East Cheshire NHS Trust Two-Year Plan Summary 2017/18 2018/19 Version 2 FOR PUBLICATION March 2017 1 P a g e
Contents 1. Link to the Local Sustainability and Transformation Plan... 3 2. Approach to Activity Planning... 5 3. Approach to Quality Planning... 6 3.1 Approach to Quality Improvement... 6 3.2 Summary of the Quality Improvement Plan... 7 3.3 Summary of the Quality Impact Assessment Process... 10 4. Approach to Workforce Planning... 11 5. Approach to Financial Planning... 13 5.1 Financial Forecasts and Modelling... 13 5.2 Efficiency Savings for 2017/18 to 2018/2019... 14 5.3 Capital Planning... 15 6. Glossary... 17 Table of Figures Figure 1: Local Delivery System Priorities... 3 2 P a g e
1. Link to the Local Sustainability and Transformation Plan East Cheshire NHS Trust forms part of the Cheshire and Merseyside Sustainability and Transformation Plan (STP). As outlined in the STP, there are significant financial and service delivery challenges facing the local population. As an organisation, the Trust is committed to delivering sustainable services that provide the best care for local people. The need to think differently about how services are delivered to meet the changing needs of our population is recognised. The Trust acknowledges the need to use its limited resources wisely, to meet the demands on the system, and stay within its allocated budgets. However, the plans outlined in the STP for Cheshire and Merseyside are still in the design phase of a large, transformational programme covering an area looking after 2,571,000 people. Cheshire and Merseyside Sustainability and Transformation Plan The Cheshire and Merseyside STP has four main priorities: Support for people to live better quality lives by actively promoting what it knows will have a positive effect on health and wellbeing; The NHS working together with partners in local government and the voluntary sector to develop joined up care, with more of that care offered outside of hospitals to give people the support they really need when and where they need it; Designing hospital services to meet modern clinical standards and reducing variation in quality; Becoming more efficient by reducing costs, maximising value, and using the latest technology. The do nothing affordability challenge is forecast to be 908m for the Cheshire and Merseyside footprint. In assessing the impact of operating within an STP approach, it has been identified that there are a number of issues with the provision of some clinical services, indicating the need for a wide ranging review of services within Local Delivery Systems (LDS). East Cheshire NHS Trust is part of the Cheshire and Wirral LDS, where plans are more closely aligned to the local populations. Cheshire and Wirral Local Delivery System Linking in to the four STP priorities, the diagram below provides a summary of the four LDS priorities. Figure 1: Local Delivery System Priorities The LDS approach supports the concept of a new model of population health to better manage demand, including the potential of four Accountable Care Systems (ACS) across the Cheshire and Wirral Delivery System; East Cheshire being one of the four areas. 3 P a g e
Eastern Cheshire Caring Together Programme The aim of Caring Together is to deliver a new system of health and social care across Eastern Cheshire that joins-up local care for its population s health and wellbeing The Caring Together Programme Board, which is made up of Chairs and Chief Executives from Cheshire East Council, Eastern Cheshire Clinical Commissioning Group, Cheshire and Wirral Partnership NHS Foundation Trust, Vernova CIC (a GP collaborative), NHS England and East Cheshire NHS Trust, is overseeing the development of proposals for the delivery of care services in Eastern Cheshire. This work builds on existing relationships and previous discussions with neighbouring providers including University Hospital of South Manchester NHS Foundation Trust, Mid Cheshire Hospitals NHS Foundation Trust, and Stockport NHS Foundation Trust. Whilst most of the Trust s current networked pathways flow into Greater Manchester, the Trust will work with the Cheshire and Merseyside STP and the Cheshire and Wirral LDS where most appropriate to maximise the benefits to patients. Key to the development of the local service model is stability in contractual arrangements for the next two years, the agreement of local services, service delivery partners and an agreed operating model. Caring Together is constructed around four pillars of care: The empowered citizen The ability of people to manage their own health and wellbeing to stay healthy and remain independent for longer; Community provided care A shift in care from a reactive hospital based setting to a proactive community based setting which is designed around care needs; Local specialist care Traditional hospital based specialists working collaboratively with GPs and community services in delivering hospital based care for patients requiring treatment(s) for a brief but severe episode of illness; Regional specialised care Care that consists of complex procedures that are required to be undertaken in regional or national specialist centres. A key part of the STP work is ensuring the delivery of consistent, quality services regardless of the point of access to the care system. The Trust has been working as an associate partner of the Healthier Together Programme in Greater Manchester and benchmarks itself against these quality standards. Creating the Necessary Linkages A range of performance and patient satisfaction measurements at the end of 2015/16 confirmed that quality remains good at the Trust due to our dedicated staff delivering excellent care and services. The Trust will work hard to sustain this quality through the coming year and is set to play a significant role in the innovation of health and social care in order to help meet the challenges facing our local health economy. To achieve this, the Trust will leverage all opportunities in each of the transformational programmes described above. Not all areas will deliver benefit, for example, the Trust has already contracted out its pathology services, payroll, IT support, financial accounting and systems and hotel services; however, there are still further opportunities to explore. It is anticipated that some of the regional wide initiatives will deliver even greater efficiencies by collaborating with others. 4 P a g e
