Transcript Document
Wye Valley NHS Trust Two Year Business Plan 2014 - 2016 Final version – March 2014
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Background
Strategic Planning Business Planning Financial Plan Savings Plan • • • •
The Trust (WVT)
Integrated care organisation created in April 2011 from; – – – Hereford Hospitals NHS Trust; Herefordshire PCT provider services; Herefordshire Council’s adult social care services A response to a looming financial deficit across the provider organisations Created to generate efficiencies from integrated care provided closer to home Potential to create new integrated pathways across health and social care • • • •
Integrated Care
Fully integrated community health services arranged into ‘neighbourhood teams’ Integrated therapy teams across acute and community Further integration with hospital discharge teams with community teams ‘in-reaching’ to hospital Formal integration with Herefordshire Council’s adult social care services ended in September 2013 • • • • •
Drivers for Change
Herefordshire’s population (183,500) represents a small catchment area for acute services Increasingly elderly population – 22% aged 65 and over Increased specialisation of medical staff driving new models of care More patients cared for in a community setting Major financial pressures in the Herefordshire health system • • •
Foundation Trust Status
Case for Change document (June 2012) highlighted that the; – Trust in its current state was not considered to be financially viable – clinical services strategy of the Trust should be reviewed – Trust should pursue an alternative organisational form WVT Futures Project commenced December 2012 to determine future organisational form Six options for future form in the Strategic Outline Case presented in March 2013 2
Background
Strategic Planning
Business Planning Financial Plan Savings Plan
Strategic Challenges
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Defining the future of the organisation Ensuring that services are safe and provide high quality care Improving the way we provide care Improving our financial performance Developing our workforce 1.
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Key enablers: Estate/PFI Information Management & Technology Procurement Quality & delivery risks • • •
1a. Defining the future - Herefordshire CCG’s Clinical Strategy
Herefordshire’s Clinical Commissioning Group (CCG) reviewed many of the services WVT provides in 2013/14 with our clinicians.
As a result, the CCG will continue to commission the full range of services that WVT currently provides but will continue to work with the Trust to review services during 2014/15 .
This aims to ensure that all services provide the best care for patients and are both affordable and clinically sustainable • • • • • •
1b. Defining the future - Wye Valley Futures Project
During 2013/14 the Futures Project team considered a number of options for the future organisational form of the Trust.
A strategic outline case set out these options to the Trust Board in March 2013 These options were subject to a ‘hurdle test’ and were then cut down to three main options. These options were: – – Acquisition by a foundation trust, An operating franchise with an independent or public sector organisation – Reconfiguring the services the Trust already provides.
Towards the end of 2013 WVT ran a series of staff and public engagement sessions, informing key stakeholders of the options being considered. Following an exhaustive examination of the options, it was found that none of them appeared to meet the stringent criteria required and therefore none of them would be likely to be approved by the NHS nationally The Trust will continue to work alongside colleagues from NHS England and the Trust Development Authority to look at possible further configurations of the three options, alongside other potential solutions, to address the financial challenges facing healthcare in Herefordshire 3
Background
Strategic Planning
Business Planning Financial Plan Savings Plan
2a. Quality & Safety
• • • • • In its recently refreshed Quality Strategy, the Trust has chosen to align its key domains to the new Chief Inspector of Hospitals domains and the NHS Trust Development Authority Planning guidance. The objective of the strategy is to ensure that essential standards of quality are maintained and that the Trust strives for continuous improvement.
The strategy is planned over a three year cycle to ensure the goals and milestones are realistic and achievable. Each year key priorities will be developed, delivered and monitored to ensure the Trust can demonstrate continual improvement.
The Trust’s key priorities identified in the strategy are: – Increasing patient and public involvement – Triangulating and responding to patient, staff and public feedback – Improving Friends & Family scores – Developing a safe and skilled workforce – – Develop and implement the 6 C’s across all staff groups Increasing staff involvement – Providing harm free care – Learning from incidents – Reducing mortality rates – Developing a clinical strategy – – Improving the access times for patients Implementing national guidance for best practice • • •
2b. Quality & Safety – Rapid Responsive Review (RRR)
The Trust has a comprehensive Patient Care Improvement Plan which was developed in response to the Rapid Responsive Review and CQC visit.
