KMPT Operational Plan 2018-19 Refreshed KMPT Two Year Operational Plan 2017/18-2018/19
Operational Plan 2018/19 The Trust s two year plan 2017/18 2018/19 was based on agreed two year contracts and sets out our approach to operational planning, our commitment to achieving priorities and targets set by NHS England and the Mental Health Task Force Five Year Forward View. This refreshed plan for 2018/19 takes into account the November 2017 Budget announcement of additional funding for emergency and urgent care and additionally for core services such as mental health and primary care. It builds on the progress made in 2017/18 and retains the focus on improving the quality of care for patients and maintaining financial balance, whilst working in partnership to strengthen the sustainability of services for the future. Activity planning The Trust s activity planning remains based on robust demand and capacity modelling and lessons from previous years winter and system resilience planning. Activity planning has been further enhanced by continuing to work together with other organisations through STPs to develop system-wide plans. The activity plans for 2018/19 are based on outputs from: the demand and capacity approach for 2016/17 forecast outturn for 2017/18 demand and capacity modelling tools that have been jointly prepared and agreed with commissioners Activity assumptions are based on demographic growth encompassing the Mental Health STP assumption of 1.9% for the next two years. The Trust s planning is based on the 2018/19 planning guidance and the specific trajectories set for 2018/19. The Trust within the K&M STP is aiming to make progress against all deliverables in the Next Steps on the NHS Five Year Forward View. These include:- Each CCG meeting the Mental Health Investment Standard (MHIS) by which their 2018/19 investment in mental health rises at a faster rate than their overall programme funding. Ensuring increased access for children and young people to receive treatment from NHS-commissioned community services. Making further progress towards delivering the 2020/21 waiting time standards for children and young people s eating disorder services. Delivering against regional implementation plans to ensure that by 2020/21, inpatient stays for children and young people will only take place where clinically 1
appropriate, will have the minimum possible length of stay, and will be as close to home as possible. Continuing to increase access to specialist perinatal mental health services. Continuing to improve access to psychology therapies (IAPT) services for people with common mental health conditions. Continuing to work towards the 2020/21 ambition of all acute hospitals having mental health crisis and liaison services that can meet the specific needs of people of all ages including children and young people and older adults. Ensuring that 53% of patients requiring early intervention for psychosis receive NICE concordant care within two weeks. The Trust plays a leading role in the specialist perinatal, psychiatric liaison and early intervention in psychosis services. The Trust continues to play its part in system wide resilience plans which cover A&E, winter and surge capacity and response. The Trust aims to have signed contract variations by the 23rd April where the 2018/19 plans have changed and these changes will be reflected in the finance, activity or other schedules for the second year of the two year contracts with its eight Kent and Medway commissioners and NHS England. Contract negotiations include Five Year Forward View key elements. EIP ensuring funding levels allow the service NICE compliant level Liaison identification of funding to move to a core 24/7 model. MIMHS funding for the Mother and Baby Unit (MBU) to be included within the contracts. The original 2 year contract included commitments from both parties to jointly work towards the items identified within the 5 year forward view for mental health. In year this included funding of EIP services, successful bids for core 24 A&E services within 50% of the acute providers within the county, successful bids for an enhanced MIMS service and a Mother and Baby Unit that is due to come on stream in August 2018. The contract supports the Trust working with all commissioners to jointly work towards the national targets for 2018-19. KMPT plans incorporate the expectation to continue to implement the priority efficiency programmes with the 10 point efficiency plan. This includes the provider operational productivity programme which is supported by the Model Hospital. Providers are also asked to implement the Getting it Right First Time recommendations. The Mental Health Getting it Right First Time programme will be set up in 2018/19, led by 2
