will diminish. A review of a staffing scorecard is being developed is to monitor progress and identify the cash releasing effect of the interventions being made. It is recognised that the current job planning arrangements are unsatisfactory. There is a lack of consistency in the current practice and adherence of the policies. A programme of review is being established to model good practice and roll out across the Trust. Anaesthetists will be the first group of consultants to go through the review. This scheme had been identified as a potential area of savings, however given a recent directive the clear the backlog of 18 weeks procedures, there has been a change in focus There are also a number of contingency schemes that are being developed which include, additional schemes in Theatres, SLR review, best practice tariff, improving erostering, management of attendance and vacancy controls where appropriate. 6.7 Key Issues There are some risks to the programme. The PMO is working with divisional colleagues to ensure that the schemes have robust workbooks with detailed plans and these are rigorously tested through the gateway process. The risks associated with workforce relate to on-going recruitment challenges and the sustainability of workforce numbers required by the safer nursing care tool. The Trust has limited the planned saving in this area to approximately 1% of gross employee costs in order to mitigate this tension. The risks associated with the length of stay project reflect the issues of scale faced by the Trust. While the Trust metrics identify a length of stay opportunity for the Trust if performance can be raised to the top decile, analysis shows that the opportunity is spread over a number of wards. A number of the wards are single specialty or function wards and the removal of bed days will have no significant impact on the cost base due to the cost base floor required to operate those units. The Trust is planning for the closure of a ward on the Outwoods site but this cannot be realised until April Some opportunist savings will be taken through the summer 2014 with the temporary closure of a ward beds. The Trust has identified an opportunity to improve the productivity in theatres; benefits will improve increasing the number of cases, reducing waiting time, staffing efficiencies and procurement standardisation. Moving forward there will be an opportunity from within this work to rationalise activity to a smaller number of theatres in order to either close or reallocate theatres. The current backlog in some specialities poses a threat as well as an opportunity for this project. There are a number of commercial schemes which will not deliver the benefits anticipated in 2014/15 this is largely due to the time it will take to go through the procurement process and engage with the relevant stakeholders. Work has been undertaken to identify more CIPs and Chief Executive has also intervened to accelerate the rate progress. A wider engagement programme is being constructed to establish CIPs from the bottom up 30

31 7 FINANCE 7.1 Introduction The Operation Plan sets out the Trust s financial plans until the end of 2015/16. In this period the Trust will run with a financial deficit and will require financial support in both years. The Trust has, in the past few years delivered high levels of recurrent CIP (albeit always under plan). Analysis carried out by KPMG for the Trust indicates that until the last financial year (2013/14) the Trust was largely in recurrent balance, after delivery of its CIP s. Increased costs in 2013/14, driven largely by the requirement to provide higher levels of nursing staff to wards as a result of the Keogh review, leave the Trust with a larger normalised deficit. The following table outlines this journey. FY 12 FY 13 FY 14 Actual Actual Actual m m m Reported deficit Less: non recurrent income Patient Income Provision from Previous Year Non Patient income provisions released Non recurrent income Add: non recurrent expenditure Impairment Non Recurrent Non Pay Expenditure Non Recurrent Pay expenditure Redundancy and MARS Expenditure provisions released Non Recurrent CIP Normalised deficit As can be seen from the analysis the Trust has been reporting a headline deficit improvement, whilst its underlying position has worsened. It was however, delivering relatively high year on year percentages of CIP s (between 4.6 and 5.2%), that were identified as recurrent. FY12 FY13 FY14 CIP achieved k 8,400 9,030 8,292 Original CIP plan k 9, Underperformance k -1, ,608 % achieved 86% 92% 84% 31