A number of actions within the plan are designed to reduce avoidable mortality, ensure gender separation in care environments, improve the equity of care across the week, improve the responsiveness of the Trust to feedback and improve the patient experience The plan is the responsibility of executive directors and executives are held to account for their performance by the CEO.
3. Improving the way we provide care
• In 2013, alongside its commissioners, WVT set about changing the way urgent care is provided in Herefordshire.
• To get the best possible advice on doing this, WVT called in the NHS Emergency Care Intensive Support Team (ECIST) and developed a plan in response to their feedback.
• WVT has an Urgent Care Programme Board working on improvements across the care pathway such as A&E redesign, acute assessment and ambulatory care, short stay care, patient flow and improving discharge arrangements.
• Stroke care has also been subject to a significant amount of improvement work and a business case has been developed to take this work forward.
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Background
Strategic Planning
Business Planning Financial Plan Savings Plan
4. Improving our financial performance
• The Trust received £9m external funding in 2013/14 • The planned gap between income and expenditure in 2014/15 is £17.7m
• A savings programme of £8.7m (5.3% of turnover) will mean that the Trust will have a deficit of £9.0m
• This is the same figure as in 2013/14 despite the Trust making investments exceeding £6m in nursing numbers and the urgent care pathway • The Trust is expected to improve its financial performance over future years and cannot expect external financial support indefinitely • • •
6. Key enablers
During 2013, WVT has developed a draft Estates Strategy and although the strategy rationalises the Trust’s buildings and lowers costs, a significant amount of capital will be required to support it.
A draft IM&T Strategy which focusses on the delivery of an electronic patient record and move away from paper notes has also been developed. The strategy will require capital to support it and the Trust will bid from NHS England’s Technology Fund.
A draft Procurement Strategy has also been developed • • • • • • • •
5. Developing our workforce
During 2013, the Trust has developed a Workforce Strategy which sets out WVT intentions regarding workforce development WVT has made a substantive appointment to the vacant CEO post during 2014 and aims to recruit to the key post of medical director The role of clinical director has been reviewed in 2013 and the new roles have been recruited to A number of key general management posts have been vacant throughout 2013 and WVT needs to develop operational capacity and capability within the organisation Likewise, leadership and management training is required to support new managers in their roles WVT has a small change team to support a significant service improvement agenda. In order to develop a culture of continuous improvement within the Trust, volunteers are being put through a ‘Lean Academy’ throughout 2014 and will be expected to deliver an improvement project within their service Nurse recruitment is a significant influencing factor on this business plan. Following the Rapid Responsive Review, nurse numbers were immediately increased to ensure safe practice. Nursing vacancy rates at WVT are also high.
The Trust has already recruited heavily from Europe and will need to consider its recruitment strategy to deliver significantly more staff.
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Background
Strategic Planning
Business Planning Financial Plan Savings Plan
7. Quality & Delivery Risks
Inpatients being inappropriately placed in areas such as the Day Surgery Unit which presents challenges to their clinical management. This can also lead to potential breaches in mixed sex accommodation and impact upon Day Case flow.
Poor financial situation undermines the integrity and effectiveness of services, leading to uncertainty over the future of the organisation, and affecting the morale and commitment of workforce.
Risk of not achieving referral to treatment times for admitted and non-admitted patients and other NHS Constitution targets.
WVT is unable to provide a 24 hour, seven day service in all areas, due to a shortage of senior medical staff and staff in departments that provide support.
The Trust is at risk of non-compliance in some inpatient adult areas with the National Quality Board NHS England Guidelines on Nurse Staffing.
Mitigation
Standard operating procedure in relation to outlying patients in the Day Surgery Unit (DSU) in place. Escalation when over 12 beds required in DSU to COO or CEO. Elective work postponed, where necessary. Governance reporting to the Board. Wye Valley NHS Trust Futures Programme defining future organisational form. Clear staff and public communications plan. TDA support. CIP programme.
