Section 1: Executive Summary 1.1 Vision and Strategy RNOH Vision - A World Class Centre of Excellence Summary The RNOH is a world renowned specialist hospital for the diagnosis and treatment of complex orthopaedic conditions. These range from the most acute spinal injuries, bone tumours and complex joint reconstruction to orthopaedic medicine and specialist rehabilitation for those with chronic back pain. We have an internationally unique mix of academic and clinical activity, linked to University College London (UCL), and the developing Academic Health Sciences Centre (AHSC) driving high quality patient outcomes and low infection rates. We treat a high proportion of the sub-specialist work carried out in the UK for example a third of UK spinal scoliosis surgery and two thirds of specialist peripheral nerve injury work takes place at the Trust. The RNOH is one of five National Commissioning Group designated bone tumour centres and one of eight Spinal Cord Injury Centres in the country. Musculoskeletal surgical procedures have consistently delivered successful outcomes for patients and made a significant positive impact on patients quality of life. The consequences of not undertaking these procedures are pain, immobility and economic inactivity - a major contributor to long-term illness and consequent inability to work. The RNOH supports patients with complex and specialist musculoskeletal intervention and rehabilitation needs that cannot be dealt with locally. In many cases we are the last and often only port of call for treatment in the UK. The RNOH was recognised as one of the top 100 healthcare employers from a survey conducted by the Health Service Journal and Nursing Times in 2010, and staff commitment and motivation were recognised in an external review as "exemplary". We aim to build on the huge loyalty to the organisation and passion for the services we provide by continuing to involve staff in our redevelopment planning as well as utilising a range of media to engage staff across the organisation. In one organisation and in one main location over the last 100 years, we have built up a critical mass of world class multi disciplinary experts providing high quality patient care for patients with complex specialist needs. 13 independent reviews in the last 30 years have led to the conclusion that this high quality, innovative and productive excellence would be diluted if the organisation was relocated to other sites or merged with other organisations. We are now ready to move ahead and realise our exciting vision as an NHS Foundation Trust. 1
RNOH Vision To be the specialist orthopaedic hospital of choice by providing outstanding patient care, research and education. Our purpose is to meet patient needs and demands through building a strong academic evidence base, supported by an appropriate range and scale of high quality accessible neuro-musculoskeletal services. UCL Partners AHSC High Quality Accessible Clinical Excellence Scale and range of neuromusculoskeletal services that ensure clinical volume and complexity are appropriate to a world class service Academic Strength Integrated Research and Education External Focus Clinical and Operational International Expertise Specialist Orthopaedic Alliance Federation of Specialist Hospitals Partnership working on other sites Measuring our status as a World Class Centre of Excellence How will we measure whether we are a world class centre of excellence? The exemplar status of high quality and accessible clinical excellence is evidenced by measurable patient experience benefits and outcomes e.g. low infection rates, low readmission or recurrence rates and survivorship, low error/negligence rates, levels of tertiary services not provided elsewhere and exemplar care pathways with low access times. The status of the RNOH as a source of expertise and support to services provided elsewhere nationally and internationally at an organisational level (not just individual clinicians) will be measured by the level of joint working with other organisations e.g. franchising, off site partnership working and joint appointments. Integration of clinical practice, education and research academic strength will be measured by grants attracted to support the Joint Academic Plan agreed with UCL. To support the vision clinically we need to: Provide the scale and range of services that ensure clinical volume, complexity and outcomes are appropriate to a world class service. This will support the Trust s role in cascading clinical practice throughout the NHS. The 2
RNOH will also provide a vision and network of support for relevant trauma services. To support the vision academically we need to Be recognised as a world leading Clinical Centre of Excellence for complex neuro-musculoskeletal disease through translational research and multidisciplinary education. Strategy to support the vision Redevelopment Programme: Our hospital facilities do not currently match our world class vision. We will rebuild and redevelop our Stanmore site. We will do this through our approved redevelopment programme which was supported by Commissioners, NHS London, Department of Health and Treasury approval of an Outline Business Case for a 90m scheme funded primarily through the private finance initiative (PFI) to allow the Trust to provide world class clinical facilities by 2015. Transformation Programme: We will deliver high quality, innovation, productivity and prevention to ensure that we are the safest, most efficient and effective provider