2. Approach to Activity Planning The Trust has a developed methodology for setting activity plans which has evolved over the last three years and includes detailed involvement and agreement with operational managers and clinical leads The activity plan also includes activity changes such as the transfer of the stroke service to Stockport NHS Foundation Trust, and the loss of the South Cheshire and Vale Royal community services contract. The Trust has undertaken its integrated annual planning process for quality, workforce, activity and finance, triangulating external drivers with the Trust s demand and capacity models. This has informed the contract negotiations and financial planning processes in the lead up to the new financial year, albeit taking a more top down approach rather than detailed bottom up planning. The Trust will use all reasonable endeavours to achieve in full the operational standards and national quality requirements (where applicable) on an ongoing basis during 2017/18 and 2018/19. For planning purposes it is assumed that any additional activity undertaken to reduce waiting list backlogs will be cost neutral. No additional activity has been built into the plan for this. Plans include actions to strengthen the resilience of elective capacity against emergency pressures with improved controls on scheduling a range of theatre productivity and provision of additional capacity through a range of initiatives. The Eastern Cheshire Accident and Emergency Delivery Board, chaired by the Trust s Chief Executive Officer, is holding partners to account for the recovery of the 4 hour standard. The recovery plan addresses gaps and improves control across the wider health economy sector with actions relating to streaming at the Emergency Department front door, NHS 111, NWAS, Emergency Department flow, 1 SAFER inpatient flow bundle and delayed transfers of care (DToC). Planning trajectories assume the Trust will achieve the 18 week referral to treatment standard with effect from June 2017 and the Emergency Care standards from April 2017. The Trust is embarking on a tripartite approach to patient flow through Emergency Department streaming, implementation of the SAFER bundle and sustainable reduction in DToCs. For each of these challenges a 90 day rapid improvement programme has been initiated with Trust management and clinical leads for each work programme. The aim of each of these and taken together is to improve patient flow through the Emergency Department and the hospital, thereby improving patient care and experience. Each of these programmes will make improvements in Q4 2016/17, which are expected to deliver sustainable, resilient delivery in 2017/18. Patient flow through the Emergency Department and the hospital has been identified as key to the sustainable delivery of the 4 hour standard going forward. Improvements in patient flow will also reduce medical outliers and thereby have a positive impact on bed availability for our elective patients, reducing the number of cancellations. 1 The SAFER patient flow bundle is a standardised way of managing patient flow through hospitals. 5 P a g e
3. Approach to Quality Planning 3.1 Approach to Quality Improvement A focus on safety and quality has always been central to everything the Trust does. The Board, through its Safety Quality and Standards Committee (SQS), will continue to oversee the achievement of the quality standards and challenges the organisation to further improve services and care for the benefit of our patients. The named executive lead for quality improvement (QI) is the Director of Nursing, Performance, and Quality. At its most recent CQC inspection in December 2014, Macclesfield District General Hospital was rated as requires improvement. The services were assessed as good for caring and the CQC found that services were provided by dedicated, caring staff. Patients were treated with dignity and respect and were provided with appropriate emotional support. To achieve organisational wide improvement with a view to achieving a good or outstanding CQC rating, the Trust has developed a comprehensive quality improvement action plan, the delivery of which will be monitored at Board level and at operational sub-committees. An assurance process has been implemented which involves the gathering of evidence of completed actions and the scrutiny of information provided. Partners, such as local commissioners and NHSI, are involved and informed of the process and progress made. Vigilance to ensure sustained improvement is through Board member and governance team walkabouts to service areas, meetings with responsible clinical and managerial leads, audits, and spot checks. Demonstrable improvements are shared across the organisation and with system