Weekly validation and tracking of patients. Additional clinical sessions held as necessary. Education and training given to clinicians re: 18 week outcome recording. Follow up guidance agreed.
Senior medical cover in place seven days a week. 24 hour cover provided by on call service. Experienced registrars or middle grade presence on site in most specialties. Additional consultants employed at weekend. Operating plan includes developments to support weekend working. Exhaustive proactive recruitment effort continues.
Bank and Agency Escalation Procedure. Bank and agency skill sets reviewed. Audit of patient acuity undertaken. Board approvals process underway.
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Background
Strategic Planning
Business Planning Financial Plan Savings Plan
7. Quality & Delivery Risks continued
There is a risk to the standards of care and safety when A&E demand is high with increasing emergency admissions, which in turn impacts upon the ability to manage patient flow. This can also result in breaches of the four hour waiting time target in A&E.
Patient flow is compromised at periods of high demand of unscheduled activity resulting in occupancy greater than 100%. This could result in poor patient experience, increased delayed discharge and lack of specialist skills when patient is in non specialist area.
Medical cover is, at times, insufficient to meet the needs of the Stroke service.
Mitigation
Triage of expected specialty patients. Cease to use cubicles in A&E majors as an inpatient waiting facility. Introduction of Clinical Assessment Unit (CAU).
See & Treat Service. CCG communication, Social Care and General Practitioner involvement to avoid emergency admissions. Outpatient Ambulatory Service & Therapies (OPAT). Non-Elective Care Redesign Change Agent in place.
Site management team manage flow according to protocols/ procedures. Twice daily bed meetings. Risk assessment to assess clinical risk of move to another area. Escalation to senior staff of any concerns of patient movement/admission. Discharge planning for all patients. Standing Operating Procedure in place covering use of escalation areas.
Process in place to escalate any concerns, including use of emergency admission routes and Consultant advice. NEWS scoring in place. Telemedicine service in place for thrombolysis treatment. Networks with other providers being actively explored with the CCG.
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Background Strategic Planning
Business Planning
Financial Plan Savings Plan
WVT’s Business Plan for 2014/16 – Key Aims Aims 2014/16
Sustain and improve overall performance on service quality
Actions
Delivery of the Patient Care Improvement Plan and the Quality Strategy action plan. Focus on patient experience and feedback
Outcome
Avoidable mortality reduced. Overall high performance on service quality. CQUIN 100% achieved. Patient experience improved. Reduced complaints.
Ensure that the urgent care performance indicators are met through focus on admission avoidance, patient flow and early supportive discharge. Improve productivity in planned care services through better scheduling and planning. Delivery of the Urgent Care Programme; including improvements across the care pathway such as A&E redesign, acute assessment and ambulatory care, short stay care, patient flow and improving discharge arrangements.
Restructure of the theatres schedule, reduced out of hours working, reduced use of the private sector, improved case scheduling. Non-elective patients receive prompt, effective care and where admitted are treated in designated bed of the appropriate specialty. Access targets achieved.
WVT provides the most productive elective services in the NHS in England. Access targets achieved. Clarify the short-term strategic goals for Continue to work with the Trust WVT including the strategic service offering and sustained financial improvement Development Authority (TDA) and commissioners. Develop a five-year integrated business plan which will form a blueprint for the Trust’s progress Agreement with the TDA as to the course of action. Clarity about strategy combined with overall performance builds confidence in the organisational capability of WVT.
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Background Strategic Planning
Business Planning
Financial Plan Savings Plan
Aims 2014/16
Enable the effective engagement of the workforce in the plans and direction of the Trust, creating a culture of commitment to its aims and enthusiasm for being involved in programmes involving change and improvement.
Achieve financial plans and cost improvement targets, laying the basis for improved financial performance in future years.
Actions
Review and revise workforce
Outcome
Top quartile staff engagement in the NHS communications. Wider engagement in change projects. Greater executive engagement with staff. Improve workforce capability through developments in education and training. Review recruitment and retention policies.