of specialist orthopaedics across the whole patient pathway in the UK. We will do this through continuing the delivery of our clinically led transformation programme. Some examples of the benefits of the transformation programme are as follows: o Eliminating unnecessary hospital stays e.g. our enhanced recovery programme, productive ward and Medihome projects o Achieving the highest standards in quality and productivity in theatre utilisation and the use of diagnostic support services o Eliminating unnecessary outpatient follow up appointments and ensuring care is transferred locally to patients where this is more appropriate o Maximising front line care resources through eliminating waste in back office functions The transformation programme is supported by the implementation of a medical management and clinical engagement plan that ensures all clinical service transformation projects are clinically led and maintain or enhance quality outcomes for our patients. Academic Strategy o Training & Education: We will provide a critical mass of high quality routine work so that we can continue to be a centre of excellence for training and research as well as providing specialist care (the current strategy is to maintain c20% routine work to support this). A potential aspiration is to enhance this 3
further would be to expand to become the Elective Orthopaedic Centre for North London, if this makes sense for the local health economy and provides the best value for money, which the Trust feels we can demonstrate through the evidence of our clinical outcomes and efficiency. o Research: We will continue to implement a musculoskeletal research programme and build our world class status through engagement with UCL Partners AHSC across the following themes: 1. Innovative implant design 2. Cell therapy and tissue engineering 3. Disability science and improvement of quality of life for independent living 4. Building the musculoskeletal evidence base to demonstrate the benefits of our services to patients 5. Specialist orthopaedics e.g. sarcoma medicine in collaboration with the Cancer Institute, peripheral nerve injury work and spinal cord injuries The academic vision is supported by a Joint Academic Plan agreed with UCL which will continue to deliver a programme of neuro-muscular orthopaedic teaching and research. We have developed plans for a musculoskeletal research programme across UCL Partners. Responding to our Commissioners: We will engage with our commissioners to target a higher proportion of work to be commissioned on a regional and national specialist commissioner basis rather than individual GP Commissioners/PCTs. We will need to continue to work to ensure specialist commissioning maintains a profile in the transition to the vision outlined in the White Paper Equity and Excellence: liberating the NHS. Building these relationships with commissioners will support an understanding of the value added by the RNOH of the services we provide. 80% of the RNOH s services are defined as specialist but only 20% are currently commissioned by specialist commissioners. We believe that if a higher proportion of activity is commissioned by specialist commissioners service planning, development and best value outcomes for patients will be enhanced. 1.2 Rationale for Foundation Trust Status Foundation Trust status will cement our future as a world class centre of excellence, in charge of our own destiny and able to innovate to make the best use of our assets for the benefit of our patients. For example: 4
o Foundation Trust status will enhance our brand as a national centre of excellence. o We will be able to utilise our significant premium land assets and associated planning permissions to assist site development plans and partnerships with private sector healthcare providers and industrial and academic partners. o As a separate organisation that understands the unique market in which we operate, we will be better placed to meet the needs of our patients and commissioners in the most efficient and effective manner with a clear focus on the value added by our services to the national health economy. Expertise to meet the specialist needs of our patients efficiently to realise this added value will be prioritised and not diluted as they would be if we were part of a larger organisation. o We will give our patients, partners and staff more say in what we do and develop our services in line with their needs. Senior clinicians and staff will have a voice engaging in what we do. This will engender the continued loyalty, dedication and expertise that we are proud of at the RNOH. This will reinforce our services and support recruitment and retention of a high calibre specialist workforce. 1.3 Market Assessment What is driving our market? According to current Department of Health definitions, musculoskeletal conditions include 200 different problems, affecting the muscles, joints and skeleton; over 9.6 million adults, and around 12,000 children, have a musculoskeletal condition in England today (Musculoskeletal Services Framework, 2006 1 ). Not surprisingly, therefore, musculoskeletal conditions are a major area of NHS expenditure which in 2006/7 accounted for 3.5 billion. By 2030, 16 ½ million of the population will be over the age of 65; 30% of 70 year olds have arthritis. It is anticipated that there will be a significant expansion in demand nationally as patients have orthopaedic interventions such as hip replacements at a younger age and, by living longer, require revision. It is predicted, therefore, that there will be a rise to over 150,000 joint replacements during this period. An ageing population and better life expectancy for those with complex physical needs create new challenges for healthcare delivery and demands upon specialist musculoskeletal services. Although medical advances mean that to some extent cases previously considered specialist can be done in a local setting, medical training changes and the reduced experience of newly qualified consultants mean that work previously taking place in local hospitals is increasingly being referred 1 Department of Health, A joint responsibility: doing it differently the musculoskeletal services framework, 12 July 2006 5