Professor Tim Briggs who has led the implementation in the Acute Sector over the past 18 months. The areas of focus for Mental Health will be: Tier 4 CAMHS Acute transfer of care Locked rehab KMPT also continues with the STP work looking at Corporate Back Office, which includes Estates and Facilities. Quality planning - Approach to quality improvement The Trust s quality standards for patient services are defined by the principles set out in the NHS Constitution and in the fundamental standards of quality and safety published by CQC. The Trust has set its quality expectations and ambitions against these standards. It has identified its quality priorities and created its quality improvement plan in line with the same standards but also taking account of national priorities, its achievements against 2016 targets, current performance, commissioners priorities and the needs of the local population. The Trust underwent its second CQC comprehensive inspection in January 2017. The Trust improved its overall rating from Requires Improvemen to Good with the Caring domain rated as Outstanding. A focussed inspection of Adult Community teams in January 2018 highlighted areas where the Trust must continue to improve. This work continues. The Trust s vision sets out a focus on continuous improvement underpinned by leadership creating a learning organisation. The Trust s strategy contains a number of trust-wide ambitious quality improvement goals. The Trust s approach to quality and quality governance is reflected in its Quality Improvement plan and Sign Up to Safety plan both in terms of development and ongoing assurance. The Quality Strategy covers patient safety, patient experience and clinical outcomes. The Clinical Strategy has been refreshed to reflect local and national priorities and issues most relevant to patients and staff. It lists the priorities as NICE standards and guidelines Quality Priorities Family Inclusion, Recovery MIMHS, Personality Disorder, Liaison Psychiatry Link with Primary Care, Acute and Community Services Working together with staff, patients and carers Working in partnership with other agencies and NHS Improving quality performance in services Develop Quality Improvement focus of all staff 3
The Board has put in place a leadership development programme for clinical leadership and non-clinical management which is based on the Trust s vision and values. It incorporates the principles of learning and impact on behaviours and encourages and trains clinical leadership and non-clinical management to participate in setting the quality agenda. 2018/19 Quality Priorities The 2017/18 improvement priorities were agreed by the Trust s Quality Committee and approved by the Trust Board through the Quality Account 2017/18 are: Patient safety To improve the recording of risk management within care plans To deliver reduction of violence inpatient care settings. To improve the quality and frequency of handovers in the Acute Care Group and across Care Groups. Patient experience Completion of the Triangle of Care self-assessment documentation by CMHT Year 2 To improve patient experience of care co-ordination Develop a standardised patient experience feedback system Clinical effectiveness Implementation of NICE guidance: Gap Analysis Quality Improvement System Rapid Process Improvement Workshops To improve the quality of care plans Year 2 The Trust has made significant progress in achieving these priorities in 2017-18. The Trust s Quality Accounts provides fuller details. The 2018/19 priorities are being reviewed and will be agreed by the same process including service user, carers and stakeholders input. The current proposed priorities are: Patient Safety To improve the integration of physical and mental healthcare on inpatient wards and community contacts To improve the management and follow up of service users who do not attend clinic appointments or assessments To improve the quality and completeness of 7 day follow ups Patient Experience To increase co-production and continuing work with carers 4
To complete the implementation of Triangle of Care including raising the profile of ToC with staff, service users and carers (continuation of 2017-18 priority) To increase the involvement of people with lived experience in service improvement and redesign Clinical Effectiveness To extend the use of the Quality improvement system by undertaking two more Rapid Improvement Workshops To develop a limited suite of agreed Patient Reported Outcome Measures (PROMs) to evidence the effectiveness of the Personality Disorder Strategy To improve the quality of clinical supervision National Quality Priorities The Trust plan takes account of the need for the national priorities and other local (STP) priorities for 2018/19 to be delivered within the financial resources available in each year. Specifically: The Trust s contribution to urgent and emergency care through Core 24 Liaison Services and the Single Point of Access model (which includes 24/7 access to Community Crisis Resolution Teams and Home Treatment Teams) facilitates the cross-system approach to urgent care for those in a mental health crisis; The Trust s achievement in meeting access and standards in Early Intervention in Psychosis (EIP) where the Trust s performance is over 80% for people beginning treatment within two weeks of referral; The Trust has virtually eradicated out of area bed use since 2016 and in conjunction with CCGs set a trajectory for further reduction in Intensive Care placements in 2018-19. The local plans to transform care for people with learning disabilities are now contained in the overarching policy called 'Building the Right Support' 2016. The Trust s