32 Total Income % of Income 4.9% 5.2% 4.6% Further work needs to be undertaken to understand the reason for the increased deficit in 2013/14 however, there is clearly a relationship to the significant increase in spend on frontline staff following the Keogh Report and an increase in cost at Burton Hospital. Staff cost for both permanent and agency staff have been increasing since FY13. In FY14 the main increase was in other non-clinical staff and in nursing. The total WTEs have risen from 2,696 to 2,786. Agency cost has also risen sharply due to increased demand for nursing staff. There was an 8% increase in Nursing establishment in This movement relates in the most part to the previously identified costs associated by the Trust with its response to the Keogh review. The Trust is investigating the movement in staffing costs, however it must be noted further investment in Nursing has been indicated by the Ward Staffing toolkit and this has been factored into the plan for the next two years. It is difficult to benchmark current nurse staffing costs and levels as there is significant volatility in use of nursing staff on wards following the Keogh report and the Ward Staff Toolkit process. We are working with KPMG to test this further. The Trust s forecast revenue position for the two years is for a deficit of 10.60m in 2014/15 and 13.1m in 2015/17. This position is after delivery of cost improvements of 7m (4%) and 8.4m (4.7%%) respectively in both years. Further work is being commissioned by the Trust to improve levels of CIP s, but this position is based on current rates of spend with a background of a requirement for potentially more investment in Nursing staff. This leaves the Trust with a normalised deficit of 10.49m at the end of the two year programme. With this level of financial distress the Trust will maintain its Capital Programme to deliver changes required to maintain and improve services. The proposed sale of the Outwoods site will deliver cash support to 2015/16, after deducting the costs of sales, this is currently estimated at 3.9m based on valuations provided by and independent valuer for the Trust. In order to finance this level of deficit, the Trust has modelled that it receives distressed Trust financial support in the form of PDC for the two years of the plan. The level of support required is 8.33m in 2014/15 and 6.97 in 2015/ I&E Summary The Trust s current forecast is for a deficit of 10.6m in 2014/15 and 13.1m in 2015/16. This is explained below: 2013/14 Forecast m 2014/15 Forecast m 2015/16 Forecast m NHS Clinical Income Private Patients Other Patient income Donated Income Other (non-patient) income Total Income Less Expenditure Pay costs (116.8) (122.1) (116.2) 32

33 2013/14 Forecast m 2014/15 Forecast m 2015/16 Forecast m Non-Pay costs (54.2) (56.9) (60.7) Total Expenditure (171.0) (178.9) (176.9) EBITDA 7.9 (0.1) (0.9) Profit/(Loss) on fixed asset disposals (0.0) 0.0 (2.0) Finance and Interest Charges (0.1) (0.1) (0.1) Impairments Total Depreciation and Amortisation (6.8) (6.9) (6.7) Total Interest Receivable PDC Dividend Paid (2.7) (3.6) (3.6) Annual Surplus (Deficit) (1.7) (10.6) (13.1) The bridge chart shows the normalised position for 2013/14 and tracks the changes to the planned movements within this plan. The assumptions behind each of the steps of the bridge for 2014/15 (and where appropriate 2015/16) are outlined below 7.3 INCOME CHANGES Tariff Deflator: The clinical income has had the following deflators applied to it in the two years of the plan. 2014/ /16 Tariff Income 1.5% 2.3% Non Tariff Income 1.8% 2.3% 33

34 Non clinical income has not had a deflator applied. Volume Changes Where emergency activity has been forecast to run over threshold a weighted average has been applied to cover the costs based on current thresholds agreed in the plan this equates to 50% of the income gain. Lost MRET income for the two years equates to 1.5m in 2014/15 and 1.8m 2015/16. Increased income relating to agreed service developments (Angioplasty) equates to 400k in 2014/15. Other activity growth in 2014/15 and 2015/16 based on the following methodology and assumptions: Point of Delivery 2014/ /16 Elective inpatients 4,137 4,202 Elective day case patients (Same day) 27,367 28,466 Non-Elective 32,065 32,499 Outpatients - first attendance 80,851 81,338 Outpatients - follow up 172, ,068 Outpatients procedures 53,632 54,359 A&E 123, ,081 Other NHS activity 40,514 40,424 Key growth factors agreed with divisions which drive the changes in activity described above were: 2.8% growth in Non-elective General Medicine and the AAC, compensating for a relatively low growth rate of 1% in A&E attendances (following an underlying historic trend) 0% growth in Obstetrics driven by a strong trend of reducing birth rate and reducing impact of immigration Growth of 2.5-3% in General Surgery (to reflect the Bowel Scope Screening Programme), ENT, Haematology and Ophthalmology day-cases driven by strong underlying growth Growth in Cardiology as the catheter laboratory becomes further established and the range of procedures offered increases Continued shift in point of delivery from elective inpatient to day-case, and from day-case to outpatient procedure. These assumptions generate incomes from individual CGG as follows : CCG 2014/ /16 m m NHS East Staffordshire CCG NHS South East Staffs and Seisdon and Peninsular CCG NHS Southern Derbyshire CCG