onto specialist centres. Rather than low volumes of specialist cases at a local level, patient safety and outcomes are enhanced through providing a critical mass in specialist service centres. What are our markets? We operate in 4 key markets: Market Description Trust Activity Indicative Earnings NHS Routine Driven by patient choice, reputation and local population needs 2,000 spells 15m NHS Specialist Driven by reputation, clinical links to 8,000 75m or Complex secondary care providers nationally spells Private (UK and Driven by reputation and private market 1,000 7m international) demand spells Academic Market Research and Teaching Driven by academic reputation and links to academic partners e.g. UCL IOMS and UCL Partners N/A 2m Where do our patients come from? The RNOH sees patients from across the UK and beyond: Commissioners (Consortia/PCT) % Trust NHS Activity London PCTs 43% East of England PCTs 20% Other PCTs across the UK 24% Specialist Commissioning Groups (Spinal Injuries) 7% National Commissioning Group (Bone Tumour) 6% Private work is 7% of our total activity and international work is 10% of this. Commissioner support for our plans o We have commissioner support for our activity plans and forecast funding assumptions with over 70% signed up to our key assumption of zero growth from 2011/12 onwards. o We have North Central London sector and NHS London support for the strategic fit of our services within the local health economy. 6
How does this affect our strategy to deliver our vision? o Our specialist skills and expertise mean that we are best placed to support commissioners in managing the potential expansion in demand for orthopaedics in an environment of zero income growth. This is because our high quality outcomes ensure the best outcomes for our patients and the most cost effective outcome for our commissioners for example getting it right first time and with low infection rates significantly reduces follow up care requirements compared to alternative care pathways. Our site development plan includes flexibility to expand to meet additional activity if our commissioners require this in the future. 1.4 1.4 Performance Overview (Historical and Future) HC/CQC Quality of Services I&E Surplus CIP Target CIP Actual Financial Standing 2008/09 Fair 0.5m 2.1m 1.6m Fair 2009/10* Good* 1.0m 3.5m 3.6m Good 2010/11 Forecast Good* 1.6m 2.3m 2.3m Good *Not published RNOH assessment based on equivalent of 2008/09 measurement methodology The RNOH has demonstrated a track record of improved performance over the last four years and we have comprehensive plans in place, described in detail in this Integrated Business Plan to build on this going forward in a challenging economic climate. Quality High quality outcomes have been maintained whilst patient activity levels have grown at an average of 5% per annum. In 2008/09 the Healthcare Commission/Care Quality Commission rated our Quality of Services only as fair due to pace of delivery of access targets for services a national challenge in orthopaedics and, in particular, spinal surgery and a reflection that demand growth has outstripped capacity. We are now delivering all access targets. Excluding access targets, we performed well on our key outcome measures including low infection rates (zero MRSA, low surgical site infections), low pressure ulcer incidence, low C-Difficile, low readmissions, top quartile patient satisfaction surveys and high and real time patient feedback results. All of our quality indicators need to be considered in the context of our complex case mix although there are other specialist orthopaedic services in the UK we have by far the highest proportion of tertiary referrals and services defined as specialist within the national specialist services definition set. 7
In the future we will continue to provide evidence of high quality outcomes through benchmarking with other specialist orthopaedic providers. The five key quality improvement priorities that we are delivering in 2010/11 as described in our Quality Account are: o Eliminating pressure sore incidence o Implementing the national VTE assessment tool o Rolling out real time patient feedback to outpatients o Improving services to children o Better complaints management Financial Performance Financially we have delivered surpluses for three years in succession and have eliminated all of our borrowing. We have improved our track record of CIP delivery year on year exceeding our target last year and on track to deliver again this year. We recognise that deficits and borrowing that we had 4-6 years ago have impacted on our liquidity performance but our sustained surplus performance and detailed CIP plans for the next year provide assurance that, in addition to our recent track record, we have developed strong governance