FINAL VERSION SET/64/16. Trust Delivery Plan 2016/17

FINAL VERSION SET/64/16 Trust Delivery Plan 2016/17 Final Version 23rd September 2016

Contents 1.0 INTRODUCTION... 2 2.0 LOCAL CONTEXT... 3 2.1 Local demographic pressures... 5 2.2 Corporate Planning... 7 3.0 DETAILED DELIVERY PLANS... 8 3.1 Trust Response to DOH Commissioning Plan Direction 2016/17... 9 3.2 Trust response to relevant Regional / PoC / Local priorities...44 4.0 RESOURCE UTILISATION... 138 4.1 Financial Strategy... 138 4.2 Workforce Strategy... 142 4.3 Capital Investment Plan... 143 4.5 Plans for Shift Left of resources and other Transformational Initiatives 145 5.0 GOVERNANCE... 147 6.0 Promoting Wellbeing, PPI and Patient/ client Experience... 150 6.1 Implementing the Making Life Better Strategic Framework for Public Health 2013-2023... 150 6.2 Involving Users and Carers... 152 6.3 Measures to assess user experience in terms of the level, quality and method of delivery of services.... 154 Appendix 1 FINANCIAL INFORMATION... 155 1

1.0 INTRODUCTION This Trust Delivery Plan has been prepared to summarise the key issues facing the South Eastern Health and Social Care Trust in the coming year and identifies: What the Trust is going to achieve, and how it plans to meet its targets; Detailed delivery plans for regional and local priorities; The resources that the Trust is going to use to deliver its services. The Trust Delivery Plan details the Trust response to the Health and Social Care Board/Public Health Agency Commissioning Plan 2016/17 and the targets within the Health and Social Care Commissioning Plan and Indicators of Performance Direction (Northern Ireland) 2016. In responding to these regional and local commissioning priorities and specific standards and targets, the Trust also sets out its plan to effectively use its resources in the year ahead, including its financial strategy, workforce strategy and capital investment plans. The Trust s governance strategy is included, as is the commitment to improving the patient experience and plans to contribute to promoting public health and wellbeing and ensuring effective and meaningful personal and public involvement. 2

2.0 LOCAL CONTEXT As the South Eastern Health and Social Care Trust looks ahead to the challenges that 2016/17 will bring, the Trust remains committed to its vision and core values which will underpin its work, ensuring that services are delivered safely, efficiently and effectively and contribute to the health and wellbeing of its population. The Trust will work in partnership with the Health and Social Care Board (HSCB), Local Commissioning Group (LCG), the Public Health Agency (PHA) and as a key stakeholder in Local Commissioning Groups to deliver the commissioning requirements. The South Eastern Trust has been proactively engaged in reform and service improvement activities across Unscheduled Care. A number of specific projects are listed below to further illustrate the positive outcomes achieved within recent months. This work continues throughout 2016/17: 1. Creation of new Frail Elderly Rapid Assessment Centre: Downe Hospital 2. Virtual Fracture Clinic at Ulster Hospital 3. Enhanced Care at Home: North Down and Ards Locality 4. Falls Prevention Service 5. Stroke: Early Supported Discharge 6. Home Oxygen Service 7. Social Care Response Pilot 8. Domnall Rehabilitation Service 9. Clinical Staffing Infrastructure & Speciality Developments 10. Patient Flow Service Improvement 11. Acute Reform Work (November 2015+) 12. Community Turnaround including creation of Discharge Hub and Social Care Referral Hub The Unscheduled Care Board revised its focus for 2016/17 on a number of core areas including Frail Elderly Assessment (including Transition Care), Patient Flow and Ambulatory Care. Building on the considerable improvement activities over the last year in Unscheduled Care, there is a need to demonstrate further reform aligned to outcome measures. Dedicated work streams have been established to gain momentum quickly and deliver change over a short timescale to prepare for winter. In parallel, there is on-going debate on the current bed capacity 3

and shortfall at the Ulster Hospital. Unscheduled care reform will focus on reducing the gap between bed shortfall but it will not eradicate it this year. Outcomes Based Accountability Given that the new Programme for Government is outcomes focused, it is timely that the Trust has already been introducing Outcomes Based Accountability within the Children s Directorate. The Directorate has embraced this new methodology to devise a re-focused strategy with two main outcomes that all children in need to experience stability, and all looked after children to experience stability. These objectives are now clearly linked to population outcomes and indicators aligned to performance measures. Adults Directorate is also embarking on this outcomes based approach this financial year. Other Directorates are also beginning to consider Outcomes Based Accountability methodologies and the Trust will progress the outcomes approach into other areas such as procurement of social care services. International Expert Panel The Trust awaits the outcomes of this International Panel and continues to develop options to create sustainable hospital services across the network of Trust hospitals against a backdrop of increasing demand for services and constrained resources. Within this challenging context, the Trust has a leadership culture and will empower its staff to reform services, improve services, to innovate and lead. To continue to support reform the Trust will utilise the Quality Improvement and Innovation Approach, through its Quality Improvement and Innovation Centre. This approach will ensure that improving care, increasing improvement capability and improving organisational performance are key principles in the Trust and will ensure the Trust provides services that are safe, of a high quality and positive experience for all who use them and continually improves these services through innovation and the growth of knowledge. The previous year 2015/16, has seen significant further progress by the South Eastern Trust in terms of delivering its overall reform agenda and specifically delivering improved health and social care services for its population. Furthermore the financial scenario and the pressures on the public finances mean this year will be even more challenging. 4