wide partners via a variety of forums and materials; Trust induction, learning events, newsletters, notice boards and local level at a glance reports. In addition teams are encouraged to celebrate and share their successes through keep in touch meetings and various other forums. The Trust has requested a re-inspection and is waiting to hear from the CQC when this will be. The Quality Strategy 2015-2019 details the Quality Improvement Plan (QIP) for the organisation. The delivery of the Quality Strategy is reviewed on a quarterly basis by the Trust s SQS Committee and assurance is provided on all elements across the year. The Quality Forum is an operational sub-committee which oversees the operational implementation of QI initiatives and the plan and reports into the Trust s SQS on a bi-annual basis. Task and finish groups covering the four key elements of the strategy are established and led by appropriate professional leads, and these report into the Quality Forum. Building on the learning and capacity and capability generated by this approach, over the next 6 to 12 months, the Trust will implement a bespoke programme, hosted jointly with the Advancing Quality Alliance (AQuA) to support staff in acquiring the skills, knowledge, and practical application of QI theory. The Trust directly employs a small, clinically led QI and Service Redesign Team; all members have a wealth of skills and knowledge in improvement methodology. Part of the role of the team is to coach colleagues through improvement initiatives. 6 P a g e
3.2 Summary of the Quality Improvement Plan For East Cheshire NHS Trust, quality encompasses four elements: Harm-free care - Care that is safe; Improving outcomes - Care that is clinically effective; Listening and responding - Care that provides a positive experience for patients, carers and families; Integrated care - Care that is co-ordinated and based around individual needs. Harm free care Safe Staffing and Care Hours per Day The Trust has a robust process in place to ensure safe staffing. Actual staffing levels are collated for each patient area in liaison with the e-rostering team and information services. Total monthly actual and expected average fill rates for both registered and unregistered staff are collated and verified by a senior nurse in each Directorate prior to final sign off by the Deputy Director of Nursing and Quality. Care hours per patient day is calculated by the information department daily and escalated appropriately. In addition, the Trust Board receives a high level exception report in relation to actual fill rates for registered and unregistered staff during the day and night which highlights inpatient areas that fall below a 90% average fill rate threshold. Nurse sensitive indicators and workforce metrics are also applied against each inpatient ward area detailing issues such as the total number of slips, trips and falls, pressure ulcers and performance against the Safety Thermometer. A triangulated approach will be adopted to inform staffing decisions that meet National Quality Board (NQB) expectations and reflect any changes in requirements or guidance provided. Mortality Reviews and Serious Incident Investigations Mortality nurses undertake a case note review and then pass it to the relevant consultant and members of the multi-disciplinary team for further review. Any learning or actions from individual reviews are shared with the clinical teams. Overarching data is shared in monthly data packs at service line Safety, Standards and Quality committees and the Mortality subcommittee. East Cheshire NHS Trust adheres to the NHS Serious Incident Framework. In order to maximise learning, all reportable serious incidents are robustly investigated using the root cause analysis process. As part of this process, a check and challenge meeting is now held after the report has been written to ensure all good practice, lapses in care and actions are identified to maximise learning from incidents. Infection Prevention and Control The Trust is committed to reducing the risk of infections by continuing to strengthen policies and processes, whilst empowering and educating staff. In support of these goals: Work will continue to ensure that all Clostridium difficile infection (CDI) cases are investigated, to identify lessons learned and improve staff knowledge and practice; Implementation of the HOUDINI project as part of harm free care will reduce the risk of catheter associated infections. This presents the opportunity to review patients with EColi bacteraemia associated risk factors; Development of workforce knowledge and skills in Infection Prevention and Control and associated risks will be undertaken and supported by the Infection Prevention and Control team. 7 P a g e