Savings programme management and staff survey. Positive commitment to WVT from the workforce. Top quartile appraisal rates. Workforce survey scores on educational training improved. Reduced sickness rates assurance mechanisms, confidence in income forecasts, budget management performance review mechanisms, rapid intervention and consequence for divergence from plan. Review Long Term Financial Model. Ensure income levels are appropriate for each service, particularly community services. Seek better financial Financial plan achieved. CIP achieved 2014/16. Targeted progress made on measures to achieve strategic financial sustainability. Trust has sufficient cash to remain a going concern. arrangements for the Trust’s PFI contract. Develop the performance culture of the Trust.
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Background Strategic Planning
Business Planning
Financial Plan Savings Plan
Integrated Business Plan - Content
1. Improving quality & safety 2. Meeting demand and access targets 3. Implementing the workforce plan 4. Delivering the financial plan 5. Delivering the savings plan
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Background Strategic Planning
Business Planning
Financial Plan Savings Plan • • • • • • • • • • •
1. Quality Performance - 2013/14
A Quality Strategy has been developed alongside a staff engagement programme, including a safety culture survey No MRSA bacteraemias against a trajectory of one, 13 C. Diff cases against a trajectory of 21 Annualised standardised hospital mortality indicator (SHMI) to June 2013 was down to 115.16
VTE assessment predicted to achieve 95% target Improvements in the Incident reporting process and the timeliness of Serious Incident investigations Reduction in the number of patient falls during 2013 Positive feedback from reviews and surveys – the Friends & Family Test scores are improving and response rates are increasing Midwife to birth ratio reached the expected level CQC visit & Rapid Responsive Review recommendations resulted in Patient Care Improvement Plan There have been mixed sex accommodation breaches in the Day Surgical Unit, identified by the RR Review Following the review, a standard operating procedure for use of the Day Surgical Unit has been introduced
Quality Challenges for 2014-16
• • • • • • • • SHMI remains one of the highest within the Trust’s immediate peer group – WVT plans to reduce this indicator below 100 in 2014/15 and maintain this performance through 2015/16 Improving performance on the Safety Thermometer to 95% to demonstrate that WVT is providing harm free care Ensuring that at least 85% of staff receive mandatory training in 2014/15 and 90% in 2015/16 Achieve top quartile performance for the Friends and Families Test score in 2014/15 and then maintain this for the whole hospital in 2015/16 Improving performance on the national inpatient survey, achieving top quartile performance in 2014/15 and top decile in 2015/16 Addressing workforce sickness, particularly long term sickness, as this is relatively high Achieving NHS Constitution targets around referrals for breast cancer, overall waits for cancer referrals and the A&E wait target Promoting equality of care across the week for inpatients and ensuring safe staffing levels in care areas 11
Background Strategic Planning
Business Planning
Financial Plan Savings Plan • • • • • • • • •
2. Demand & Access – Delivery 2013/14
Four hour A&E target not met (forecast 92%) Continued reductions in longer lengths of stay • Significant changes made to urgent care pathway Significant reductions in the use of beds in escalation areas • Day case and outpatient activity over-performing CQUIN; expected delivery of 100% Intermittent RTT trust-wide performance Two week wait target for breast symptomatic not met Improved capture and quality of community data • • •
Demand & Access – Planned Delivery 2014/16
Reconstruction of the urgent care pathway to mitigate performance issues Achievement of all national NHS Constitution targets including: – – – RTT A&E four hour wait Cancer waiting times 100% CQUIN delivery planned Continued engagement with local CCG to ensure activity levels are managed appropriately Improving seven day access
3. Workforce - Delivery 2013/14
• • • • • • Recruitment of a substantive HR Director HR department brought back in-house Development of a Workforce Strategy Significant levels of agency spend used to offset vacancies in medical and nursing posts Major recruitment drive across Europe successful in driving up numbers of substantive nurses Midwife and health visitor levels increased
Workforce Plan 2014/16
• Triangulation with finance and activity plans • Planned workforce net reduction potential of 38 WTE • • • posts Workforce changes subject to quality impact assessment by Medical & Nursing Directors Significant reduction in agency staff expected Business plans include increase of 36 WTE nurses after Rapid Responsive Review to ensure safe practice • A further 50 full time nurses may be required to bring levels up to suggested nursing levels. Nurse levels will be increased in a phased approach 12