role is specialist in-patient services to provide short term highly focused assessment and treatment; The Trust s Quality Improvement Plan is based on its CQC inspection report and is in the process of implementing a Quality Improvement Strategy and methodology. The Trust has undertaken a major review of care planning across the organization both in inpatient and community settings. The RiO system has undergone significant upgrade to allow new care planning template to be implemented. This has been supported by comprehensive training, new policies and procedures and auditing systems. The new care plans incorporate a focus on infection prevention and control, falls, sepsis, pressure ulcers, end of life care and patient experience, ensuring all care plans are personalised and constructed with and for the individual patient. Additionally during 2017/18 the Trust implemented the three tier risk system. The compliance and quality of care plans is routinely monitored to ensure standards are maintained and 5
improved. The Trust continues to promote infection prevention and control as the heart of good management and clinical practice. Antimicrobial stewardship is an initiative to reduce Gram negative bacterial infections and is maintained through our Antimicrobial prescribing and management policy. Although our cases of Gram negative infections are minimal, we still proactively take steps to minimise the risk. The care plans also assist in the Trust s achievement of national CQUINs such as physical health and risky behaviours. The Trust position and actions in relation to the standards of seven day care services fall under four main initiatives. Therapeutic Staffing model has been rolled out across the Trust ensuring access to therapies and activities at weekends and in evenings. Single Point of Access provides a portal for 24/7 care. The Trust is working with CCGs and Acute Trusts to establish core 24 Liaison Psychiatry Services at all the acute A&E departments in Kent and Medway. We are working towards ensuring consultant review of inpatients at weekends and that reviews are available as required at weekends by consultants for patients under crisis teams. The limitation is medical recruitment which the Trust is working on with the agency reduction programme board and the development of the recruitment premium for consultants who take hard to fill posts. One of the key priorities in the Trust s Nursing Strategy is developing a clinical career structure for Nurses and creating Nurse Consultant roles. These new senior clinical will help build and develop competencies and confidence for the nursing profession and will support medical colleagues by releasing them to focus on the more complex, challenging and highly specialist functions. We are currently out to advert for 4 Consultant Nurse posts in our CMHT and MHLD services. Care planning audits are augmented by Medications Management audits including drugs review in line with anti-microbial resistance guidance. KMPT is also fully involved in national clinical audits which are incorporated in the Trust s Clinical Audit Annual Plan and monitoring. The Trust has innovated beyond the Safer Staffing models by implementing its Therapeutic care model. This recognises the input of other care professionals such as occupational therapists and psychologist in the recovery model. It focuses on activities and therapies being available on a seven day basis, one to one care and increasing the number of care hours per patient day available on wards and in the community. The Trust continues to monitor and improve its performance in Early Intervention in Psychosis and Improving Access to Psychological Therapies and was successful in tendering to expand its Mother and Infant Mental Health Service (MIMHS). This led to the organisation being selected as one of four new national inpatient providers for mothers and babies. 6
The Trust has taken account of national learning from deaths reports and is compliant with the reporting of deaths to the Trust Board. The Trust continues use it s three times weekly mortality review group to enable all deaths to be reviewed within 48 hours and investigations conducted appropriately. Performance - Regulatory and national targets Ref. Measure Target 2017/18 1 Regulatory Targets 1.1 CPA patients receiving follow-up within 7 days of discharge 95% 94.7% 1.2 CPA patients receiving formal 12 month Review 95% 90.1% 1.3 Delayed Transfers of Care 7.5% 7.6% 1.4 Admissions to Inpatient Services had Access to CRHTs 95% 100.0% 1.5 Meeting commitment to serve new psychosis' cases by EIS 1 95% 127.4% 1.6 MHMDS Data Completeness: Identifiers 97% 99.7% 1.7 MHMDS Data Completeness: Outcomes for Patients on CPA 50% 80.3% 1.8 EIP Waiting Time Proxy (Referral to Care Coordinator in 2 Weeks) 50% 79.1% 1 Possible to achieve over 100% where new cases accepted to date exceeds average cases required per month to meet target Workforce planning Approach to workforce planning The Trust has refreshed its People Strategy, with 4 key HR pillars. This aligns to the organisations vision and to support the quality and safety of service provision to patients/service users (adhering to Safer Staffing and provision of 7 day services) see diagram below: 7