Falls The Trust plan is to deliver a year-on-year reduction in avoidable falls leading to a 50% overall reduction in incidents with harm, from a 2014 baseline, and the elimination of any avoidable serious harm arising from a fall. Through the implementation of the latest evidence based practice, every patient at a risk of falls receives appropriate, consistent assessment and has a personalised care plan for in hospital and at home. Assessment documentation will be audited for measurable impact. Falls awareness and education across the Trust will be reviewed and included in statutory and mandatory training. Sepsis Improvement in the management of sepsis will be facilitated through the Trust-wide Sepsis Steering Group. New screening tools for sepsis and a care-bundle approach will be delivered Trust-wide in order to achieve best practice and national guidance for the sepsis CQUIN. The Sepsis Steering Group will monitor audit data which will be escalated to the Board via the Clinical Audit Research and Evaluation (CARE) group. Pressure Ulcers There will be a continued focus on the delivery of a year-on-year reduction in avoidable pressure ulcers leading to a 50% overall reduction, from a 2014 baseline, and the elimination of avoidable Grade 3 and 4 pressure ulcers. This will be delivered through: The continued promotion and embedding of the bespoke pressure ulcer e-learning package as part of clinical statutory and mandatory training; Ongoing bespoke training for clinical area hotspots identified through Safety Thermometer and Incidence reporting; A sustained pressure ulcer awareness campaign React to Red running from May 2016-May 2017; Developing a cohort of pressure ulcer champions to act as liaison between the specialist service and the clinical environment helping to cascade and embed evidence based practice within their own teams. Quarterly audits of Stage 2 pressure ulcers will provide improved information relating to themes, trends, patterns, and special areas of variance and concern in order to be able to plan an appropriate response. Improving outcomes National Clinical Audits The Trust undertakes audits for areas flagged by the Healthcare Quality Improvement Partnership (HQIP). Progress, outcomes, and recommendations of National Clinical Audits are reported to Service Line audit meetings, the Trust s Clinical Audit and Research Effectiveness group, and are included in the annual quality account. Four Priority Standards for Seven-day Hospital Services In order to improve performance against the standards a project team was formed under the leadership of the Clinical Director for Medicine and the Deputy Director of Operations. The focus for action was agreed to be on the following initiatives: Improve access to diagnostics through delivery of a seven-day service for ultrasound; Enhance arrangements for prioritisation of patient reviews over the weekend, including patient flow facilitator infrastructure to support discharge processes; 8 P a g e
Accepting the benefit of these initiatives the Trust recognises that to fulfil the standards further networking arrangements will be required with other providers to ensure access to consultant/senior review of patients seven days per week. Actions from the Better Births Review It has been acknowledged for some time that the number of babies delivered at the Trust is low compared to other English units. However, the Review states that there is no clinical reason why an obstetric unit cannot operate safely in a remote rural area with a relatively small number of births each year, providing it has sufficient staff and access to 24/7 support services, clear pathways and transfer guidelines for specialist care. The report does not state the number of deliveries required to sustain a service. However, it does refer to a recommended size demographic footprint. National CQUINs The Trust will work in partnership across the STP and LDS to achieve the attributed CQUIN indicators, ensuring consistency of delivery and sharing of best practice wherever possible. Progress will be monitored monthly through the Trust Safety, Quality, and Standards Committee. Listening and Responding End of Life Care Working with the End of Life Partnership, the Trust is focused on key priority areas: The utilisation of Electronic Palliative Care Co-ordination Systems (EPaCCS) to share essential end of life information between the hospice, community and hospital settings; Working with partners to provide a service plan for the delivery of palliative care services 7 days a week for community and acute settings; Working with the End of Life Partnership to promote the use of advanced care planning both within the acute Trust and community; Achievement of the 2016/17 end of life CQUIN in order to meet patients preferred place of death. Patient Experience The Trust will continue to focus on patient experience as a key component of the quality agenda, along with clinical effectiveness and safety. The Trust will carry out a wide-ranging patient feedback programme to include national surveys, peer review, and accreditation. The local survey plan will use a range of methodologies such as focus groups, interviews, real time, and online feedback and will include areas where there are changes to services and there is a duty to involve and consult. The programme will take account of the requirements of the Equality Act 2010 and compare the experiences of people with protected characteristics against those of the general population. Themes will be identified by triangulating feedback from a variety of sources such as national and local surveys, Friends and Family Test and NHS Choices. Work will be undertaken to ensure that systems for gathering and utilising patient experience feedback are sustainable. 9 P a g e