arrangements to manage future financial risk. Ensuring the financial governance of the organisation is maintained, the Trust has developed a 9-year cost improvement strategy supported by immediate transformation projects to make sure it meets the latest NHS planning assumptions and the longer-term costs of the Stanmore site redevelopment. The plans aim to deliver cost reductions of 33 million, averaging 4% per annum of total spend, over the 9-year period. This is clearly not without risk and the Trust has provided significant assurance to the Department of Health that in the event its CIP strategy or transformation programme fails to meet the savings targets, sufficient alternative schemes exists to mitigate financial exposure both to the Trust and the Treasury from its public private partnership. With the support and input of clinical staff, examples of service reconfiguration the Trust is introducing productivity and efficiency improvements which include: Reducing future length of stay from the current 6 days, without affecting the recurrent delivery of the 2010/11 activity levels the number of beds will be reduced by 28 to 189 by 2018/19; Delivering services from a more efficient estate; Extension of self-care model for rehabilitation patients; 8
Reducing the number of patients that do not turn up for appointments and redirecting care to local settings where appropriate; Introduce electronic stock management processes and systems across the Trust; Revising and developing new roles for clinical staff, reflecting modernised practice and integrated clinical pathways. For example, the development of new roles such as enhanced practitioners, clinical specialists and assistants to support consultant delivered services; Redesigned systems of working to improve productivity and where appropriate accessing the use of shared services Delivering the identified cost reduction schemes will ensure the Trust remains financially viable by achieving surpluses every year of its 9-year plan whilst meeting the costs of its site redevelopment under tough NHS planning assumptions. 1.5 Summary SWOT Analysis Strengths We have a reputation for excellent clinical services a jewel in the crown in the NHS with examples of world class services. This is evidenced by: 13 independent reviews in 30 years concluding in support for the services provided Consistent referral growth (averaging 5% per annum for 10 consecutive years) and demographic and medical training changes driving likely continuation of sustained demand Patient outcomes zero MRSA, low surgical site infections, C-Difficile, low readmissions Top quartile patient satisfaction ratings Top 100 NHS Employer HSJ/Nursing Times We have an evidenced based focus on high quality outcomes and clinical leadership consistent with current How will we build on these strengths? We will continue to maintain an evidence base for high quality outcomes monitored in our Board to ward Key Performance Indicators and published in our Annual Quality Accounts. We will continue our medical management and clinical engagement plan established as part of our clinically led transformation 9
Strengths political vision described in Equality & Excellence - Liberating the NHS We serve all ages cradle to grave we provide one of the largest critical mass volume of paediatric orthopaedic procedures in the UK and patients with life long conditions are served throughout their life by the RNOH s services We have a track record of academic partnership and clinical innovation unique mix of clinicians, academics, engineers and industry. For example we have developed new techniques such as the internal proximal femur and the non-invasive grower which received two national awards. We have pioneered the use of autologous chondrocyte transplantation in the U.K. High market share in super-specialist activities e.g. spinal surgery, bone tumour, peripheral nerve injury. How will we build on these strengths? programme. This will be monitored by the Transformation Committee on behalf of the Trust Board We will continue the delivery of the National Clinical Advisory Team October 2009 review recommendations on Children s Services at RNOH. This will be monitored by the Director of Children s Services on behalf of the Trust Board We have agreed and implemented a Joint Academic Plan with UCL and this is monitored on behalf of the Trust Board by the Joint Academic Committee. We will agree an updated academic vision and Joint Academic Plan in partnership with UCL Partners AHSC. Our Medical Workforce plan includes our plans to recruit, retain and succession plan for expert specialist clinicians Weaknesses The fabric and estate of the Stanmore site hub is not fit for purpose Our Healthcare Commission/Care Quality Commission ratings have historically only achieved fair due to the pace of delivery of access targets for services this has been a national challenge in orthopaedics and, in particular, spinal surgery and a reflection that demand growth has outstripped capacity. We have not always been able to provide Trauma units with appropriate timely access for spinal trauma to spinal injuries unit due to our capacity constraints in the past Historically inward-looking with a focus on specialist cases rather than leading on cascading clinical excellence for How will we manage these weaknesses? We will deliver our Redevelopment Programme supported by the associated assurance process We will implement our embedded and agreed demand and capacity plans at consultant level established as part of the delivery of 18 week access We will develop links across UCL Partners by agreeing an expanded academic partnership that builds on our current Joint 10