35 CCG 2014/ /16 NHS West Leicestershire CCG Birmingham and the Black Country Non Contract Activity Income (CGS) Total Central Funds and Initiatives The Trust has assumed that it will receive support from the recently announced Waiting List and Sustainability funds in 2014/15. Funding of 1m has been assumed against winter pressures and 300k against 18 weeks targets. 7.5 Allowance for Fines and Challenges The income budget allows for fines valuing 700k to be levied against underperformance, this figure is in line with previous levels of dispute, and fines it covers the following areas: Penalties/challenges ' weeks 180 Ambulance turnaround 185 Procedures not carried out 70 A & E 80 Sleeping accommodation 15 Never Events / cancer breach 50 CDIFF / MRSA 70 Monthly reconciliation issues 50 Total Non Clinical Income The Non Clinical income is largely in line with the previous year, however non recurrent income of 400k for HEFT Maternity Pathway is removed from the 2014/15 budget. Training and Education 5.7 Cquins 3.2 PMU 1.2 Car Parking 1.2 Maternity Pathway 1.1 Catering 1.1 Community Inc Room Rentals 1.0 Cancer Network Drugs 0.9 Other Estates and Facilities inc Site Rentals 0.8 R&D 0.8 Diagnostics 0.6 m 35

36 m Drugs for SSHC and other non CCG users 0.5 Cancer Posts / Elderly Medics for CCG 0.4 IVF 0.4 Prescriptions and Appliances 0.3 Other 0.3 Occupational Health /HR 0.2 Excellence Awards 0.2 Records 0.1 Medical Income Generation 0.1 Accommodation 0.1 Recurrent Income 20.2 Non Recurrent HEFT -0.4 Non Recurrent Andrew Ward Lease 0.1 Model for 2014/ CQUINS are as laid out below, the plan assumes full delivery of the CQUIN targets, expenditure of the 500k in 2014/15 is provided for deliver this income. A larger sum of 700k is allowed for in the second year of the plan. Scheme Income 000 Dementia 160 Family & friends 160 Medication errors 160 Sepsis Care Bundle 160 ST/PU 160 Safe & Effective Care 2,304 Amber Care 96 CQUIN Support Team 0 Total 3,200 No further changes in non-clinical income were factored into 2015/ Non Recurrent The Trust has provided 400k in the current forecast to cover potential income risk with HEFT re maternity pathways. Non return income on the short-term lease of Community property to the MHSFT of 100k. 7.8 EXPENDITURE CHANGES Inflation Costs 36

37 The key assumptions made for the expenditure forecast in both years are as follows: Costs For Growth Margin costs of activity growth have been assumed at 30% of income for outpatients and 50% of gross income for inpatients and day cases. Developments Service developments\cost pressures to the value of 6.8m have been included in the first year of the plan these are briefly detailed in Appendix 2. These have been analysed into the following groups: 2014/ /16 m m Investments in quality/patient care Investments in better governance Investments in service developments (ex Angioplasty) Other Total Investments to improve quality and patient experience A significant sum of this investment is to address shortfalls of nursing staff 3.0m in 2014/15 with a full year effect of 3.5m (both figures pre workforce CIP). This figure includes an allowance for premium rate payments to agencies. The Trust has just had an audit of its controls on Nursing Agency staff carried out by internal audit, that indicates that controls are good, but needs some fine tuning and rota management could be improved. There is therefore a CIP target to reduce this expenditure by a realistic amount ( 500k), against the backdrop of the Ward Staffing Toolkit suggesting that further investment in 140 nursing WTE s is still required. The Director of Nursing is reviewing these numbers and auditing the tool. Nevertheless the plan 2014/5 allows for some of this investment as agreed with Director of Nursing and Trust Board, with 700k in 2014/15 and a full year effect to 1.2m in 2015/16. Additional costs of supporting the Hyper Acute Stroke Unit are included in the plan at 40k in 2014/15 rising to a full year effect of 79k. 37

38 The other major investment included in the quality developments is the frail elderly team this investment of 160k in 2014/15 rising to a full year effect in 2015/16 of 400k is to review and modernise the frail elderly pathway, improving quality of care to patients and flow through the hospital. Investments to improve Governance The strengthening of the governance in the trust is a key issue arising from external reviews carried out during the last year. Investments have underway to strengthen clinical leadership, provide a stronger governance framework for the Trust Board, including a stronger performance management framework/pmo function and improved leadership of the Trust s ICT function. Angioplasty Costs for the Angioplasty development are calculated as 400k for a full year against income of 800k, The service will commence in October Other developments cover largely cost pressures identified during budget setting Contingency The plan allows for a contingency of 1m to cover costs arising from the recent CQC visit, and costs of advisors to support the further development of the strategic visions and support delivery of that plan. 7.9 CIP Schemes The table below illustrates the portfolio of projects and schemes that make up the programme and the savings to be achieved in 2014/15 and 2015/16. 38