3.3 Summary of the Quality Impact Assessment Process The Quality Impact Assessment (QIA) identifies any potential impact on the quality of care provided to patients at East Cheshire NHS Trust through the implementation of individual service development and Quality, Innovation, Productivity and Prevention (QIPP) schemes. This includes potential direct or indirect impact as a result of issues arising from service changes, including workforce capability and capacity, changes to service specification, model, estate or accommodation issues. QIAs are completed for all schemes that will result in one or more of the following: Change to skill mix and/or headcount; Service redesign; Change to business process that will directly or indirectly impact quality (safety, patient experience, and effectiveness of care). This includes back office and support services; Income generation schemes where they are to be provided within existing resources. Responsible Officers (RO) are responsible for the delivery of a scheme and completing the Quality Impact Assessment. The RO will need to consider recommendations arising from Francis, Keogh, Berwick, Cavendish, and Clwyd Hart reports. Key stakeholders, such as other service lines, key professional groups must be engaged in the process. The Project Sponsor must review the QIA before submission for scrutiny and approval process. Finance and Governance teams meet on a regular basis to confirm that QIAs have been developed and approved in line with the approved process, ensuring that they move through the process on a timely basis. Review and Approval There are two stages of the review process, both of which consist of Scrutiny Panels: Stage 1 Membership comprises of the Deputy Director of Corporate Affairs and Governance and the Deputy Director of Nursing and Quality. This panel is responsible for ensuring that quality impacts, risks, and associated controls have been properly identified and described and that those which do not meet requirements outlined above are communicated back to the Responsible Officer. Stage 2 Membership comprises of the Director of Nursing, Performance, and Quality, the Medical Director, and the Director of Corporate Affairs and Governance. This virtual panel is accountable for ensuring that risks to patient safety, clinical effectiveness, and patient experience are adequately managed. Where impacts and/or risks are deemed unacceptable schemes will be rejected and rationale provided to the RO. Monitoring Once the QIA has been approved, the QIA continues to be monitored for the duration of the scheme, as with other risks, through the relevant service line SQS sub-committee. The risk must remain open for six months after scheme implementation to allow for any residual impact to be identified after which it should be reviewed at the relevant SQS sub-committee, minutes uploaded, and closed. Key performance metrics are identified for each scheme including information such as increase in incidents; complaints and PALS concerns; waiting times. 10 P a g e
4. Approach to Workforce Planning Within the local system, the Trust is working with partner organisations to deliver integrated services across health and social care and over the planning period expects to see a move to more agile working aligned to community spokes supporting place based care. Approach The workforce plan has been developed in conjunction with Clinical Directors and Associate Directors for each of the three directorates to ensure accurate inclusion of service specific intelligence and plans. Delivery of the Trust s workforce plan will be closely monitored via monthly performance meetings, triangulated with other evidence and indicators. Board assurance is provided through the Finance, Performance, and Workforce Committee. Overview Workforce Availability The workforce plan highlights current staffing challenges with a high level of vacancies particularly across acute nursing and a number of other specialist clinical roles. Sickness levels above plan are also impacting on overall workforce availability particularly across acute areas. The future position is likely to be exacerbated by national and regional workforce shortages and a local ageing workforce. The impact of the above is a continued, though reduced, reliance on temporary staff including bank, fixed term appointments, and agency workers, in order to maintain safe staffing levels across the organisation. Recruitment and Retention To mitigate supply shortages the Trust is actively pursuing a range of recruitment and retention initiatives including a rolling recruitment campaign, targeted incentive packages and working longer arrangements. The Trust is actively promoting its presence in the job market by attending job fairs, holding regular open evenings and open days, and attending regional and national careers fairs. The Trust hosts the Career and Engagement Hub on behalf of Cheshire Pioneer and is proactively working with local education providers. Through this work the Trust is focusing on schemes to increase the availability of work based experience and learning for young people. The key aim is to attract more people to pursue careers in health and care and in so doing, improve workforce supply in the medium to longer term. A cohort of nurses from overseas were due to commence employment across the Trust in 2016. Due to forces outside the Trust s control this has taken significantly longer than expected, however they are now expected in planned phases throughout 2017 Skill Mix The Trust is actively pursuing skill mix solutions including-ward based pharmacy assistants, nurse associates and apprentices. To address current trust grade, hard to recruit to junior doctor vacancies the Trust is exploring the option of creating a Foundation Year 3 Programme (FY3) across surgery, care of the elderly and trauma and orthopaedics. It is envisaged that the FY3 level will be more attractive than a standard Trust Grade post and will provide development that meets the standards for application for further training at specialist training level. 11 P a g e