2.1 Local demographic pressures As outlined in the Commissioning Plan 2016/17, on Census Day (27 th March 2011) the South Eastern Trust had a resident population of 346,911 persons accounting for 19% of the Northern Ireland total. (Source Commissioning Plan 2016/17 NISRA, 2014 MYE). Population projections indicate an increase in population to 365,384 by 2020, with the highest increases forecast in the 75+ age group. The increase in people aged 85 and over is also significant as this group tends to have the greatest need for Health and Social Care services. Currently the main hospital bases are: Ards Community Hospital, Downe Hospital, Lagan Valley Hospital and the Ulster Hospital. Community bases are located in many local towns and villages from Moira in the West to Portaferry in the East and from Bangor in the North to Newcastle in the South. In addition to this geographical spread, there is also a noticeable diversity in its population characteristics, embracing areas of relative wealth and prosperity as well as pockets of considerable deprivation and need. There are 6 Wards across the Trust which are considered to be in the top 10% of the most deprived Wards in Northern Ireland. The South Eastern Trust population of older people is rising year on year. This demographic pressure will have major implications on the provision of Health and Social Care Services. Projected overall growth projected to 2024 would suggest that the Trust should see a 42% increase in the population of over 65s. Population projections indicate an increase in population to 365,384 by 2020, with the highest increases forecast in the 75+ age group. The increase in people aged 85 and over is also significant as this group tends to have the greatest need for Health and Social Care services. The Trust delivers, in partnership with key stakeholders, a wide range of health and social care services that make demonstrable improvements in the health and wellbeing of the population. The Trust will continue to monitor and review these arrangements to ensure the effective and efficient use of resources. 5

The Trust will deal with in-year demographic growth through the implementation of a wide range of services as noted in the responses to the local, regional and target priorities sections. Funding that would traditionally cover demographic growth which has been allocated to the Trust already will not be sufficient to deal with historic demographic growth pressures, service developments or gaps in services, such as bed capacity. 6

2.2 Corporate Planning In 2015/16, as per Department of Health guidance, the Trust extended its existing Corporate Plan 2011-15, by way of a Corporate Plan Addendum. Further to this, the Department of Health advised Trusts that future Corporate Plans should be developed in line with the Spending Review Cycle and new Programme for Government, 2016/17. This will offer a consistency of approach across all Trusts. As a consequence of this, Trusts and other Arm s Length Bodies (ALBs) have either extended their existing corporate plans, or drafted a strategic context to append to business plans for 2016/17. As this addendum is an extension to the Corporate Plan 2011-15, the existing vision, purpose and values will remain in effect during the interim period until the new Corporate Plan is launched in April 2017. However, this Addendum outlines the priorities that the Trust will pursue in the coming year as part of its strategic and commissioning direction. On 25 May 2016 the Trust Board endorsed the 2016-17 Corporate Plan Addendum and agreed the following proposed timescale for developing the next Corporate Plan 2017-21: Programme for Government initial draft received June 2016. Full Programme for Government is anticipated Autumn 2016. All ALBs will be expected to produce four year Corporate Plans covering the period 2017-2021, for launch on 1 April 2017. 7

3.0 DETAILED DELIVERY PLANS Commitment to maximise performance to meet targets and indicators The Trust will to work in partnership with the Health and Social Care Board, Public Health Agency and South Eastern Local Commissioning Group to maximise performance and strive to meet the targets outlined within this delivery plan. The Trust has developed robust monitoring and accountability arrangements for the delivery of targets and projects. Targets are monitored and performance reported to Trust Board each month through the Performance Scorecard. This includes ministerial priorities, a range of safe and effective care indicators, and a number of internally agreed indicators. Some measures, such as some Health Development targets, are reported quarterly. Performance is also on the agenda of monthly Performance Monitoring and Improvement Review Meetings, which are an integral element of the Trust s Operating Cycle. Performance is also on the agenda of each Directorate s senior management team meetings and the Trust s Executive Management Team. By Exception highlight specific targets where material risk to full or substantial delivery In the responses to the Targets and Standards, the Trust has identified those that may be at risk at not achieving full or substantial delivery and has rated them according to this risk in section 3.1. The Trust will work with the Health and Social Care Board as the Commissioner to minimise these risks and to agree where additional funding or resources are required. 8