39 The CIP schemes are described in detail in Section 6 above. Central Funds and Initiatives Costs of 300k have been included to cover the waiting list funding, this is primarily to cover the cost of clearing the ophthalmology backlog. Costs of 600k have been estimated to cover the Winter Pressures funding, with 400k being applied to non-recurrently cover the cost of additional nursing required by the ward staffing benchmarking toolkit. Community PDC Non-recurrent support (deferral of PDC interest payments) agreed for the Trust when it took over the community hospitals unwind and this sum becomes payable in year - 0.9m. 39

40 Non Recurrent Items The non-recurrent costs relate to the 300k spent against Waiting List issues in Ophthalmology and the 600k (badged as Central Funding) relates to non-recurrent winter pressure funds Additional assumptions for 2015/16 The forecast I&E position for 2015/16 is a deficit of 13.1m The bridge from the plan for 2014/15 to 2015/16 is shown below. The movements in the plan not previously explained are as follows: The Trust is currently looking at closing the theatres at Sir Robert Peel, this closure will form part of the forthcoming consultation being undertaken by NHS South East Staffs and Seisdon and Peninsular CCG. The closure will mean work will transfer to the Queens site and Heart Of England FT work will either revert to their main site or come to Queen s. There is expected to be some leakage of work with the move losing 420k income in 15/16 (albeit with a saving of 126k for marginal costs). And for 16/17 forwards the Trust losing 560k income (and a reduction in costs of 168k). The other costs shown in the bridge both relate to the sale of Outlands with costs relating to the sale and the impairment being shown as non-recurrent items in the I&E account. The normalised deficit at the end of 2015/16 is 10.49m 7.11 Capital Plans The Trust had previously planned a larger capital investment programme during , however this scheme was funded from land sales and borrowing against future land sales. The valuations used as the basis for this planning have proved to be out of date, in additional an anticipated sale of the Margaret Stanhope Building on the Outwoods site for a current use valuation to an NHS organisation has fallen through, meaning the site will be offered up for development. The Trust therefore has reviewed its position on Capital affordability and is proposing a capital budget of 7.0m and 6.3m in each of the two years of this plan. The Trusts revised capital plan covers investments in maintaining estates infrastructure, re-providing accommodation for services housed in the Outwoods site to enable the disposal of the site in 2015/16 and maintenance and minor incremental improvement of the Trust s IT infrastructure to support the migration to the major upgrade of its Patient 40

41 Administration Systems (PAS) and business systems (including providing an improved data warehouse). Other funds are provided to allow for replenishment of medical equipment. It should be noted that the requirement to replenish and refresh equipment for Pathology, Radiology soft FM services (eg Catering) will be negated by the subcontracting of these services over the next 12 months. In addition to the routine replacement of equipment, the Trust is investing in its Endoscopy Unit to to meet JAG accreditation standards following the recent inspection. The Trust will also invest in best of breed IT solutions for its radiology department ahead of the tendering process for that department, to resolve a potential clinical risk and to enable the implementation of Meditech Version 6, by procuring a Radiology Information System in 2014/15. Use of this system will be written into the tender specification of the Radiology tender and the system will be fully integrated into the Meditech product. The Trust plans to sell the Outwoods site during 2015/16. Recent valuations undertaken by the DTZ show an income of 4.5m with costs of sales (gaining outline planning permission and some enabling works) have been estimated at 600k. The Trust have engaged professional advisors to support this programme and provide firmer estimates. These costs exclude the cost of re-provision of space on the Queens site (or Community Hospital sites) for displaced services, which will be funded from the 2015/16 Capital scheme, again professional advisors are currently reviewing the Trust s estate to provide options for this re-provision, this work will be completed by the end of July. The Trust will incur a loss on the sale of this property of 2m, due to the difference in current use and open market valuations. Further major developments will be planned to ensure that the Trust s asset base will support the future clinical and business model for the Trust that will evolve over the forthcoming months. This work will be undertaken in partnership with the Trusts advisors. Until this position is understood, the Trusts five year plan contains routine capital spend only. Capital Programme 2014/ / / / / /16 Q1 Q2 Q3 Q4 m m m m m m Estates & Facilities replacement/maintenan ce Medical equipment replacement including PACs IM&T Contingency and provision for site refurbishment and redesign Relocation of Endoscopy decontamination Total Balance Sheet The balance sheet and a summary of cash movements are shown in the Table below. It is assumed finance support is received by the Trust in both years. 41