Productivity and Efficiency As part of the drive towards greater efficiency the Trust is committed to upholding the principles of pay restraint around the use of agency workers to achieve financial balance. The Trust is actively working to increase its bank workforce across all staff groups and has been one of the few Trusts to successfully recruit a medical bank. The introduction of weekly pay has supported this initiative. The Trust is looking to improve medical productivity through workforce transformation projects. This will include reviewing all job plans and rotas and the implementation of medical e-rostering in all specialty areas to ensure optimal utilisation of staff mapped to service need. The job planning process has been refined and includes a review of all supporting rotas. The process will be informed by a range of data including capacity and demand modelling, quality information and financial information to inform a triangulated approach to the workforce planning of specialties as part of the annual planning cycle. This work is already underway in the Emergency Department, orthopaedics and the anaesthetics service. It is expected that the 2016 junior doctor contract will have minimal financial impact for the Trust in year 1 and 2 of implementation as the organisation employs a very small number of junior doctors (at the F1 and F2 grade) directly. As part of shared delivery plans the Trust is exploring productivity opportunities identified in the work undertaken by Lord Carter of Coles in relation to reducing absence and aligning transactional middle and back office functions but the Trust recognises this may vary depending on the timescales relating to the STP and Caring Together. In addition to the above the Trust is leading and actively participating in the North West HR streamlining programme which seeks to reduce unnecessary duplication and improve processes across workforce pathways Leadership and Improvement Capability The Trust recognises the importance of workforce development and in particular development of system leadership at this crucial time. To facilitate this, an executive team development programme, commencing January 2017, has been commissioned through the NHS Leadership Academy and Deloittes. As a participant in the Caring Together programme, the Trust is benefiting from a number of interventions aimed at strengthening system wide leadership across the wider health and social care economy. Health and Wellbeing The Trust is, in line with the national CQUIN, looking at improving the health and wellbeing of staff by increasing the support available to staff in order for them to remain healthy and well. This work covers physical activity, mental health and improving access to physiotherapy for people with musculoskeletal issues. Organisational Change Over the last 18 months the Trust has experienced a period of unprecedented change with several service changes and transfers that have materially affected the workforce structure across the organisation. This included staff transferred out of the organisation as part of the community services contract commissioned by South Cheshire and Vale Royal CCG and stroke service transfer in October 2016. As a result of these key changes to services the Trust has realigned its management structure. 12 P a g e
5. Approach to Financial Planning 5.1 Financial Forecasts and Modelling The Trust has agreed its control total with NHS Improvement for 2017/18 and access to STP funding. At Month 8 2016/17, the Trust is ahead of its financial plan, after receipt of some nonrecurrent income/benefits. The Trust s QIPP planning has also been successful with the Trust forecasting to deliver savings in 2016/17. In order to derive the Trust s financial plan for 2017/18, the consultation national tariff, where available, or a local tariff, where no national tariff exists has then been applied to activity. The Trust has assumed CQUIN of 2.5% in line with national guidance. The Deputy Director of Nursing, Performance, and Quality takes the lead within the Trust, agreeing schemes with the commissioners with sign off being undertaken by the Clinical Management Board. The financial plans assume that the Trust will achieve the majority of its CQUIN targets. The CQUIN guidance splits this into three elements: 1.5% relating to CQUIN schemes, 0.5% relating to STP engagement, and 0.5% relating to financial control total deliverability and creation of a risk reserve. The guidance states that 0.5% must be retained as a risk reserve until, yet to be defined, conditions are met later in the year, and utilised against agreed investment priorities. Therefore a risk reserve has been created for this. Due to the reduced timescale, pay expenditure has been modelled at a high level, using existing budget-setting policy principles. However, it should be noted, that the detailed budget-setting is being undertaken in parallel with the planning process. The Trust has modelled known changes to pay inflation, incremental drift, national insurance, and pensions. Where the figures are not yet available, the Trust has used NHS Improvement published assumptions. The Trust has also included the estimated impact of the introduction of the national Apprenticeship Levy. This levy will be charged on Trust expenditure, and whilst the Trust can notionally utilise this from training expenditure, it cannot utilise it for staffing costs or backfill whilst the apprentices undertake mandatory training. Therefore the Trust expects a pressure from this. It has been stated that this is included in NHS Improvement s tariff inflation uplift, however, as the Trust s inflation calculation is coming out higher than the 2.1% allowed for in the tariff the Trust does not believe this is fully recompensed, and therefore has included it in its planning assumptions. Non-pay expenditure modelling has taken account of known contractual inflation uplifts The Trust has utilised NHS Improvement non-pay inflation assumptions for any remaining material inflation pressures. As detailed in the efficiency savings section, the Trust is engaging fully with the Carter review, and ensuring the procurement team focus on increasing non-pay savings for the organisation. The annual plan assumes a 3.4% QIPP target. Internally, plans have been triangulated to ensure consistency with the Trust s overall strategy and to confirm income, expenditure, capital, cash, and workforce are aligned. 13 P a g e