3.1 Trust Response to DOH Commissioning Plan Direction 2016/17 Key to RAG Status and Deliverability Deliverability RAG Number Target is Achievable and Affordable G 25 Target is Partially Achievable/ near achievement or will A 14 be achieved in year Target is Unlikely to be Achievable/Affordable R 9 Target requires further clarification from HSCB/ DHSSPS / To be confirmed C 0 Not applicable N/A 2 TOTAL 50 (Note - 1 priority split G/G/A) Summary of Targets Outcome 1 Health and social care services contribute to; reducing inequalities; ensuring that people are able to look after and improve their own health and wellbeing, and live in good health for longer Target RAG Status 1.1 Tackling Obesity G 1.2 Long Term Conditions Structured Education G 1.3 Reduction in Smoking G 1.4 Suicide Prevention Rates G 1.5 Universal Child Health Promotion Framework R 1.6 Children in Care No Placement Change G 1.7 Children in Care Children Adopted From Care G Outcome 2 People using health and social care services are safe from avoidable harm Target RAG Status 2.1 Infection Rates MRSA and Clostridium Difficile A 2.2 Patient Monitoring NEWS KPI A 2.3 Implementation of Delivering Care A 2.4 Residential and Nursing Home Care Failure to Comply Notices G 2.5 Residential and Nursing Home Care Notice of Decision G Outcome 3 People who use health and social care services have positive experiences of those services. Target RAG Status 3.1 Palliative Care Place of Care G 3.2 Adult Inpatient same gender accommodation A 3.3 Mixed Gender Inpatient Accommodation - Policy G 3.4 Children Permanence Pathways G 9

3.5 Patient Experience Survey G Outcome 4 Health and social care services are centred on helping to maintain or improve the quality of life of people who use those services. Target RAG Status 4.1 GP Access Baseline Study N/A 4.2 GP Out of Hours Call Triage R 4.3 Ambulance Calls Category A N/A 4.4 Emergency Department Attendance 4 hour/ 12 hour R 4.5 Emergency Department Treatment 2 hours A 4.6 Hip Fractures A 4.7 Thrombolysis A 4.8 Outpatients R 4.9 Diagnostic Tests R 4.10 Inpatient/ Daycase Treatment R 4.11 Urgent Diagnostic Test Reporting A 4.12 Urgent Breast Cancer Referrals G G A 4.13 Access to Mental Health, Dementia and Psychological Therapies R Outcome 5 People, including those with disabilities or long term conditions, or who are frail, are supported to recover from periods of ill health and are able to live independently and at home or in a homely setting. Target RAG Status 5.1 Learning Disability and Mental Health Discharges R 5.2 Unplanned Admissions A 5.3 Allied Health Professional Treatment A 5.4 Direct Payments G 5.5 Self Directed Support G Outcome 6 People who provide unpaid care are supported to look after their own health and wellbeing, including reducing any negative impact of their caring role on their own health. Target RAG Status 6.1 Increase in the number of Carers Assessments G 6.2 Community Based Short Breaks G 6.3 Carers Assessment Baseline G Outcome 7 Resources are used effectively in the provision of health and social care services. Target RAG Status 7.1 Hospital Cancelled Consultant led outpatient appointments A 7.2 Complex Discharges R 7.3 Pharmacy Efficiency Programme A 7.4 Delivery of Elective Activity A Outcome 8 People who work in health and social care services are supported to look after their own health and wellbeing and to continuously improve the information, support, care and treatment they provide. Target RAG Status 8.1 Seasonal Flu Vaccine G 10

8.2 Staff Absence Levels G 8.3 Responding to Staff Survey G 8.4 Operational Workforce Plans G 8.5 Quality 2020 Attributes Framework G 8.6 Patient and Service User Complaints G 11

Appendix 2: Trust Response to DOH Commissioning Plan Direction (Ministerial Outcomes and Objectives) Desired Outcome 1. Health and social care services contribute to; reducing inequalities; ensuring that people are able to look after and improve their own health and wellbeing, and live in good health for longer. COMMISSIONING PLAN PROVIDER RESPONSE DIRECTION OBJECTIVES RAG Status 1.1 In line with the Departmental strategy A Fitter Future For AIl by March 2022 reduce the level of obesity by 4 percentage points and overweight and obesity by 3 percentage points for adults, and by 3 percentage points and 2 percentage points for children. The Trust is contributing to this regional target via a number of initiatives. A number of examples are outlined below: The Daily Mile engagement took place with seven schools in spring with a view to piloting this initiative. On the success of this we are now launching the programme through a series of road shows whereby the founder of the programme will present to schools in the four areas of the Trust. Childhood Obesity aged 0-4 SEHSCT are developing a Trust wide care pathway which integrates weaning, a family 10 week education support programme and home based family support. This is in keeping with health visitors assessing children s BMIs and having a clear mechanism for support and onward referral. 90 families will benefit from MEND 2-4 programmes provided through Surestart services and voluntary partners where no Surestart exists. Let s Prevent Diabetes this 6 hour patient education programme is offered Trust wide. Within year 100 clients will be supported to exercise more with the use of a pedometer, lose weight and set client centred health goals through on-going telephone health coaching support. SPEAR a new research project, subject to ethical approval, will support 50 type 2 diabetics to set health goals which may include the use of a pedometer through health coaching. Step Challenge Campaign Trust wide all relevant partners are being encouraged to support clients to sign up to this campaign. Pedometers are issued through the HD department and on-going PR work continues. Weight loss for adults with a learning disability on-going work continues to G 12