Weaknesses high burden orthopaedic conditions to local NHS services Sustainability of small, sub-specialist, stand alone service lines with challenging succession planning issues i.e. dependent on skills not widely available or continually being developed Reliance on partner organisations for clinical support services not viable to be provided in-house e.g. general medical and surgical cover, pathology, mental health, general medical paediatrics. These partner organisations may not be focused on RNOH priorities Opportunities Population demographics indicate potentially growing demand for the services RNOH provides Patient Choice seeking high quality outcomes rather than local convenience Using our land assets and planning permissions to enhance private sector partnerships New clinical and academic vision strategies (links with AHSCs, industry and aspiring Biomedical Research Unit status) Threats Economic drivers, the funding environment and organisational financial sustainability assessments have historically focused on short term cost of patient care intervention rather How will we manage these weaknesses? Academic plan with UCL. We will consider options for off-site working and franchising models to support services on other sites Our medical workforce plan includes our plans to recruit, retain and succession plan for expert specialist clinicians. Our service line reporting work will inform the development of specialist service critical mass We will maintain strong contract management arrangements with the NHS Trusts that provide our clinical support services. We will build links with alternative providers through academic and service links such as across UCL Partners or the Specialist Orthopaedic Alliance to maintain an understanding of alternative providers How will we exploit these opportunities? We will work with commissioners on managing demand, appropriate referrals to RNOH s specialist services and offering increased capacity if required We will potentially utilise the planning permission on our site for significant clinical facilities expansion to private providers to work alongside the NHS facilities on our site. This will provide a potential future revenue stream for future service development, subject to working within our Private Patient Income cap We will continue to build our links with AHSCs such as through our developing partnership with UCL Partners How will we manage these threats? We will use our links and influence as part of the Specialist Orthopaedic Alliance to ensure the added value of specialist orthopaedic providers is understood by commissioners and wider health economies. 11
than the overall value added economic benefit of high quality outcomes across patient lifetime The Transformation Programme may not deliver at a pace sufficient to meet redevelopment affordability requirements We will continue to experience financial volatility driven by income risks case mix/volume variation, tariff volatility (e.g. PbR changes, NHS R&D funding, PP market contraction) We will utilise the direction of travel indicated in the White Paper Equity and Excellence: liberating the NHS to recognise the value of high quality outcomes across the whole patient lifetime pathway. We have established a clinically led transformation programme and associated risk management and assurance framework in line with Managing Successful Programmes methodology to provide assurance on delivery. The pace of the redevelopment may need to be adjusted according to progress on delivery of transformation. The Trust has a track record of managing the current estates risks if this leads to delay in the redevelopment programme We have established embedded consultant level demand and capacity plans linked to clinical unit plans, directorate plans and the overall Trust Long Term Financial Model. We have a track record of improved performance in an environment of extreme tariff volatility for specialist services 1.5 Managing our risks What are our key risks to delivering our vision and how are we managing them? Section 7 of this Integrated Business Plan describes in detail the risks that we face and how we are managing them. Our three main headline risks are as follows: 1. Redevelopment delay and affordability risk There is a potential risk of delay in progress of the new hospital and maintaining the affordability of the development. The Stanmore site is not compliant with Care Quality Commission core standards and will remain noncompliant until the redevelopment programme is completed. To manage this risk we have a fully approved redevelopment programme and an associated assurance framework for delivery agreed with our commissioners, SHA and Department of Health. The programme includes a 90m PFI scheme for which the Outline Business Case was approved by NHS London in February 2010, DH/Treasury in March 2010 and confirmed following Treasury review in June 2010. This scheme is scheduled to complete Gateway 2 in October 2010 and go to market in November 2010. Full Business Case financial close is scheduled in June 2013 and construction completing in financial year 2015/16. 12