2018/19 Financial Position With respect to the 2018/19 financial modelling, this has been undertaken at a very high level. It has been assumed that activity remains steady between the two financial years and that there are no significant service developments or changes. Due to the various tariff and grouper iterations it has not been possible to run this simultaneously through the 2018/19 grouper, whilst the Trust was focussing on 2017/18. A key assumption is that the 2017/18 3.4% QIPP is met recurrently. It has also been assumed that the NHS Improvement inflation indices are applied. Financial and performance information on the Trust is reported to the board via its governance structures and published on our website which is updated regularly please use the following link to access this information http://www.eastcheshire.nhs.uk/about-the-trust/trust-board/trustperformance.htm 5.2 Efficiency Savings for 2017/18 to 2018/2019 The Trust has identified a tranche of efficiency opportunities and is currently working with its main commissioner to re-design services to be delivered within recurrent contractual income. There is a continued focus within the organisation to increase productivity and reduce expenditure, with a particular focus on schemes which have a recurrent financial impact. The contribution from commercial income is currently limited and mainly on small scale service line based provision. The Trust continues to work with its commissioners to support the appropriate use of hospital services in line with the Caring Together approach. Collaborative working has supported joint efficiency including areas such as gain share on infliximab biosimilar utilisation, which will continue into 2017/18. The Trust has actively engaged in the Carter review and has been reviewing the information contained within the model hospital. As the model hospital is developed it will look to explore opportunities identified through benchmarking against its peers. The Trust has submitted its draft Hospital Pharmacy Transformation Plan. It is currently rated green on its resource metrics but will be exploring ways in which implementing the plan will support productivity through the impacts of continual improvements in medicine optimisation as well as improved stock control metrics. The Trust uses a programme management approach to the identification, quality assurance and monitoring of delivery of its QIPP which has been rated as providing high assurance in the most recent audit. Following directorate assessment of viability, ideas enter a formal quality assurance and monitoring process. This includes a detailed risk assessment of achievement of QIPP plans including quality impact assessment as described in section three, triangulation of quality, workforce, activity, and finance implications, and an assessment of the size of the opportunity, along with a profile of financial savings. The Trust risk rates its QIPP delivery on a traffic light system, with defined criteria for transitioning from one rating to another. Detailed information captured at a granular level within the QIPP Tracker supports a range of reporting to different organisational forums. 14 P a g e
Trust performance on QIPP is reported at Trust Board through the Integrated Monitoring Report and reviewed in greater detail at Board and management sub-committees. This includes a Recovery Board at which directorates are held to account for identification and delivery of QIPP. The Recovery Board is also the forum for review of cross-cutting schemes and the identification of organisational barriers to delivery. The Finance, Performance, and Workforce sub-committee of the Board also has monthly assurance reports as part of the Finance report and requires service line presentations on those areas not achieving plan. Agency Rules The Trust continues its work to limit Trust spend on agency and is committed to upholding the principles of pay restraint within the agency market while still ensuring safe and effective services. The Trust has in place an executive led pay bill group which monitors temporary staff expenditure and enacts strategies to reduce spend for all staff groups. The Trust continues to make progress in terms of nursing, healthcare assistant and medical staff utilisation although in some cases the cap can be exceeded due to specialist or hard to recruit posts where the Trust struggles to secure below cap resource. Procurement The Trust has supplied data to facilitate the Purchasing Price Index Benchmarking and anticipates that, when the pricing benchmarking data is released, it will be able to negotiate reduced prices on areas where the Trust is above benchmark values. The Trust already works collaboratively with the Cheshire and Merseyside Cluster which is coterminous with the Cheshire and Merseyside STP. The Trust can confirm that mandated products will be introduced if not already in use and will not deviate away from the mandate. All other products will be masked to ensure they cannot be ordered. Wherever possible, the Trust will procure from recognised frameworks and minimises the use of waivers. All waivers are signed off by an Executive Director or the Chief Executive. Progress against the delivery of the Procurement Transformation Plan is monitored monthly through the Procurement Steering Group which reports into the Trust Recovery Board. 