support the staff teams Trust wide to encourage clients to reduce sedentary behaviour, utilise the Step by Step programme, attend specialist physical activity sessions and make healthier choices in relation to food to support weight loss. This year 40 more adults with a learning disability will participate in the Step by Step walking programme Staff health and wellbeing at Ulster Hospital a newly appointed coordinator will provide increase opportunities for staff to engage in physical activity including walking groups, outdoor gym classes, indoor classes, Couch to 5km. Tied into these will be linkages to weigh management support Physical activity for children with a disability 60 children with special needs will be supported through special schools to learn to cycle Physical activity for adults with a disability 100 plus adults with a range of disabilities will be supported to play Boccia and New age kurling on a regular basis. This includes attending competitions. Partnership working Trust wide continues with 2 staff members providing advice and consultancy on a range of physical activity initiatives: Healthwise, Buddy scheme, Holiday leisure scheme provision, MacMillan Move More, Park run 1.2 In line with the Department's policy framework, living with Long Term Conditions, continue to support people to self-manage their condition through increasing access to structured patient education programmes. In 2016/17, the focus will be on consulting on and taking steps to begin implementation of the Diabetes Strategic Framework and implementation plan with the aim that by 2020 all individuals The Trust is committed to supporting people to self-manage their own conditions through structured education programmes and will work towards having programmes in place for all newly diagnosed diabetics by 2020, this will require additional resource to be allocated. Currently, within paediatric diabetes the Trust provides, CHOICE (Structured Education Programme for Children) to all newly diagnosed Type 1 Diabetics. There is a need for foreign language clinics (Programme for Polish clients facilitated in January 2016) and a refresher clinic for adolescents transitioning to Adult services is required The Trust is currently responding to the Diabetes Strategic Framework Consultation document and awaiting outcome of same. G 13

newly diagnosed with diabetes will be offered access to diabetes structured education with 12 months of diagnosis. Baseline:Q3 15/16 1130 1.3 In line with the Department's ten year Tobacco Control Strategy, by March 2020 reduce the proportion of 11-16 year old children who smoke to 3%; reduce the proportion of adults who smoke to 15%; and reduce the proportion of pregnant women who smoke to 9%. 1.4 By March 2020, to reduce the differential in the suicide rate across NI and the differential in suicide rates between the 20% most deprived The Public Health Agency is the lead organisation in achieving this target. The Trust contributes to this target through the delivery of a range of initiatives, a few of which are outlined below: The team was integral in working towards Smoke-free Trust sites and worked with the Trust PR Department to develop a social media video and campaign which has been nominated for a Chartered Institute for Public Relations National Award in London The Trust has two smoking cessation midwives who are delivering a range of interventions include contacting all pregnant women before booking to offer stop smoking support, as part of the smoke-free wombs initiative. Recently, in the context of these efforts, the Trust smoking at booking rate reduced from 15.4% to 12% in the last twelve months a fantastic result. Smoking Cessation interventions are tailored to the needs of clients, particularly hard to reach individuals, and are currently being delivered to inpatients, outpatients, staff, pregnant women and their partners, clients with Mental Health issues, prison populations, and Looked After Children. Brief Intervention Training is offered and delivered to Trust staff and to voluntary, community and other statutory groups on request. The team are also involved in activities designed to prevent young people starting to smoke, by providing information and resources to schools, and health promotion fairs etc. The Public Health Agency commission a range of services, both via Trusts and directly with providers, in relation to suicide prevention. The Trust delivers a number of initiatives in relation to suicide prevention via its Protect Life Implementation Group. Recent examples include: G G 14

areas and the NI average. Areas of focus for 2016/17 should include early intervention and prevention activities, for example through improvement of self-harm care pathways and appropriate follow-up services in line with NICE guidance. 1.5 By March 2018 ensure full delivery of the universal child health promotion framework for NI, Healthy Child, Healthy Future. Specific areas of focus for 2016/17 should include the delivery of the required core contacts by health visitors within the pre-school child health promotion programme. Early support for people presenting with self-harm at ED for the first time, ensuring they receive a full psycho-social assessment. The Self Harm Intervention Project, funded by the PHA, is now fully operational across the SE area The bereaved by suicide service is offered to all family members where a loved one has died by suicide. Post-vention is also early intervention. SD1 process fully implemented across the SE area Community response plans have been finalised and are ready to be utilised when required. A range of training programmes, including Safe-Talk, Asist, Understanding Self Harm, are being delivered by the Trust to a staff across sectors and community members. High profile events have been organised for both World Mental Health Day, World Suicide Prevention Day The current difficulty in recruitment means that the South Eastern Health and Social Care Trust do not have a full quota of Health Visitors. The current status of Immunisation Clinics within the Trust requires 2 members of qualified staff which includes Health Visitors, which therefore impacts on the available resource for Healthy Child Healthy Futures. The effect of the introduction of the 3 Year Contact as part of Early Intervention Training Programme may further impact on South Eastern Trust s ability to achieve the above target. An additional 4.86 HVs are required to operationalize the regional caseload model in order to achieve the above target. R Baseline: 95% of children to receive a 2 year contact from Health Visitor 94.5% Nov 2016, 6 months in arrears 1.6 During 2016/17, the HSC must ensure that as far as possible children on the edge of care, children in care, and care experienced To address this objective the Trust has put a number of measures in place as follows- Ensure robust care planning for permanence is in place and addressed at G 15