Although there is currently no Plan B alternative estate solution for the services provided by the RNOH, we have a track record of maintaining high quality care in our failing infrastructure and we will flex the pace of implementation according to the pace of delivery of interdependent projects such as our transformation programme. We also have a strong PFI project team in place, and associated advisors, including a Director with a track record of delivery of PFI projects to ensure that the PFI project is delivered within the agreed parameters of our financial plan. 2. Transformation Programme pace of delivery to ensure financial plans are delivered There is a potential risk of not delivering the RNOH s Service Transformation Programme supported by clinical engagement. The clinical and financial sustainability of services, including the affordability of the site redevelopment programme, is dependent on the delivery of the Trust s service transformation programme. The programme is currently on track but significant clinical change projects remain ahead and we will continue to enhance clinical engagement initiatives to provide delivery assurance. We have also developed downside mitigation proposals (described in detail in our risk section) that we will implement if necessary to ensure our overall strategy is delivered. We have established a programme infrastructure to oversee and support the delivery of the programme and are following recommended Managing Successful Programmes methodology. The programme is also linked in with wider Quality, Innovation, Productivity and Prevention initiatives across the NHS to support delivery. 3. Sustaining access times performance Historically rising orthopaedic demand without corresponding increases in capacity expose us to the potential risk of not delivering on sustainable access performance. We have been meeting overall 18 week access performance thresholds and our 18 week access action plan was delivered in all areas except Spinal Deformity from April 2010. However spinal deformity performance is projected to be sustainable by March 2011 at the latest. There remains risk, therefore, of individual 18 week patient breaches and median waits above thresholds until March 2011. We now have a track record of significant improvement in access performance and remain on track to deliver our plans agreed with commissioners and the SHA in respect of 18 week access. 1.6 Leadership and Management The RNOH has a strong and established team of Non-Executive Directors with background in finance, law, business operational management and managing significant capital programmes. We have had a Board development programme in place for over 2 years and have appointed Board development specialists to support this process. This has included Board observation and feedback and comprehensive reviews of the work of the Board, its agenda, the assurance processes it has 13
established, the information it receives to support these and the committee structure that has been set up. The Executive team has three key new appointments that have been made recently in Executive Director roles - Operations, Nursing and Finance. The Board development programme has included team development to ensure these new post holders embed quickly with the established executive team. The medical management and clinical engagement plan is a key component to bring together the vision and strategy with clinically led implementation of our plans for the future. 1.7 Conclusion The RNOH has been referred to in one of its many independent reviews as a Jewel in the Crown 2 of the NHS. Our services have, independently, been described as world class 3. Wider NHS planning uncertainty and local RNOH historical financial constraints have meant that the infrastructure of the hospital has not developed at the same pace as the clinical excellence, high quality and patient and staff loyalty to the organisation. We now have an exciting vision for the future supported by a clear strategy and underpinned by well developed plans described in detail in this Integrated Business Plan. The Business Plan demonstrates that: o We have secured strategic fit support from commissioners and NHS London. Our activity plans are supported by our commissioners and our specialist expertise is needed and will continue to be under demand from patients and their commissioners. o We can evidence clear clinical engagement with our vision, our strategy and its associated plans. o We have secured full government approval of our redevelopment plans to move ahead with a 90m PFI scheme to secure world class facilities for our world class services. o We have a track record of high quality clinical care, improved financial performance and, more recently, meeting access performance standards. We have financial plans and a comprehensive nine year CIP plan worked up in detail through our transformation programme project plans, with the first phase now in implementation stage. The transformation programme will deliver sustainable performance across all key quality and performance Indicators. o We have a clear supporting framework in place to deliver our vision including a clinical service strategy, workforce plans, IM&T strategy 2 Professor Sir John Temple Review of the RNOH March 2006 3 National Clinical Advisory Team RNOH Review October 2009 14
and implementation plans, estates strategy and site redevelopment programme in place to deliver financially and clinically sustainable specialist services into the future. We are confident that Foundation Trust status will cement our future as a world class centre of excellence, in charge of our own destiny and able to innovate to make the best use of our premium land assets for the benefit of our patients. 15