5.3 Capital Planning The Trust is operating in a constrained capital environment. Given the constraints on capital resources, all potential schemes have been risk assessed, and only those assessed at a 16 or above have been prioritised (maximum score is 25). This is reviewed, challenged, and managed through the Trust s Capital Planning committee, a sub-committee of the Clinical Management Board which has a mixture of representation from clinical and corporate departments. The Trust keeps its estate asset lives under review as part of its valuation process. It is currently utilising a significant number of fully depreciated assets and replaces these on a risk based approach as described above. 15 P a g e
Right Here, Right Place, Right Now underpins the Informatics strategy for the delivery of agile, reliable and innovative solutions for the safe and secure access to integrated care records. This is clearly evidenced by the Cheshire Care Record which enables the care professional to view the primary, secondary, community, social and mental health records of patients they are delivering care to. It provides an invaluable view of the whole patient record which six months ago did not exist, the patients benefit from not having to repeat their details but just verify them and are reassured that the Trust knows about them; the care professionals benefit from having sight of recent consultations and up to date medications from all care sectors, ensuring a continuity of care. The estates strategy is to optimise the long-term core estate, considering reinvestment opportunities to offset backlog maintenance and improve functional suitability. 16 P a g e
6. Glossary ACS Accountable Care Systems An ACS brings together a number of health and care providers to take responsibility for the cost and quality of care for a defined local population within an agreed budget. AQuA Advancing Quality Alliance NHS health and care quality improvement organisation at the forefront of transforming the safety and quality of healthcare. CARE Clinical Audit Research and Evaluation Observational studies to evaluate the effectiveness of health care. CCG Clinical Commissioning Group An NHS organisation responsible for the planning and commissioning of services for the health of the local population. CDI Clostridium Difficile Infection A bacterium which infects humans. CQC Care Quality Commission Independent regulator of all health and social care services in England. CQUIN Commissioning for Quality and Innovation A framework which encourages care providers to share and continually improve how care is delivered. DToC Delayed Transfer of Care Occurs when a patient is medically fit for discharge but is still occupying a hospital bed. EPsCCS Electronic Palliative Care Coordination An electronic patient system used in end of life care. Systems FY3 Foundation Year 3 Training grade of medical practitioner. HQIP HOUDINI Healthcare Quality improvement Partnership Haematuria Obstruction Urology Decubitus Input Not for resuscitation, and Immobility An organisation that promotes quality in UK health services, by increasing the impact that clinical audit has on healthcare quality. A nationally-recognised catheter removal protocol. LDS Local Delivery System Local health and care plans for a sub-set of the population within a STP footprint. NHSI NHS improvement An organisation which supports NHS trusts to give patients consistently safe, high quality, compassionate care within local health systems that are financially sustainable. NQB National Quality Board Part of NHS England, established board to deliver high quality care for patients throughout the NHS. NWAS North West Ambulance Service Emergency ambulance service across the North West of England. PALS Patient Advice and Liaison Service A body created to provide advice and support to NHS patients and their relatives and carers. QI Quality Improvement Formal approach to the analysis of performance and systematic efforts to improve it. QIA Quality Impact Assessment Assessment used to define the quality standard. QIP Quality Improvement Plan A plan put in place to implement future quality improvements. QIPP Quality Innovation Productivity Prevention QIPP is an umbrella term used to describe the approach the NHS is taking to reform its operations and redesign services in to make the best use of the potential of innovation and targeted investment in prevention. RO Responsible Officer An individual who has the responsibility for the delivery of a scheme or project. SAFER Senior Review, All patients, Flow of Patients, Early discharge, Review A standardised way of managing patient flow through hospitals SQS Safety Quality and Standards Committee A Board sub-committee with responsibility for overseeing safety and quality and standards. STP Sustainability and Transformation Plan The NHS and local councils have come together in 44 areas covering all of England to develop proposals and make improvements to health and care. These proposals, called sustainability and transformation plans (STPs), are place-based and built around the needs of the local population. 17 P a g e