children are protected from harm, grow up in a stable environment, and are offered the same opportunities as their peers. For 2016/17, specific areas of focus should include ensuring that the proportion of children in care for 12 months or longer with no placement change is at least 85%. Baseline : All to have Permanence Plan within 6 months (n = number of children without a permanence plan) 77.8% March 2016, 100% April, May and June 2016 1.7 During 2016/17, the HSC must ensure that as far as possible children on the edge of care, children in care, and care experienced children are protected from harm, grow up in a stable environment, and are offered the same opportunities as their peers. For 2016/17, specific areas of focus should include ensuring a three year time frame (from date of last admission) for 90% of children who are adopted from care. each Looked After Children Review. Ensure the care plans of all children admitted to care are presented to the Permanence Panel for Review. Ensure that there is a choice of placements for children and young people to meet their needs. Agree the outworking of the Foster Care Paper presented in January regarding pressures within foster care and proposals to aid recruitment and retention. Review and increase the number of fee paid carers in line with Foster pressures paper To further support achievement of the target the Trust would need some additional resource as follows- Additional resource required: 3 x Band 4 support workers to support young people when placements are fragile. 40k to cover the increase in foster care fees. To address this objective the Trust has put a number of measures in place as follows- Ensure robust care planning for permanence is in place and addressed at each Looked after Children (LAC) Review. Ensure the care plans of all children admitted to care are presented to the Permanence Panel for Review within time scales Ensure that cases proceeding for adoption are managed in a timely manner in line with timescales outlined above. Track all cases across Trust proceeding for adoption to identify trends / reasons for delay. Training for all field work social workers and Assistant Principle Social Worker in respect of the importance of permanence planning for children in care. Continue to provide social workers with Bond Salon training Continue to implement and review the Home on Time Scheme G 16

To further support achievement of the target the Trust would need some additional resource as follows- Additional resource required: Training in relation to permanence planning and the decision making process within the LAC Review process. 17

Desired Outcome 2: People using health and social care services are safe from avoidable harm Rag Status COMMISSIONING PLAN DIRECTION OBJECTIVES 2.1 In the year to 31 March 2017 secure a reduction of 25% in the total number of in-patient episodes of Clostridium difficile infection in patients aged 2 years and over and in-patient episodes of MRSA infection compared to 2015/16. Baseline: March 2016 86 c. diff (target <55), 9 MRSA(target<7) PROVIDER RESPONSE Work is on-going with clinical and social care teams across the Trust to deliver on the actions outlined for 2016-2017 within the Trust Infection, Prevention and Control (IPC) Strategy and the Infection Prevention & Control Committee Action Plan 2016-2017 Some examples include - Initiatives to continue on-going work to further improve invasive device management Ensuring that invasive devices are appropriate for individual patient need and are managed in line with clear clinical practice guides. Working with prescribers to ensure compliance with Antimicrobial prescribing guidelines and incorporating IPC advice into a Trust Microapp. Continue to review in detail MRSA blood stream and Clostridium difficile infections and work with Public Health Agency and GP colleagues as agreed to review Clostridium difficile infections in community. The IPCT will report to PHA any aspects of Community prescribing identified in RCAs not understood to be compliant with primary care antimicrobial guidelines. Review after first two quarters any progress with PHA and any identified trends to enable close working with local GPs. Further publication of Infection Prevention and Control (IPC) policy summaries for clinical staff and teams. Under consideration at present regarding possible associated resources are:- Service development to be undertaken to review the cost-effectiveness of a pre-loaded sodium chloride syringe for flushing following cannula insertion/ intravenous additive administration. To include associated costs/resources Further development of information summarising key points of IPC policy/guidelines for clinical staff and teams. Support the review of the IPC A 18

2.2 From April 2016, ensure that the clinical condition of all patients is regularly and appropriately monitored in line with the NEWS KPI audit guidance, and timely action taken to respond to any signs of deterioration. Baseline: February 2016 Medicine:85% Surgical:75% W&CH: 90% Community: 100% 2.3 By March 2018, all HSC Trusts should have fully implemented the first four phases of Delivering Care, to ensure safe and sustainable nurse staffing levels across all medical and surgical wards, emergency departments, health visiting and regional infection control manual in conjunction with PHA. Continue to incorporate IPC guidance into the Trust Microapp. Clinical initiatives to maintain robust aseptic principles/ blood culture contamination rates, incorporated into the roll out of sepsis bundles. Staff training/awareness new trolleys, specific packs etc. The number of cases developing CDI within 48 hours of admission has doubled in the last year the and PHA informal data shows that 40% of CDI cases in the SET catchment area were hospital onset and community associated CDI and 9% were community onset, hospital associated Given the aforementioned this target for CDi will be difficult to achieve as the Trust perceives improvement will be best achieved by work being undertaken with community prescribing matters by HSCB/PHA and local GP colleagues. The NEWS KPI has been rolled out across secondary care. Compliance is lowest in relation to prescribing frequency of observations. It is anticipated that the updated NEWS regional chart will be launched June 2016 and the Trust will support this launch with training. The plan is to train champions who in turn will cascade an agreed training programme (the detail on frequency will be part of this programme). Work is progressing towards an agreed regional trigger reset (pilot completed), NEWS guideline can then be finalised when reset agreed. Another study day for frontline staff and ward sisters/charge nurses is planned for September 2016, NEWS will be an agenda item. NEWS will remain a standing agenda item on the deteriorating patients working group. Monthly KPI reports to link process and outcome. Within Secondary Care, Phase 1 is being implemented and progress is being monitored biannually by the PHA. However full implementation is being impacted upon by the regional shortage of registered nursing staff. Phase 2 the Trust is waiting for the PHA to agree the staffing model and the additional resources required to enable implementation will then have to be secured. Phase 3 the regional work is not completed and the pace of this will impact on the timelines for implementation. A A 19