42 7.13 Cash flow The Trust s revenue position presents a challenge for the two years in regards of cash balances. The current assumption within the plan is that Distressed Trust Funding will be provided to finance the deficit in both years. In year two land sales support this balance, but further support is still required. Outline cash flow forecasts are as follows: Ex PDC Inc PDC Forecast Forecast Forecast Forecast for 2014/15 for 2015/16 for 2014/15 for 2015/16 '000 '000 '000 '000 Opening Balance ,834 Income and Expenditure Inflows NHS 171, , , ,295 Other 9,257 9,186 9,257 9,186 Revenue Inflow 180, , , ,481 Outflows Total Pay -115, , , ,726 Total Non Pay -68,596-68,790-68,596-68,790 Revenue Outflow -183, , , ,516 Interest Received Interest Paid PDC Dividend Paid -3,582-3,582-3,582-3,582 Net I & E Cash Position -6,863-4,643-6,863-4,643 Capital Inflows PDC 8,325 6,

43 Ex PDC Inc PDC Sale of Asset/Other 115 4, ,500 Capital Inflow 8,440 11, ,500 Outflows BACS -7,388-6,300-7,388-6,300 Loan (Lease) Capital Outflow -7,767-6,828-7,767-6,828 Net Capital Cash Position 673 4,643-7,652-2,328 Closing Balance ,834-14,805 The key issues driving the cash position are as follows: (a) (b) Income and expenditure deficits of 10.6 million in 2014/15 and 13.1 million in 2015/16 total 23.7 for the 2 years. Excluding depreciation (which is a non-cash charge used to fund capital) and working balance adjustments, such as allowing for the receipt of unpaid debts as at , this reduces cash funds over the 2 years by 11.5 million. Capital expenditure, including items classed on loan repayments for assets deemed to be purchased under Finance Leases, total some 14.6 million. (c) Asset sales produce projected income of 4.6 million for the 2 year period m Cash position at I&E impact on cash Asset Sales receipts 4.6 Capital Net impact The Trust could generated a limited amount of additional cash by extending creditor payment terms but these have not yet been modelled in the above. Currently the Trust pays a number of significant suppliers on 45 day terms, whilst the smaller level suppliers are on 30 day terms (or shorter where contractually obliged). Excluding scheduled NHSLA payments, extending average creditor payment terms would generate approximately 180K per day. The Trust is in the process of tightening its cash management processes and cashflow forecasting, however, these improvements will not allow the Trust to manage its cash position without support. In detail for 2014/15, without support the following cash flow indicates that cash will run out in December This forecast is based on the continued CCG advance of 5 million. If this advance is removed then the Trust would require support in August

44 7.14 CoSRR The Trust whilst in deficit the Trust will deliver a CoSRR of 1, the Trust is investigating Strategic transformational change to return to financial balance, the process for this is outlined in the 5 year strategic plan Downside scenarios considered The sensitivity of each element of the plan was considered in formulating a downside scenario. The inflationary costs of pay are therefore not considered to be a material risk to the Trust. In terms of non pay inflation, 74% of the Trust s drugs costs are pass through and there are no significant NICE issues that are anticipated to impact on the remainder of the costs. In light of the plan containing a contingency reserve this was again felt to mitigate risk. However the following items were considered a downside risk Downside scenarios included in the plan The plans do not reflect QIPP schemes reflected in the contracts given that only the values and not the details of the schemes have been received by the Trust. The total value of QIPP schemes is 2.2m and the downside scenario reflects the impact of 50% being successful in 2014/15 and that further demand management schemes were brought forward in 2015/16 from that modelled in the 5 year strategic plan for 2016/17. The categories of the QIPP schemes are given in the Table below:- Target 2014/ /16 Scheme Elective Non Elective Outpatients A&E / MIU Total If 50% of the QIPP schemes are successful the Trust would look to take the following mitigating action in order to maintain the planned deficit at 3m in either year:- 44