Background Strategic Planning Business Planning
Financial Plan
Savings Plan • • • • •
4a. Financial Performance – 2013/14
Expected to deliver five year breakeven duty by delivering year end breakeven position External support required: £9m Savings programme will deliver £6.6m, partly recurrent, partly non-recurrent Over-performance of £2.2m against HCCG contract Capital expenditure of £3.1m forecast • • • • • • • • • •
Financial Plan – 2014/16
Plan for 2014/16 based on the Trust’s Long Term Financial Model Achievement of financial balance over 5 years Forecast Income - £163m in 2014/15 (excluding external support) reducing to £160m in 2015/16 Expenditure Budgets - £172m Savings Plan - £8.7m; – equivalent to 5.3% of overall turnover; Increased income reliant on contract negotiations External support required £9.0m (covers requirement to generate five-year surplus) Significant cash flow pressures – early agreement on and access to external support essential Position includes £0.5m provision for redundancies and £0.8m contingency Limited capital investment – WVT will therefore bid for ‘distress’ capital of £2m 13
Background Strategic Planning Business Planning
Financial Plan
Savings Plan
4b. Risks to the Financial Plan
Failure to secure appropriate level of external support Lose some or all arbitration issues and fail to agree contract with CCG in line with financial plan. Fail to secure income levels in line with activity levels through contract negotiations Failure to deliver required level of CIP, recurrently, each year
Mitigation
This would leave the Trust with a minimum deficit in 14/15 of at least £9m – no mitigation Increased external support of up to £6.2m; seek tariff plus (via modification route) Give notice on such services, in order to minimise financial exposure Executive Directors must be held accountable for delivering the required level of savings. This will be done via the enhanced performance management framework Failure to conclude contractual disputes with a favourable outcome and failure to negotiate more financially advantageous contracts Major cash flow problems caused by any/all the above Failure to secure additional capital resources Quality and safety risks (relating to issues such as nursing staffing levels and seven day working caused by inability to invest both revenue and capital An adverse outcome to disputes would mean additional savings measures will have to be identified. A failure to agree a better contract would mean continued reliance on external support for a longer period – no mitigation Working capital management; short term and long term cash borrowing from the DoH Increased use of leasing which will increase pressure on revenue budgets; explicit prioritisation regarding equipment replacement; cease all changes to buildings; restrict IT developments; Increased deficit and, therefore, external support, increased income or increased savings 14
Background Strategic Planning Business Planning Financial Plan
Savings Plan for 2014/16 – Strategic Response
Planned Care • Optimise theatre and outpatient capacity for elective work • Minimise caseload treated through additional capacity (high cost) solutions • Redesign services to improve productivity • Reduction in use of agency staff Urgent Care • Reconfigure urgent care services at the County Hospital • Eliminate use of inpatient escalation areas • Reconfigure community hospital beds, including medical cover • Reduction in use of agency staff Estate Utilisa tion • Site rationalisation according to Estates Strategy • Business rates review • Reducing contract rates Commercial Opportunities • Procurement savings programme • Focus on reduction in non-pay expenditure • Theatres stock management Contract Income • New contracting guidance/charges • Local flexibility changes • Ensuring appropriate income levels
Savings Plan
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Background Strategic Planning Business Planning Financial Plan
Savings Plan Theme Delivery Workforce Enabling Total Executive Sponsor Scheme
Neil Doverty Maureen Bignell Planned Care Productivity Urgent Care Transformation Developing Community & AHP Services Corporate Services Transformation Patient Support Services (A&C) Workforce Remuneration Technological Innovation Howard Oddy Estates Utilisation Commercial Opportunities Contract Income
Programme Lead
Service Unit Manager Service Unit Manager Service Unit Manager Trust Secretary Service Unit Managers HR Business Partner Head of Programme Management Head of Estates Head of Procurement Associate Director of Finance All other small schemes
Saving Total £’000
1,654 2,217 235 262 300 180 110 1,225 698 1,564 255
8,700
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