district nursing services. Phase 4 the Phase 4 document is nearing completion. Within Hospital Services implementation has been completed in the Gynaecology Ward and will be rolled out to Paediatrics, Neonatology and maternity services. 2.4 The HSC, through the application of care standards, should seek improvements in the delivery of residential and nursing care and ensure a reduction in the number of (i) residential homes, (ii) nursing homes, inspected that receive a failure to comply notice. 2.5 The HSC, through the application of care standards, should seek improvements in the delivery of residential and nursing care and ensure a reduction in the number of (i) residential homes, (ii) nursing homes, inspected that receive a failure to comply notice and that subsequently attract a notice of decision. To further support achievement of the target the Trust will require additional resource. The Regulation and Quality Improvement Authority (RQIA) is the lead on delivery of this target as regulator. However, the Trust is committed to contribute to improvements as part of its duty of care and will work collaboratively with RQIA and other organisations to avoid the number of failure to comply notices. The Trust will continue to deploy internal governance structures to help ensure issues are addressed at the earliest possible stage and that learning can be shared. The Trust has contract monitoring processes in place for all independent sector providers to ensure compliance with contract terms and conditions and Departmental standards. The Trust would further welcome the opportunity to be advised of any serious concerns identified through care inspections before failure to comply notices are issued. The Regulation and Quality Improvement Authority (RQIA) is the lead on delivery of this target as regulator. However, the Trust is committed to contribute to improvements as part of its duty of care and will work collaboratively with RQIA and other organisations to avoid the number of failure to comply notices. The Trust will continue to deploy internal governance structures to help ensure issues are addressed at the earliest possible stage and that learning can be shared. The Trust has contract monitoring processes in place for all independent sector providers to ensure compliance with contract terms and conditions and Departmental standards. The Trust would further welcome the opportunity to be advised of any serious concerns identified through care inspections before failure to comply notices are issued. G G 20

Desired Outcome 3: People who use health and social care services have positive experiences of those services Rag Status COMMISSIONING PLAN DIRECTION OBJECTIVES 3.1 To support people with palliative and end of life care needs to be cared for in their preferred place of care. By March 2018 to identify individuals with a palliative care need and have arrangements in place to meet those needs. The focus for 2016/17 is to develop and implement appropriate systems to support this. 3.2 By March 2017, all patients in adult inpatient areas should be cared for in same gender accommodation, except in cases PROVIDER RESPONSE The Trust continues to work with Regional Palliative Care Programme Board to ensure that Regionally agreed guidance is implemented across the Trust. In 2016/17 the Trust working with the Palliative and End of Life Informatics Subgroup will record palliative and end of life patients as per the guidance (draft at present). This new recording matrix will help the Trust understand the demand for palliative and end of life care and prioritise services delivery in 2018 Supporting Staff regarding identification Advance Care Planning (ACP) and Advance Communication Skill are core educational priorities for the Trust supporting staff to engage with patients and their families around the identification of their preferred place of care. The palliative care strategy for Children and Young People has not launched yet. This may lead to significant resource implications across acute and community services. To further support achievement of the target the Trust would need some additional resource as follows- Additional resource required: Additional Clinical Coding and Informatics staff Accommodation arrangements will change at UHD site during 2017 with opening of new hospital ward block with 100% provision of single rooms 288 rooms in total. For the wards that remain in the existing block, there will be continuing efforts to segregate males and females into 4 bedded bays within a ward. Once the next G A 21

when that would not be appropriate for reasons of clinical need (or alternatively timely access to treatment). 3.3 Where patients are cared for in mixed gender accommodation, all Trusts must have policies in place to ensure that patients' privacy and dignity are protected. 3.4 HSC should ensure that care, permanence and pathway plans for children and young people in or leaving care (where appropriate) take account of the views, wishes and phase of capital work is completed on Ulster site in 2019 remaining wards will also then relocate into 100% single rooms. Recent analysis of mixed gender accommodation management evidenced that ward managers are utilising local ward resource optimally to avoid mixed gender bay occurrences and are working well with bed managers to resolve at earliest opportunity when it is necessary to place a patient in a mixed gender bay. The Downe Hospital does not have mixed gender bays and it is a very rare incident in Lagan Valley Hospital and only when clinical need dictates. The Mental Health Services Inpatient Estate consists of four wards with variable standards of accommodation. While the service considers that mixed gender wards are appropriate, for example, promoting reduced rates of violence and aggression, the Downe Mental Health Inpatient Unit is the only facility that contains single bedroom accommodation throughout, thereby providing appropriate privacy and dignity for all genders. The other three wards consist of mainly dormitory accommodation and these are gender specific. However, they may become male/female interchangeably, depending on demands upon the service. Also toilets and bathrooms are designated as male or female. The Trust has a mixed gender accommodation policy in place that is kept under regular review. The Mental Health Services Inpatient Estate consists of four wards with variable standards of accommodation. While the service considers that mixed gender wards are appropriate, for example, promoting reduced rates of violence and aggression, the Downe Mental Health Inpatient Unit is the only facility that contains single bedroom accommodation throughout, thereby providing appropriate privacy and dignity for all genders. The other three wards consist of mainly dormitory accommodation and these are gender specific. However, they may become male/female interchangeably, depending on demands upon the service. Also toilets and bathrooms are designated as male or female. The Trust is committed to including the views, wishes and feelings of children and young people into care, permanence and pathway plans. The Trust will Continue to roll out the Mind of My Own (MOMO) app for young people Continue to work with Voice of Young People in Care (VOYPIC) in the preparation of young people to attend their looked after children reviews and pathway plan reviews. G G 22