45 (a) (b) Replace elective work in specialties where the 18 week target is challenging to achieve generating ( 250,000), the extra capacity will allow the Trust to reduce expected fines by 50k in year Reduce costs associated with the activity that has been reduced, targeting areas that incur costs at premium rates ( 550,000) (c) Further reduction in corporate costs and overheads ( 130,000) 7.16 Implementation plan The Board has agreed a number of work-streams, supported by a PMO to implement the plan. These are high priority initiatives for the Trust, reporting progress directly to the Board and are agreed by all parties to be fundamental to the success of the organisation. It should be noted that these are separate and additional to the business as usual processes, such as improving quality, identifying and meeting CIP plans and meeting waiting list targets. 1) Working with Commissioners: Setting up a team to work with the CCG to understand new models of care. This will include managing the proposed Community expansion and taking the Trust s offer to CCGs for discussion. This will include the impact of the LTC PIN, including assessing the impact of both winning the contract and being unsuccessful in being appointed Lead Provider. The commissioners will put the LTC PIN out to tender in mid-july Market analysis also identified opportunities to increase care provided in the community, with care of the elderly activity high in non-elective and relatively low in elective relative to peers. This will be addressed as part of the response to the long-term conditions PIN Further development and implementation of CCG assumptions and benchmarking, and agreement regarding top decile performance helping the system to move care outside hospitals and reducing loss-making non-elective admissions. This will create capacity for the Trust to deliver more sustainable elective work. 2) Organisational Development including Partnerships and Alliances Continue negotiations with UHNS including setting out BHFT s approach to the negotiation, signing Heads of Terms and developing targets and a timetable in order to measure and monitor both progress in negotiation, and the shifting of activity The approach to partnership needs to be replicable, and opportunities to further partner should be explored as they arise Continue discussions with commercial partners relating to a potential joint venture for noncore, non-clinical services redesigning processes and driving efficiencies for the Trust. 3) Managing the repatriation of activity from other providers Incorporate the findings of the CHE work undertaken by KMPG and published on the 11 th July Plan for and undertake additional activity arising from changes to Mid Staffordshire Hospital Actively work with GPs and CCGs in the specialties identified through the CHKS/Dr Foster market analysis work in order to grow market share in services which make a contribution. Build upon strong existing links with some GPs in order to drive this process. 4) Internal Planning Developing a Finance Plan which will include: Developing SLR and SLM for the Trust 45

46 A clear approach to CIP governance, including responsibility for the identification and delivery of CIP, timescales and reporting Introduction of external support Diagnosing underlying causes of the deficit and routes to reducing the cost-base Capital planning (including potential developments to the elective care centre and community hospitals). Develop an Estates Plan (informed by the community hospital consultation) Set out rationale for future of community hospitals once this has been determined More detailed planning of bed and support services requirements, in light of the activity shifts proposed, plus the detail of the repatriation information and the negotiations with UHNS, plus the shift from Mid Staffordshire This will include a decision relating to whether an elective care centre expansion is required in order to accommodate repatriated work, or whether non-elective activity has been reduced to such an extent this is not necessary. Develop an Organisational Development Plan Setting out how the Trust will source the staff, skills, and provide the training to support the above developments Improving Clinical Leadership (through the use of SLM) Develop relationships with the LET-B in order to support workforce and the Deanery relating to the medical workforce specifically Develop an IT Plan The Trust is currently reviewing management and governance of its ICT strategy. Currently the Trust receives services from the Staffordshire Shared Services HIS. It has an old network infrastructure that, whilst extremely stable is in need of upgrade and modernisation to provide better and more flexible services to users The Trust has a fully integrated Patient Administration System that includes an integrated financial system including full e-procurement and scheduling systems. This system is due for a major upgrade during 2015/16. This upgrade will provide the organisation an opportunity to review its operating procedures to apply lean techniques and improve efficiency The Trust has very rich data, for example the finance system is linked to patient episode data allowing direct allocation of theatre prosthesis to a patient and cost centre in the general ledger. However, the Trust needs to invest in a modern data warehouse to allow this information to be easily extracted and utilised by the operational management in an intelligent form. This will be addressed by the system upgrade programme and the new performance management framework over the next 6 months The Trust Board has agreed for the create of a Chief Information Officer post reporting to the Director of Finance, who will work through the issues outlined above to produce an ICT strategy that support the Trust s clinical and operational models as outlined above. The steps that the Trust will take in order to deliver upon the strategic opportunities are set out in the Gantt chart below. 46

47 7.17 Governance The Trust takes very seriously the criticism of its governance arrangements in response to external scrutiny during 2013, and has introduced a number of changes that focus on improving its Board and quality governance, as well as its performance management and supporting information systems. The Board of Directors has welcomed the findings and challenges posed by these reviews and is committed to building on its achievements thus far to further embed the changes during 2014 and onwards. The Trust has made a comprehensive response to the findings from external reviews together with its licence undertakings. Such actions have included: 47

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