As a key part of the revised approach to Business Planning for 2017/18 and 2018/19, the 4 HR pillars all have an impact on workforce planning for the future achievement of the Trust s objectives, including local and national activity, the 9 must do s and financial plans. As part of the business plans, there is the opportunity to review ways of working and associated workforce numbers/ skills to achieve any changes required (including the use and further roll out of the therapeutic staffing model, plus the introduction of the Single Point of Access). There are already further review and transformation projects in place, working with other stakeholders i.e. Primary Care and CCG s and opportunities to review the structure of the workforce with the new Apprenticeship Levy launch and Associate Nurse Practitioner roles. All of the above workforce changes are being included as part of the wider workforce plan, with actions, risks and mitigations identified for 2018/19. KMPT has supported 9 trainee Nursing Associates to enrol on the fast followers programme that commenced in January 2017. The staff come from a range of services across the organisation and will graduate in January 2019. This cohort has been in collaboration with University of Greenwich and other Kent providers. KMPT is further involved in the new West Kent Collaborative with MTW taking a lead procurement role to put forward another 10 trainees and will be lead provider for specialist learning disability and mental health placements to the Trainees on this programme throughout Kent. As part of the Trust s six monthly establishment reviews, 8
the skill mix will be reviewed and enhanced to ensure the skills and knowledge held by this staff group bridges the gap between Health Care Assistants and Registered Nurses. The workforce and organisational development elements are also being reviewed as part of the wider STP strategies, with involvement informally and formally as part of the workforce STP. One focus of this is the need to work across the region to have an integrated strategy to the approach for demand and management of the reduction of the use of temporary staffing. Specific STP areas with workforce implications are; Live Well, Open Dialogue, SPoA, complex needs, Liaison and Personality Disorder. Reduction of temporary staffing use to support financial and quality targets is also being addressed at a local level. There is a Programme Board supporting the achievement of the key priority areas, with Care Group Directors and teams involvement in the following work streams; information spend, changes to practice, workforce modelling, recruitment, retention, absence, rostering, corporate services (removal of agency spend), NHSP/agency caps/overtime and medical. Our WFOD Director currently leads the Temporary Staffing Group across Kent. We have already introduced a step down rate card for medical and nursing across Kent. This has a greater positive impact on the acute Trusts as KMPT is already operating below the rate card rates. We are currently exploring the possibility of a central bank across Kent and this will look at bank rates paid. Our WFOD Director also leads on the Corporate Services Kent STP work and the group is currently working on a business case to outsource payroll across Kent. We also lead on the Mental Health workforce work stream and this work will be further developed once we have agreed the care model. The People Strategy has an underpinning People Plan, with identified actions to address the 4 pillars, plus the business as usual developments in the HR services, and specific learning action plan. Progress against the Strategy and Plan will be reviewed by the Workforce and Organisational Development Committee and the Trust Board. Any risks to achievement are also noted within the risk register as appropriate. As part of the People Plan, culture and staff engagement are also identified as key to supporting the achievement of the changes and further improvements required and to ensure that the culture is focused on making the patient central to everything we do and that we embed a just learning culture. At the Trust our aim is to become an employer of choice. Critical to achieving that objective is staff engagement through which we agree and deliver our shared actions to improve staff experience wellbeing and influence in service delivery demonstrated through feedback in our Friends and Family Survey and our annual Staff Survey results. This is all underpinned by the requirement to ensure we meet the workforce and wider organisational goals set as part of the Equality and Diversity objectives. 9