feelings of children and young people. Ensure the agenda of the review process listens to the views of the Children and young people first. Promote greater understanding and use of IT e.g. mobile devices to record young people s views verbally as well as written presentation to panels. 3.5 By March 2018, to increase by 40% the total number of patients across the region participating in the PHA Biennial Patient Experience Survey, with particular emphasis on engaging patients in areas of low participation. Additional resource required: Mobile devices must be available to every team across the Trust to facilitate work with young people. Last time, the regional questionnaire returns total was 1881. The Trust achieved 440 returns which equated to 23.4% of the total returns. The new target of a 40% regional increase in total returns calculates as 2633. PHA has been consulted to clarify (a) data collection period, (b) administration method(s) and (c) availability of questionnaire version to be used. There is no reason why the Trust cannot achieve a suitable contribution toward the regional returns target of 2633. 10,000 Voices - band 6 nurse has been funded to meet this requirement G 23

Desired Outcome 4: Health and Social care services are centred on helping to maintain or improve the quality of life of people who use those services Rag Status COMMISSIONING PLAN DIRECTION OBJECTIVES PROVIDER RESPONSE 4.1 By March 2020 to have increased access to services delivered by GP practices. The focus for 2016/17 is on developing a comprehensive baseline of such activity, to be used to inform future work. Target not applicable However, the Trust is committed to working in partnership with GP practices to increase access to services in primary care. N/A 4.2 From April 2016, 95% of acute/ urgent calls to GP OOH should be triaged within 20 minutes. Baseline: 84%April 2016 There are a number of issues that will have a significant impact on the delivery of this target and the associated performance Funding not matching increasing demand. There are over 100,000 contacts per annum and growing. Since 2010-2015 there has been 20% growth overall with LaganDoc seeing biggest spike in demand (33%). Workforce availability Availability of GPs, Nurse Triage and achieving the appropriate skills mix Actions to improve performance include - On-going recruitment, local and regional incentives for GPs and GP practices Training and awareness for call handlers for correct call prioritisation Cross site triaging in times of pressure Advance the implementation of skill mix R 4.3 From April 2016, 72.5% of Category A (life threatening) calls responded to within 8 minutes, 67.5% in each LCG The Northern Ireland Ambulance Service is responsible for this particular target. N/A 24

area. 4.4 From April 2016, 95% of patients attending any type 1, 2 or 3 emergency department are either treated and discharged home, or admitted, within four hours of their arrival in the department; and no patient attending any emergency department should wait longer than 12 hours. Baseline (SET): 77.1% 4 hour, 12 hour breaches 1,606. The Trust continues to make progress towards the 4/12 hour standard in spite of increased levels of emergency care activity. The greatest challenges are on the Ulster site and consequently most of the proposed service developments are focused in this area. An independent review of bed capacity at the Ulster site was commissioned by the Trust and undertaken by Alamac Consulting in autumn 2015 which signalled a significant bed shortfall. The Trust s ability to create sufficient capacity will depend on both reform work and also considerable investment in capacity beyond demography funding. Actions for 16/17 include: 1 Trial of ED self-registration for minor cases (Saviance) 2. Further development of ED urgent care service at Ulster 3. Enhancement of ED senior doctor cover OOH and weekends over 7 days 4. Increase in medical bed capacity( 4 beds in Ward 25,re-designation of plastics ward to medicine) 5. Further LOS reductions in medicine through enhancement of ambulatory medicine, medical day case unit. 6. Plans to increase bed capacity by between 10-30 beds this is dependent on finance and the ability to recruit into nursing posts. 7. A number of work streams are currently happening with focus on contributing to the 4 and 12 hour performance targets. These include: Patient Flow Ambulatory Increased ED Consultant cover at weekends. Re-designation of Plastics ward to Medical Ward. Development of frailty assessment unit in Ulster. R 25

Consultant Geriatrician support to ECAH model. Further development of urgent care service in ED. Review of inpatient endoscopy capacity. Expansion of Paediatric Ambulatory. Commencement of Urology Ambulatory service. New arrangements for social work input into COE wards to facilitate earlier discharge. A number of these developments have already been funded by 15/16 demography. Downe Since 2014/15 there has been increased activity in the Downe hospital ED. 4 hour performance is currently at 90%. 12 hour performance is a small feature. Actions for 16/17 include: Further development of Frail Elderly Assessment Unit LVH Since 2014/15 there has been increased activity in the Lagan Valley hospital ED. 4 hour performance is currently at 90%. 12 hour performance is a small feature. 26

4.5 By March 2017, at least 80% of patients to have commenced treatment, following triage, within 2 hours. 4.6 From April 2016, 95% of patients, where clinically appropriate, wait no longer than 48 hours for inpatient treatment for hip fractures. Baseline: 78% cumulative at 31 st March 2016 The Trust has achieved this target for the year 15-16, with the Ulster Hospital at 81%, Lagan Valley Hospital 90% and Downe Hospital 92%. This has been due to the considerable investment in permanent and locum staff to match attendance levels. This will be the case again for 16/17. The Trust will continue to work with the HSCB regarding the investment required to provide consultant led lists. The Trust is unique in that it has only one Trauma & Orthopaedic theatre and no elective surgery to downturn to address peaks in fracture activity. Further investment would be required to provide consultant cover to all fracture lists, provide a fully enhanced trauma model and deliver the 95% compliance in a sustainable fashion. The Trust will be unable to achieve 95% in a sustainable way, without additional investment and within current resources the Trust would aim for an 80% - 85% achievement of the target. A A 27

4.7 From April 2016, ensure that at least 15% of patients with confirmed ischaemic stroke receive thrombolysis treatment, where clinically appropriate Baseline: Cumulative 9.4% or 39 patients 4.8 By March 2017, 50% of patients should be waiting no longer than 9 weeks for an outpatient appointment and no patient waits longer than 52 weeks. Baseline: 9 weeks 33.6% March 2016 52 weeks 51.4% March 2016 Last year the Trust lysed 9% of patients. The Trust has concerns that the 15% target does not reflect respected targets elsewhere and indeed it would be better to use population based target e.g. 10 or 15 per 100,000 (e.g. Scotland s model) This target could lead to unsafe practice inducing practitioners to thrombolyse cases when it s not clinically appropriate (e.g. stroke mimics, TIAs, and wake up strokes). Following changes to recent guidelines the Trust will now be considering for thrombolysis very mild and severe strokes (previously the regional guidelines had these listed as relative contraindications to lysis) this may increase the Trust rate somewhat. The Trust will continue to review all ischaemic stroke cases who did not receive thrombolysis to identify if any clinically appropriate cases have not received thrombolysis. The Trust would also welcome the opportunity to have further dialogue with commissioner leads regarding the caveat where clinically appropriate. If patients who are deemed not clinically appropriate because they present too late or are on anticoagulants or other contraindications were removed from the denominator the Trust would be very close to meeting the target. The Trust will continue to work towards achieving all agreed SBA volumes, however due to a number of factors it is unlikely to be achieved. Demand is outstripping capacity with the gap increasing annually. In addition, the demand for urgent and cancer referrals continues to rise and due to this continuing increase routine referrals continue to wait an unacceptable length of time. Within specific specialities there are also some conditions and treatment plans that require increased frequency of review e.g. dermatology biologics which impact on capacity for new patients. The Trust regularly reviews all waiting lists and ensures that patients are taken in order of priority and then in chronological order within sub specialities. Opportunities continue to be explored to reform and modernise the programme to maximise capacity. A R Additional resource required: Significant investment across a range of specialities will be required to sustain improve performance. 28

4.9 By March 2017, 75% of patients should wait no longer than 9 weeks for a diagnostic test and no patient waits longer than 26 weeks. Baseline: 9 weeks 35% March 2016 (scopes) 9 weeks 88% March 2016 (Imaging) Waiting times within a range of specialities remain challenging. The Trust continues to reform and modernise the service delivered to provide additional capacity and meet demand both in routine and red flag referrals where possible. Additional Investment is required to provide additional capacity to meet the demand for services. Without this additional resource, waiting time targets are not achievable Investment Proposal Templates are currently awaiting approval in order to close the gap in funding e.g. within CT Colonography, Ultrasound and Plain Film Reporting, specifically in terms of Reporting Radiographers. R 4.10 By March 2017, 55% of patient should wait no longer than 13 weeks for inpatient/daycase treatment and no patient waits longer than 52 weeks. Baseline: 13 wks 51.9% March 2016 52 weeks N/A Additional resource required: Trust continues to work with Commissioner on a range of specific specialities to consider investment proposals that will facilitate delivering this target. At March 2016, 1,133 patients were waiting 52 weeks plus for their inpatient/day case procedure. The Trust achieved, in 2016, 51.9% of patients seen for their inpatient/day case procedure within 13 weeks. The demand for urgent and cancer treatments continues to rise and due to this continuing increase routine treatments continue to wait an unacceptable length of time. The Trust regularly reviews all waiting lists and ensures that patients are taken in order of priority and then in chronological order within sub specialities. The Trust will continue to work towards achieving all agreed SBA volumes, however due to a number of factors it is unlikely to be achieved. Inpatient service delivery has been impacted by unscheduled care demand during winter months. Patients are being re-designated as day cases where clinically appropriate. Co-morbidities limit progression of day case activity at present. The Trust is scoping a range of initiatives to improve performance, including - R Access to new day Procedure Unit Facility in Ulster Hospital Spring /Summer 29