We have introduced a number of engagement tools to help improve communication: Big Conversation Big Conversation on the road Leaders events As a senior executive team we have working with days on a regular basis where we work alongside our employees. This year we will be focussing on some key areas Career paths Leadership, management and staff development Succession planning We will also be doing further work across the organisation to ensure we embed a just learning culture. Our staff engagement score has improved and sits at 3.76 (75%) and our response rate has increased from 41.7% in 2015 to 53.5% in 2017. Triangulation of plans - The Trust has a number of vacancies where they are using agency and bank. The Trust ensures as part of its business planning process that robust substantive establishments are set for all budget holders to manage. The Trust holds a monetary budget against agency for the premium costs of vacancies and to enable monitoring of performance against the agency cap. In order to meet the challenge of medical recruitment, we offer a new hire bonus and are also advertising abroad. We currently use locum and agency cover where risks are identified and cannot be mitigated. We are reviewing roles and have recently removed some Specialty doctor vacancies and are recruiting Nurse Consultants instead. We have a monthly meeting of senior executives looking at the vacancies and ensuring we are doing all we can to recruit or redesign roles. Agency spend is monitored closely. All appointments above cap have to be risk assessed and are approved by the CEO and Medical Director before appointments are made. Financial planning The Trust has in place a robust financial and business planning process. The process has focussed on the following items: Budget Setting Principles for 2018/19 Care Group plans for 2018/19 Accurate budgets to reflect establishments and Care Group requirements 10
Preparing the Financial Plan for 2018/19 The financial planning process for 2018/19 was launched to the organisation in October 2017. Since then care groups have worked with corporate functions to collate their plans and developments in an overarching business planning pack. Care Group draft business plans include: Performance and Quality Metrics Workforce Activity Income and Expenditure Overview Cost Improvement Plan (CIP) Capital Investment Programme Risks The Trust s Strategic, Operational and Financial plans have taken account of the national planning guidance was issued in February by NHS England. Our plans are heavily linked with the Sustainability and Transformation Planning (STP) and its responsibility for delivering our individual control totals, and working within an agreed system control total for the STP footprint. Our financial plans are also based on the nine national must dos. The plans reconcile finance, activity and workforce, and reflect robust, stretching and deliverable plans directly derived from the STPs and consistent with performance targets. 2017/18 Pre Audit Outturn The Trust is has a pre audit a year end deficit of 3.4m pre MEA adjustment before technical adjustments which is on plan for the control total set by NHS Improvement of 2.8m after technical adjustments. The forecast capital spend for 2017/18 is 5.5m. 2018/19 Financial plan The control totals issued by NHS Improvement were a deficit of 2.83m for 2017/18 and a deficit of 1.12m for 2018/19. For KMPT the revised total for 2018/19 is now a 1.829m deficit. This has been accepted by the Trust. Cost Improvement Plans (CIPs) A 4% CIP target has been set for 2018/19 equating to 6.7m. This is in line with the value set and delivered for 2017/18 and in line with the nationally expected 2% equal to 3.5m. The Trust has a robust process in place for risk assessing CIP schemes. 11
The Chief Operating Officer and Director of Finance are to lead a care pathway programme aimed at delivery of best practice, operational effectiveness and efficiency. The intent of the programme is to improve people s experience and the quality of their care. It has three underpinning objectives: To design and deliver consistently outstanding mental health treatment To enable mobile/flexible working and better use of technology To make the best possible use of the Trust s estate (land and buildings) Delivery of clearly described care pathways will improve patient and staff satisfaction, efficiency, productivity and lead to the delivery of outstanding service provision. It will support the organisation to offer safe, compliant clinical interventions to more people without the need for increased finances. The Trust launched at its Board Seminar in March an operational productivity and clinical pathway programme that will be led by the Director of Finance and Chief Operating Officer ultimately to deliver a two year CIP programme. This programme will review our clinical pathways and look at driving out unwarranted variation. There are monthly Quality Performance Reviews (QPRs) in place with the Care Groups to monitor their financial performance. These will also be focussed on CIP delivery. We monitor agency spend on a regular basis and have kept within our control totals for this financial year. We are looking at alternative roles where we know we have difficulty recruiting and will also be introducing substantively employed central teams who will be allocated to areas where we are short staffed. Capital Investment Programme The proposed capital programme for 2018/19 equates to 10.2m. The programme includes backlog maintenance schemes, Information Technology, the Mother and Baby Unit and modernising inpatient environments. There is one planned disposal for 2018-19. The main risk to achieving it is in ensuring those remaining activities are relocated in good time. There is a project board coordinating all of the service relocations and a specific, dedicated project group responsible for the most challenging of those relocations. Risk Assessment There are a number of key risks to the Trust s current financial plan. These risks have been identified as follows: 12
Contract negotiations Inflation risk Pay expenditure CIP risk Kent and Medway Sustainability and Transformation Plan Partners from across health and social care within Kent and Medway have collaborated to develop the mental health priorities set out within the Kent and Medway Sustainability and Transformation Plan. As part of this process all parties have agreed priorities for service improvement and change in out of hospital and acute services including: Promoting well being and reducing poor mental health Delivering integrated physical and mental health services Delivering improved care for people and their carers when in a crisis The Kent and Medway health and social care system has developed its case for change, and published this in February 2017. The Kent and Medway STP has been submitted in line with national timeframes. Initial feedback on our plans has highlighted that we have a clear recognition of the issues faced and clarity of what needs to be done. We now need to put increased emphasis on delivery of the plans and deliver at pace and scale. 13
The STP is a complex change programme and aims to transform the way we delivery care against four key themes: i. Care transformati on ii. Productivity and Modeling iii. Strategic enablers iv. System leadership STP Position Transforming our care for patients, moving to a model which prevents ill health, intervenes earlier, and delivers excellent, integrated care closer to home. This clinical transformation will be delivered on four key fronts: Local care (Out-of-hospital care) Hospital transformation Mental health Prevention We will undertake a programme to identify, quantify and deliver savings through collaborative provider productivity addressing the following areas: CIPs and QIPP delivery Shared back office and corporate services (e.g. finance, payroll, HR, legal) the Trust is leading on this for the Kent and Medway STP Shared clinical services (e.g. pathology integration) Procurement and supply chain Prescribing We need to develop three strategic priorities to enable the delivery of our transformation: Workforce Digital Estates A critical success factor of this programme will be system leadership and system thinking. We have therefore mobilised dedicated programmes of work to address: Commissioning transformation - enabling profound shifts in the way we commission care Communications and engagement - ensuring consistent communications and inclusive engagement The Mental Health workstream is moving at pace under the leadership of KMPT CEO and Medical Director. KMPT has taken a strategic role in leading the development of the Sustainability and Transformation Plan. This provides us with a solid platform from which to grow and develop our services in line with the systems vision for mental health services. It will be important to ensure we address a number of critical risks and issues as we implement change, this includes: 14
Working collaboratively with Acute providers to design and implement an effective core 24 liaison service Working with primary and community services to ensure a more effective integration of physical and mental health services Working collaboratively as a system to address workforce issues strategically and not at an organisational level Ensuring that we free clinical time to not only engage in but lead service change and implementation Engaging effectively with our service users and carers to coproduce delivery and implementation plans The Kent and Medway Sustainability and Transformation Plan sets out a framework for the future operating model of the health and social care system. Within this system the Trust must build on its strengths as a specialist mental health provider and work more collaboratively with partners to ensure an increased level of integrated service delivery between physical and mental health care. We must also seek to work collaboratively to deliver improved service user outcomes, financial and operational efficiency and a workforce strategy which promotes recruitment, retention and succession planning at a system level. Delivering MH FYFV K&M STP Integrating Physical and Mental Health Care Promoting Mental Wellbeing 15
We made solid progress in 2017-18 as the table below describes The Kent and Medway health economy is undergoing significant change through the implementation of the critical transformational programme articulated in the Sustainability and Transformation Plan. This will affect the Trust s operational plan and will require the implementation of new models of care, new ways of working and staffing models and the delivery of financial balance. 16
The Trust s response is set within the context of the Trust s Strategy, Vision and Values, driven by the clinical outcomes that we seek to achieve, the behaviours we expect and the standards that we seek to deliver. The model also reflects the environment that we operate within and the peple that we serve. It is captured in the diagramme below. 17